ST LOUIS HILLS ASSISTED LIVING AND MEMORY CARE.

PRINTED: 10/16/2025 FORM APPROVED Missouri Dapartment of Health and Senlor Sarvices STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED Cc 07594 B. WING | 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 0X4) (D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (Xs) PREFIX (EACH DEFICIENGY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE PATE DEFICIENCY) ST LOUIS HILLS ASSISTED LIVING ANB MEMORY CA A201] 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantlally constructed and shall be maintained in good repalr and In accordance with the construction and fire safety rules {n effect at the Ime of tnitlal Ilcensing. H/Ilt This regulation js not met as evidenced by: Class |i* Based on observation and Interview, the facility falled to ensure all areas of the faclilly ware malntalned in good repair when several baseboards, wails and doors were damaged with varlous sizes of scuff marks and multiple ceiling tiles had water damage and/or were missing, The census was 69, 4, Observation on 9/26/25 between 6:40 A.M, and 4:00 P.M., of resident room 315, showed the following: -Inside the bathroom; -The Inside of the tollat bow! was rusted and encrusted; -The calling in the front left corner, above the shower, the ceiling material was rlpped and hanging down, which exposed pipes and wires, The area measured approximately 3 feet long; -In ihe shower, on the back left ledge of the shower, which attached to the wall, covered wlth orange rust, The area measured 1 foot long; -The kitchenette sink and counter op were ramoved, which exposed the plumbing underneath, The kitchenette and counter top sink were placed In the shower. 2, Observation on 9/26/25 between 6:30 A.M. and 4:30 P.M., of the dining room, In the back of the room near (he private dining room, showed three celling tiles missing which exposed wires and Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPRLIER REPRESENTATIVE'S SIGNATURE ad Q2TEN if continuation sheal 4 of 24 (X6) DATE ‘ay | | | | PRINTED: 10/15/2025 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 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 1 pipes. 3. Observation on 9/26/25 between 6:30 A.M. and 3:00 P.M., of the dining room, in the front of the room near the front lobby, showed five ceiling tiles with brown circles of water damage and by the sprinkler head, two ceiling tiles with light brown circles of water damage. 4. Observation on 9/26/25 between 6:35 A.M. and 4:00 P.M., of the second floor, showed one broken ceiling tile, above resident room 209. Part of the ceiling tile was missing. 5. Observation on 9/26/25 between 6:50 A.M. and 4:00 P.M., of the third floor area of refuge, adjacent to resident room 305, showed the air conditioning unit cover had been removed, which exposed the air conditioning wires. 6. Observation on 9/26/25 between 6:55 A.M. and 4:00 P.M., of the fourth floor area of refuge, adjacent to resident room 409, showed the air conditioning unit had been removed from the wall, which exposed wires. 7. Observation on 9/26/25 between 7:00 A.M., and 4:00 P.M., showed the bottom of the door of resident room 419, covered in black and white scuff marks. 8. Observation on 9/26/25 between 7:05 A.M. and 4:00 P.M., showed the hallway baseboard between resident room 417 to 419, covered in black scuff marks. 9. Observation on 9/26/25 between 7:10 A.M. and 4:00 P.M., showed the bottom of the door of resident room 409, covered in black scuff marks. The scuff marks were deep and exposed the light Missouri Department of Health and Senior Services STATE FORM oe QZTE11 If continuation sheet 2 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 colored wood of the door. During an interview on 9/26/25 at 7:25 A.M., Level One Medication Aide B said he/she had never seen anyone paint the doors or baseboards since he/she started about three months ago. 10. Observation on 9/26/25 between 8:30 A.M. and 4:00 P.M., by resident room 210, showed two ceiling tiles missing, which exposed wires. 11. During an interview on 9/26/25 at 3:59 P.M., the Administrator said the ceiling tiles have been like that and she asked the Maintenance Director to be replace the ceiling tiles but he had not. She did not know why they were not replaced, but thought it was because she did not have enough Maintenance staff to complete the task. She said the baseboards, doors, and walls were not ona schedule. She said the maintenance staff might have a schedule, but she just was not aware of it. *The higher the classification merited due to extent of the violation. 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. I/II This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to ensure resident rooms were kept clean and orderly when resident rooms were found with dried feces and food debris on the floor, doorframes and other areas and were filled with Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 excessive clutter. The census was 69. 1. Observation on 9/26/25 between 7:10 A.M. and 4:00 P.M., of resident room 309, showed the following: -The shower floor, in the bathroom, covered with several areas of dried feces; -The floor in front of the toilet, covered with a very thick layer of yellow/orange colored urine. The area extended out from the front of the toilet about 18 inches. The smell of feces and urine permeated the room; -The bathroom floor, covered with several areas of dried feces; -The sink, in the kitchenette, filled with dirty brown, foul smelling water, up to the rim; -The entire room floor, covered with debris and food particles, with a heavy concentration in front of the resident's brown leather recliner; -The floor, in front of the recliner, covered with several areas of dried feces; -The recliner covered with feces smears and dried food and debris; -The closet doors, covered with a large area of dried feces; -The outside doorframe, which lead into the bathroom, covered with a large area of dried feces. 2. Observation on 9/26/25 between 12:30 P.M. and 4:00 P.M., in resident room 217, showed the following: -Against the wall on the left side of the chair: -Approximately 12 boxes filled with various household belongings; -A brown paper bag filled with paper towels; -A large piece of Styrofoam from an empty box placed on top of the pile; -A cardboard banana box filled with baskets and other bags; Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 -A cardboard chip box frilled with a plastic trashcan and a floormat; -A shower chair placed on top of the pile of other items; -Articles of clothing tucked between the boxes; -In the chair: -Several articles of clothing thrown on the chair; -In the kitchenette sink: -Soiled food containers. 3. Observation on 9/26/25 between 1:00 P.M. and 4:00 P.M., of resident room 304, showed the following: -The entire room covered with cardboard boxes, which were filled with various household items such as kitchen utensils, paper products, books, lamps and empty containers; -Several walkers, rollators and canes were scattered throughout the room; -The entire kitchenette counter covered in clean and dirty dishes stacked on each other; -Old, dried food sat on the television stand; -A pile of rocks and onions were on top of a red microwave; -A broken lamp on the bedside table; -Soiled clothes on the floor and on top of the boxes in front of the television; -The resident lay on one side of his/her bed and on the other side of the mattress were more boxes filled with various items; -A used urinal sat on his/her bedside table which dripped urine on the beside table. 4. Observation on 9/26/25 between 7:00 A.M. and 4:00 P.M., of resident room 315, showed the following: -Several large plastic wrappers on the floor; -Several unopened boxes of gloves scattered Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 throughout the floor; -Three cardboard boxes of opened flooring propped up against a wall; -Several cardboard boxes filled with various items and one cardboard box pilled high with blankets, sheets and a mop head; -A small paint roller on the floor; -Empty cleaning supply boxes; -A broom head without the handle; -Soiled rags. 5. Observation on 9/26/25 between 10:00 A.M. and 4:00 P.M., of the bathroom in resident room 319, showed dried yellow urine on the tiles around the toilet. The bathroom had an extreme urine odor which permeated the bathroom and spread out into the bedroom and hallway. 6. During an interview on 9/26/25 at 3:46 P.M., the Regional Director of Nursing said she was in resident room 304 last month and she had to remove about 20 Amazon boxes. She had not been in that room since then, but remembered breaking down several boxes with the resident. She was not aware the resident's room was cluttered again. She understood it could be considered a fall hazard because of how cluttered the room was. 7. During an interview on 9/26/25 at 3:45 P.M., the Administrator said the staff clean the resident rooms once a week. She did not know the regulation read the resident rooms required to be cleaned daily. She said she did not ensure the staff were cleaning the resident rooms because she gave that task to the Housekeeper Supervisor. She said she had not been in resident room 304 recently. She said she did not know the resident rooms were in this condition. Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 *The higher the classification merited due to the extent of the violation. 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. 1/II This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to provide proper care per the resident's individualized service plan (ISP) when the facility staff did not follow the resident's ISP indicating the resident required the assistance of a Hoyer lift (mechanical lift) for one of seven sampled residents (Resident #1). The census was 69. Review of Resident #1's medical record, showed the facility admitted the resident on 9/29/23, with diagnoses which included high blood pressure and Alzheimer's disease. Review of the resident's ISP dated 2/28/24, showed the resident required staff assistance transferring with use of Hoyer lift. During an observation and interview on 9/26/25 at 10:40 A.M., showed Care Partner (CP) E and Certified Medication Technician (CMT) F entered the resident's room. The resident lay in bed. There was a Hoyer lift against the wall across from the resident's bed. CP E and CMT F provided care to the resident. CP E moved the resident's Broda Chair (a specialized reclining wheelchair) next to the resident's bed. CMT F Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 said the resident was a two person Hoyer transfer, but the staff did not use the Hoyer lift. He/she said the staff did not like the sheet/pad that was with the Hoyer lift and the resident moved too much. CMT F lifted the resident under the resident's arms and CP E lifted the resident around the waist. At the same time, they sat the resident up from laying position in the bed and lifted the resident to the Broda chair. During an interview on 9/26/25 at 2:15 P.M., the Administrator said the staff should have used the Hoyer lift to transfer the resident, they are not qualified to make those decisions themselves. 19 CSR 30-86.047(47)(A) Physicians Orders Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to follow physician's orders when residents did not receive their medications according to their Physician's orders (POS) for three of nine sampled residents (Residents #8, #9 and #15). The census was 69. 1. Review of Resident #8's medical record, showed the facility admitted the resident on 3/21/22, with diagnoses which included dementia with Lewey bodies (a type of dementia characterized by changes in sleep, behavior, Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 cognition, movement, and regulation of automatic bodily functions), muscle weakness and difficulty in walking. Review of the resident's POS dated 8/2025, showed the following: -Alendronate (used to treat osteoporosis), 70 milligrams (mg). Take one tablet by mouth once week; -Anoro Ellipta, (used to treat chronic obstructive pulmonary disease (COPD)), one puff. Inhale one puff one time daily; -Aspirin (used as a blood thinner), 81 mg. Give one tablet by mouth one time daily; -Clindamycin (antibiotic), 300 mg. Give one capsule by mouth three times daily for seven days; -Clonazepam (used to treat panic disorders), 0.5 mg. Dissolve one tablet under the tongue two times daily; -Clotrimazole (antifungal), 1-0.05%. Apply topically to affected area two times daily; -Donepezil (used to treat dementia), 5 mg. Give one tablet by mouth at bedtime; -Duloxetine (used to treat depression), 120 mg. Give two capsules by mouth every morning; -Ferrosol (used to treat iron deficiency), 325 mg. Give one tablet by mouth one time daily; -Gabapentin (used to treat pain), 100 mg. Give two capsules by mouth two times daily; -Gemtesa (used to treat an overactive bladder), 75 mg. Give one tablet by mouth one time daily; -Loperamide (used to treat diarrhea), 2 mg. Give on capsule by mouth two times daily; -Melatonin (promotes sleep), 3 mg. Give on tablet by mouth at bedtime; -Metoprolol (used to teat high blood pressure), 25 mg. Give one tablet by mouth on time daily; -Mirtazapine (used to treat depression), 30 mg. Give on tablet by mouth at bedtime; Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 -Nystatin powder (antifungal). Apply topically to affected area two times daily; -Omeprazole (used to treat acid reflux), 40 mg. Give one capsule by mouth one time daily; -Pentoxifylline (used to treat leg pain), 400 mg. Give one capsule by mouth one time daily; -Potassium chloride (used to treat low potassium levels), 10 milliequivalent (meq). Give one tablet by mouth two times daily with meals; -Preservision (used to help vision). Give one capsule by mouth one time daily; -Rexulti (used to treat depression), 1 mg. Give on tablet by mouth in the morning; -Solifenacin (used to treat overactive bladder), 10 mg. Give one tablet by mouth one time daily; -Vitamin B-12, 500 micrograms (mcg). Give one tablet by mouth one time daily; -Vitamin B-6, 50 mg. Give one tablet by mouth one time daily; -Vitamin D, 50000 unit. Give one capsule by mouth one time weekly. Review of the resident's medication administration record (MAR) dated 8/2025, showed the following: -Alendronate not administered to the resident on 8/4, with /no documentation as to why; -Anoro Ellipta not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Aspirin not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Clindamycin not administered to the resident on 8/1, for the noon timeframe and 8/4, for the morning time, with no documentation as to why; -Clonazepam not administered to the resident on 8/4, for the morning dose, on 8/15, for both the morning and evening dose, on 8/24, for the morning dose, with no documentation as to why. On 8/25, the resident was not administered the medication, with "not available" documented; Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 21 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 6543 CHIPPEWA ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA SAINT LOUIS, MO 63109 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 10 -Clotrimazole not administered to the resident on 8/4, for the morning dose, with no documentation as to why. The resident did not receive the medication on 8/9, for the morning dose, with "not here" documented. The resident did not receive the medication on 8/15, for the morning and evening dose; -Donepezil not administered to the resident on 8/25, with "not in cart" documented; -Duloxetine not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Ferrosol not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Gabapentin not administered to the resident on 8/4, for the morning dose and on 8/15, for the morning and evening dose, with documentation as to why; -Gemtesa was not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Loperamide not administered to the resident on 8/4, for the morning dose, on 8/15, for the morning and evening dose, with no documentation as to why. The resident did not receive the medication on 8/26, with "not in cart" documented; -Metoprolol not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Mirtazapine not administered to the resident on 8/27, with "not in cart" documented; -Nystatin powder not administered to the resident on 8/4, for the morning dose and 8/15, for the morning and evening dose, with no documentation as to why; -Omeprazole not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Pentoxifylline not administered to the resident on 8/4, for the morning dose and 8/15, for the morning and noon dose, with no documentation as to why. The resident did not receive the Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 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 11 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 medication on 8/25, for the evening dose, with "not in cart" documented and on 8/29, with "not available" documented; -Potassium chloride not administered to the resident on 8/4, for the morning dose and 8/15, for the morning and evening dose, with no documentation as to why; -Preservision not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Rexulti not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Solifenacin not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Vitamin B-12 not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Vitamin B-6 not administered to the resident on 8/4 and 8/15, with no documentation as to why; -Vitamin D not administered to the resident on 8/4, with no documentation as to why. Review of the resident's POS dated 9/2025, showed the following: -Alendronate, 70 milligrams. Take one tablet by mouth once a week; -Clonazepam, 0.5 mg. Dissolve one tablet under the tongue two times daily; -Gabapentin, 100 mg. Give two capsules by mouth two times daily; -Gemtesa, 75 mg. Give one tablet by mouth one time daily; -Pentoxifylline, 400 mg. Give one capsule by mouth one time daily. Review of the resident's MAR dated 9/2025, showed the following: -Alendronate not administered to the resident on 9/29, with no documentation as to why; -Clonazepam not administered to the resident on 9/22, for the evening dose, with no documentation as to why; Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 -Gabapentin not administered to the resident on 9/12, for the evening dose with no documentation as to why; -Gemtesa not administered to the resident on 9/3, with "not on hand" documented and on 9/4, with "medication unavailable" documented; -Pentoxifylline not administered to the resident on 9/6, for the evening dose, with "order" documented and for 9/7-9/10, for the evening dose, with "not available" documented. The resident did not receive the medication on 9/14 and 9/15, for the evening dose, with "not available" documented. 2. Review of Resident #9's medical record, showed the facility admitted the resident on 4/1/20, with diagnoses which included diabetes, edema, high blood pressure and kidney disease (stage 3). Review of the resident's POS dated 8/2025, showed the following: -Atorvastatin (used to treat high blood pressure), 10 mg. Give one tablet by mouth one time daily; -Benzonatate (used to treat a cough), 100 mg. Give one capsule by mouth three times daily; -Blood sugar checks. Check and record blood glucose two times daily before breakfast and dinner; -Breo Ellipta (used to treat COPD). Inhale one puff one time daily, rinse mouth after use; -Butenafine (used to treat fungus infections). Apply topically to left foot two times daily until healed; -Carvedilol (used to treat heart disease), 3.125 mg. Give on tablet by mouth two times daily with meals; -Clotrimazole, 1%. Apply topically to affected area two times daily; -Fluticasone spray (used to treat allergies), 50 Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 13 of 21 PRINTED: 10/15/2025 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 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 13 mcg. Use two sprays in each nostril daily; -Furosemide (used to treat fluid retention), 40 mg. Give one tablet by mouth two times daily; -Humalog (insulin, used to treat diabetes), 100 milliliters. Injected 5 units two times daily before breakfast and dinner, if blood glucose is greater than 200. If blood glucose is less than 200, hold; -Jardiance (used to treat diabetes), 25 mg. Give one tablet by mouth in the morning; -Oyster shell (used for calcium), 500 mg. Give on tablet by mouth two times daily; -Potassium chloride, 10 meq. Give one tablet by mouth one time daily; -Triamcinolone (used as an anti-inflammatory) 0.1%. Apply topically to affected areas two times daily; -Vitamin B-12, 500 mcg. Give one tablet by mouth one time daily. Review of the resident's MAR dated 8/2025, showed the following: -Atorvastatin not administered to the resident on 8/6 and 8/21, with no documentation as to why; -Benzonatate not administered to the resident on 8/1, for the noon dose, with "refill requested, not administered" documented. The resident did not receive the medication on 8/3, 8/6, 810, and 8/12, for the noon dose, with no documentation as to why. The resident did not receive the medication on 8/15, for the morning and evening dose, with no documentation as to why. The resident did not receive the medication on 8/20 and 8/21, for the noon dose, with no documentation as to why; -Blood sugar check not completed on 8/6, for the morning time, with no documentation as to why. The blood sugar check not completed on 8/15 and 8/17, for the evening time, with no documentation as to why. The blood sugar check not completed on 8/21, for the morning time, with "no working meters" documented. The blood Missouri Department of Health and Senior Services STATE FORM oe QZTE11 If continuation sheet 14 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 sugar check not completed on 8/27, for the morning time, with "not given" documented; -Breo Ellipta not administered to the resident on 8/9, with "not here" documented. The resident did not receive the medication on 8/15, with no documentation as to why; -Butenafine not administered to the resident on 8/15, with no documentation as to why; -Carvedilol not administered to the resident on 8/3, for the evening dose, with no documentation as to why. The resident did not receive the medication on 8/6, 8/12, 8/20, 8/21 and 8/27, for the evening dose, with no documentation as to why; -Clotrimazole not administered to the resident on 8/3, 8/6, 8/10 and 8/12, for the evening dose, with no documentation as to why. The resident did not receive the medication on 8/13, for the evening dose, with "not on hand" documented. The resident did not receive the medication on 8/15, 8/20 and 8/21, for the evening dose, with no documentation as to why; -Fluticasone not administered to the resident on 8/15, with no documentation as to why; -Furosemide not administered to the resident on 8/15, for both the morning and evening dose, with no documentation as to why; -Humalog not administered to the resident on 8/6, for the morning dose, with no documentation as to why. The resident did not receive the medication on 8/15 and 8/17, for the evening dose, with no documentation as to why. The resident did not receive the medication on 8/21, for the morning dose, with no documentation as to why; -Jardiance not administered to the resident on 8/15, with no documentation as to why; -Oyster shell not administered to the resident on 8/15, for the evening dose, with no documentation as to why; Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 15 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 -Potassium chloride not administered to the resident on 8/15, with no documentation as to why; -Triamcinolone not administered to the resident for the morning and evening dose on 8/15, with no documentation as to why; -Vitamin B-12 not administered to the resident on 8/15, with no documentation as to why. Review of the resident's POS dated 9/2025, showed the following: -Atorvastatin, 10 mg. Give one tablet by mouth one time daily; -Blood sugar checks. Check and record blood glucose two times daily before breakfast and dinner; -Carvedilol, 3.125 mg. Give on tablet by mouth two times daily with meals; -Clotrimazole, 1%. Apply topically to affected area two times daily; -Humalog, 100 milliliters. Injected 5 units two times daily before breakfast and dinner if, blood glucose is greater than 200. If blood glucose is less than 200, hold. Review of the resident's MAR dated 9/2025, showed the following: -Allopurinol not administered to the resident on 9/18, with no documentation as to why; -Blood sugar checks not completed on 8/21, for the evening time and on 8/23, for the morning time, with no documentation why; -Carvedilol not administered to the resident on 9/14, with no documentation as to why; -Clotrimazole not administered to the resident on 9/14, with no documentation as to why; -Humalog not administered to the resident on 9/21, for the evening dose and 9/23 for the morning dose, with no documentation as to why. Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 21 PRINTED: 10/15/2025 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 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 16 3. Review of Resident #15's medical record, showed the facility admitted the resident on 5/11/24, with diagnoses which included high blood pressure and hyperlipidemia (too many lipids in the blood). Review of the resident's POS dated 6/2025, showed the following: -Eliquis (a blood thinner), 5 mg. Give one tablet by mouth two times daily; -Fluticasone (used to treat allergies), 50 mcg. Use two sprays in each nostril daily; -Hydrochlorothiazide (used to treat high blood pressure), 25 mg. Give 1/2 a tablet (12.5 mg) by mouth one time daily; -Loratadine (used to treat allergies), 10 mg. Give one tablet by mouth one time daily; -Losartan (used to treat high blood pressure), 50 mg. Give one tablet by mouth one time daily; -Vitamin D-3, 5000 unit. Give one capsule by mouth one time daily. Review of the resident's MAR dated 6/2025, showed the following: -Eliquis not administered to the resident on 6/2, for the afternoon dose, with no documentation as to why; -Fluticasone not administered to the resident on 6/2 and 6/9, with no documentation as to why. The resident did not receive the medication on 6/11, with "not available" documented; -Hydrochlorothiazide not administered to the resident on 6/2, for the evening dose, 6/7-6/9 for the morning dose, and on 6/13, for the morning dose, with no documentation as to why; -Loratadine not administered to the resident on 6/2 for the evening dose and on 6/9, for the morning dose, with no documentation as to why; -Losartan not administered to the resident on 6/2, for the evening dose, 6/7-6/9 for the morning Missouri Department of Health and Senior Services STATE FORM oe QZTE11 If continuation sheet 17 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 dose and on 6/13, for the morning dose, with no documentation as to why; -Vitamin D-3 not administered to the resident on 6/2, for the evening dose and on 6/9, for the morning dose, with no documentation as to why. 4. During an interview on 9/26/25 at 3:55 P.M., the Regional Director of Nursing said if there was a blank in the resident's MAR, it was safe to say the resident did not get their medication. She said she expected the staff to document a reason why the resident did not receive the medication and then follow up with the resident's Physician to let them know, as well as document that conversation with the Physician. She said she expected the staff to pass the medications following Physician's orders appropriately. She said there should not be blanks in the resident's MARs. 5. During an interview on 9/26/25 at 3:57 P.M., the Administrator said she was not aware there were blanks in some resident's MARs. She said the staff should have documented something on the resident's MAR and she expected the staff to contact the resident's Physician and let them know the medication was not administered. She said the conversation with the Physician should be documented in the resident's medical record as well. She said there should not be blanks in the resident's MARs. *The higher the classification merited due to the extent of the violation. M0O00257918 M0O00256025 Missouri Department of Health and Senior Services STATE FORM 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 18 of 21 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 19 CSR 30-87.020(11) No Deodorizers/Sprays to Eliminate Odors Deodorizers or sprays shall not be used to cover up odors. Odors shall be eliminated to the source by prompt cleaning of bedpans and commodes, floors, furniture and equipment and by proper ventilation. II/III This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to eliminate odors at the source when an extremely strong urine odor was present through half of a hallway, in the elevator and in a resident's room. The odor was so strong it offended other residents. The census was 69. Observation on 9/26/25 between 6:30 A.M. and 7:30 A.M. and between 11:00 A.M. and 12:00 P.M., in the back of the dining room, near the elevator, showed an extremely strong urine odor present. The odor came from Resident #16. The resident was dressed in dirty clothes and his/her hair was greasy and matted. The resident's legs were exposed and were covered with layers and dry flaky skin. At 11:00 A.M., the resident was The resident was still dressed in the same dirty clothes. A strong urine smell permeated around the area the resident sat. During an interview on 9/26/25 at 12:35 P.M., Resident #13 said he/she smelled the urine odor in the dining room, and it offended him/her. He/she said the odor comes and goes and when he/she smelled it, he/she thought "ugh" and the resident proceeded to shake his/her head. The resident sat at the table directly across from Missouri Department of Health and Senior Services STATE FORM seated back at the same table in the dining room. 6899 QZTE11 PRINTED: 10/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 19 of 21 PRINTED: 10/15/2025 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 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 19 Resident #16's table. Observation on 9/26/25 between 7:14 A.M. and 4:00 P.M., of the third floor between resident rooms 309 and 319, showed an extremely strong urine odor was present and permeated throughout the hallway. The urine odor became unbearable the closer the Regulatory Auditor got to resident room 319. Observation on 9/26/25 at 12:22 P.M., in resident room 319, near the third floor elevator, showed a heavy urine odor inside the resident's room. Upon entrance to the resident's room, the odor was so strong, it burnt the Regulatory Auditor's nose. When the Regulatory Auditor opened the resident's bathroom door, she had to hold her breath because the urine odor was breathtaking. During an interview on 9/26/25 at 2:25 P.M., Resident #10 said he/she smelled the odors on and near the elevator multiple times a day. He/she said the odor was "very offensive." During an interview on 9/26/25 at 2:34 P.M., Resident #11 said he/she did not leave his/her room that much, but when he/she did leave the room, he/she noticed a urine odor. He/she said, "it's not clean back by the elevator." The resident said he/she did not go to the dining room that often, but when he/she did, he/she smelled the urine odor there too. The resident resided on the third floor, near room 319. During an interview on 9/26/25 at 3:35 P.M., Resident #14 said he/she smelled the urine odor all over the facility but mainly on the third floor and inside the elevators. He/she said the odor was "a little offensive." Missouri Department of Health and Senior Services STATE FORM oe QZTE11 If continuation sheet 20 of 21 PRINTED: 10/15/2025 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 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 20 During an interview on 9/26/25 at 4:03 P.M., the Regional Director of Nursing said she knew there was an odor coming from Resident #16, but did not know the odor was strong enough to be affecting other residents at this point. During an interview on 9/26/25 at 4:02 P.M., the Administrator said she knew there was an odor coming from Resident #16, who refused any care from the staff and refused showers most days. She was not aware the odor had gotten so bad, to the point it was affecting other residents. *The higher classification merited due to the extent of the violation. M0O00257918 Missouri Department of Health and Senior Services STATE FORM oe QZTE11 If continuation sheet 21 of 21 PLAN OF CORRECTION Provider/Supplier St. Louis Hills Assisted Living and Memory Care Name: Street Address, City, Zip: 6543 Chippewa Street, St. Louis, MO 63109 Date of Survey: 09/26/2025 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 SUBSTANTIALLY CONSTRUCTED & MAINTAINED -The Executive Director has conducted a walk through 10/21 and 10/22 to identify areas of concern. ~The Maintenance team will ensure there are no missing ceiling tiles throughout the community, and all damaged tiles be replaced. e An audit will be completed 2x weekly by ED to ensure completion by 11/10/25 and 1x weekly thereafter for maintenance. -All internal doors will be cleaned and painted so there is no chipped paint or visible wood. Any visible cracks in the wails will A3201 19 be assessed, then filled and new paint applied. All missing or damaged thresholds will be replaced. CSR 30- ra 86.032 * An audit will be completed 2x weekly by ED to ensure completion by 11/10/25 and 1x weekly thereafter for maintenance. e The Director of Maintenance or designee will continue to do semi-monthly inspections of interior walls, interior doors, floors, etc. to ensure the community is being maintained properly. - All doors will be inspected for proper functioning, including lock and latch working appropriately, e =©Any doors not working properly will be repaired by 11/10/25, - The Executive Director or designee will do monthly inspections of interior landscape to ensure the building is maintained and safe for staff and residents. 11/30/25 ROOMS NEAT, ORDERLY, CLEANED DAILY oso. -On 10/17/25, meeting held with housekeeping team to discuss the daily housekeeping schedule and review of housekeeping 86.032 : ; cleaning checklist. -Each housekeeper will be individually trained on the proper way to clean resident rooms. 11/30/25 -At scheduled All Staff meeting on 10/27/25, caregivers will be educated on daily room touches to include trash pick up, incontinence accident clean ups, and picking clothing up off the floor as a daily task. - ED or designee will complete audit of 4 rooms 2x weekly to ensure rooms are being cleaned properly and as scheduled. A4777 19 CSR 30- 86.047 PROPER CARE PER INDIVIDUAL SERVICE PLAN -DON or designee will ensure that all residents have a current Individual Service Pian developed, outlining residents’ current needs and preferences by 10/31/25. -Ail community staff will be in-serviced on what an Individualized Service Plan is, expectations of care to be completed per ISP, and when and how to document refusals of care. -DON or designee will conduct at least 2 weekly spot checks of care and document findings and provide education when needed. -DON and/or designee will conduct 3 ISP audits weekly for 8 weeks then 1 ISP audit weekly ongoing. A4798 19 CSR 30- 86.047 11/30/25 PHYSICIANS ORDERS FOLLOWED - DON and Regional Director of Compliance will in-service ail staff licensed to administer medications on proper medication administration and the importance of following physician's orders by 11/30/25. - DON or designee will observe 1 medication pass weekly for 8 weeks, - DON or designee ongoing will observe 2 med pass monthly, staff will be educated as needed documentation of observations and training will be completed and provided for review. -DON or designee will review medication exception report and passed medication report 3x weekly for 8 weeks and 1x weekly ongoing. A6011 19 CSR 30- 87.020 NO DEODORIZERS/SPRAYS TO ELIMINATE ODORS -All unapproved deodorizers and sprays will be eliminated from the building by 10/24/25. - All staff will be in-serviced on proper protocol on the cleaning of odors or source of odors by 10/27/25. -ED or designee will complete audit of 4 rooms and 1 common area 2x weekly to ensure the absence of odors. 11/30/25 41/30/25 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. AOL 8 oe Coane lO - 73-2 PRINTED: 01/30/2026 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 R-C B, WING 01/43/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 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) ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA Free of Obstructions Exits, Stairways, and Fire Escapes. (G) All stairways and corridors shail be easily negotiable and shall be maintained free of obstructions. If This regulation is not met as evidenced by: Based on observation and interview, the facility falled to ensure the areas of refuge were easily 1/14/26 Inspected all AOF/stairwells/ corridors/pathways — | 2/17/2026 negotiable and maintained free of obstructions, for any items when medical equipment, desks, large pieces of 1/20/26 Signs posted in all AOR stating “no storage drywall, resident furniture, and office equipment llowed" were stored within the space. The census was 70, 1/20/26 all AOR cleared 2/17/26 All staff education will be educated about storage 19 CSR 30-86.045(2\(A) Area of refuge- A space in AOR jocated in or immediately adjacent to a path of travel leading to an exit that is protected from the ax weekly for 4 weeks and weekly after- audits will be ffacts of fire, either by means of separation from completed by Maintenance Director or designee to ensure no e , y sas pi . items are stored in AOF other spaces in the same building or its location, permitting a delay in evacuation. An area of refuge may be temporarily used as a staging area that provides some relative safety to its occupants while potential emergencies are assessed, decisions are made, and evacuation has begun. 1. Observations on 01/06/26 between 10:00 A.M. and 4:00 P.M., of the second floor area of refuge, on the right side, showed the foilowing: -A broom; ~Four dining room chairs; -Part of a metal scale; -A briefcase; -Two lamps; -A large Route 66 picture; -A glass vase; -A black trash can. Missouri Department of Heatth and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6} DATE Dicector o€ Operc STATE FORM 6898 QZTE12 if conlinuation sheet 1 of 12 PRINTED: 01/30/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X71) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION JDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 07594 8. WING 04/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA | ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA SAINT LOUIS, MO 63108 | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION {x5} i (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE ' REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE : DEFICIENCY) Continued From page 1 2, Observations on 01/06/26 between 10:15 A.M. and 4:00 P.M., of the fourth floor area of refuge, on the right side, showed the following: -A black trash can; ~An aloe plant; -A broom and dust pan; ~A headboard of a bed; ~A baseboard of a bed; -A woaden top, black metal desk; -A mechanical lift; -A pair of white slippers; ~Two wheeichairs, 3. Observations on 01/06/26 between 10:24 A.M. and 4:00 P.M., of the fifth floor area of refuge, on the right side, showed the following: -A vacuum; -A stepstool; -A rollator; -A wheelchair; -A galt-belt; -Six very large pieces of drywall: -A sit-fo-stand lift; ~The top part of an air conditioning unit; -A lamp. 4, Observations on 01/06/26 between 10:07 A.M. and 4:00 P.M., of the third floor area of refuge, on the right side, showed the following: ~Two computer routers; -An exit sign in the corner of the room. and 4:00 P.M., of the seventh floor south area of refuge, showed the following: -A piano and bench; -A bowling set; -A dining table; -Two wheelchairs; -Three walkers; Missouri Department of Health and Senlor Services STATE FORM bae8 QZTE12 If continuatlon sheet 2 of 42 | 5. Observations on 01/06/26 between 1:56 P.M. i Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X4} PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: _. B. WING 6543 CHIPPEWA SAINT LOUIS, MO 63109 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 -A pile of clothes and blankets; -A box of disposable briefs; -One dining chair. 6. Observations on 01/06/26 between 2:03 P.M, and 4:00 P.M., of the sixth floor south area of refuge, showed the following: -A folding table; ~Two chairs; -One easel; ~One hat rack, 7. Observations on 01/06/26 between 11:10 A.M. and 4:00 P.M., of the third floor south area of refuge, showed two dining chairs. 8. During interviews on 01/13/26 at 10:20 A.M. and on 01/27/26 at 12:04 P.M., the Director of Administration said the staff should not be storing items in the areas of refuge. She said the drywall should be stored in the maintenance room. She said staff usually stored things in the vacant licensed resident rooms which were currently under renovation. During an interview on 01/13/26 at 10:24 A.M., the Administrator said the items stored in the areas of refuge should be stored in a storage room. She said a lot of it probably had to do with the building being six floors, and it was easier for staff to store things in the areas of refuge. She said she needed to let the staff know why it was important to keep the areas clear, for things like emergencies. {A3201}) 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed Missouri Department of Health and Senior Services STATE FORM {A3201} QZTE12 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION PRINTED: 04/30/2026 FORM APPROVED (x3) DATE SURVEY COMPLETED R-C 01/13/2026 (x5) {EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ff continuation sheet 3 of 42 PRINTED; 01/30/2026 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 R-C B. WING 01/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION 5) 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) ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA {A3201}| Continued From page 3 {A32014} and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. H/III | This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, please refer to the Statement of | Deficiencies dated 09/26/25. Class H* Based on observation and interview, the facility failed to ensure all areas of the facility were maintained in good repair when several baseboards, walls, and doors were damaged with various sizes of scuff marks and multiple ceiling tiles had water damage and/or were missing. The census was 70. 4, Observations on 01/06/26 between 1:32 P.M. and 4:00 P.M., of resident room 315, showed the following: -Inside the bathroom: 1/14/26 full community walk through was completed by -The inside of the toilet bow! was rusted and aintenance and ED designee encrusted; -The ceiling in the front left corner, above the shower, the ceiling material was ripped and hanging down, which exposed pipes and wires. Weekly maintenance rounds will be completed by ED and The area measured approximately 3 feet long; Director of Maintenance or designees i -In the shower, on the back left ledge, which attached to the wall, covered with orange rust. The area measured 1 foot long; ~The kitchenette sink and counter top were removed, which exposed the plumbing underneath. The kitchenette and counter top sink were placed in the shower. 1/14/26 Maintenance work order book placed at the front desk 2/17/26 all staff education will be completed about the work! order process ! Observations on 01/06/26 between 12:00 P.M. and 4:00 P.M., of resident room 514, showed the following: Missouri Department of Health and Senior Services STATE FORM 6993 QZTE12 If continuation sheat 4 of 12 PRINTED: 01/30/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C B. WING 01/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA {43201} | Continued From page 4 {A3201} -Asign on the door which read, “under major reconstruction"; -The carpet in front of the sink covered with a large black area, which measured approximately 2 feet long and 1 foot wide; -The cabinet doors of the sink were completely covered in dried, red dots; -There was a hole in the wall to the left of the sink which measured approximately 1 foot long and 6 inches wide; -The alr conditioning unit was torn apart which exposed several wires. During an interview on 01/13/26 at 10:08 A.M., the Director of Administration said there should not be a hole in the ceiling in room 315. She said since resident rooms 315 and 514 were not in use, it was not a top priority. During an interview on 1/13/26 at 10:10 A.M., the Administrator said there shoutd not be a hole in the ceiling in room 315. She said resident rooms 315 and 514 were not the biggest priority because they were vacant rooms. Room 5714 has been under construction for a few months. 2. Observations on 01/06/26 between 1:33 P.M. and 4:00 P.M., showed the bottom of the door of resident rooms 409, 417, and 419, covered in black scuff marks. The scuff marks were deep and exposed the light colored woad of the door. Observations on 01/06/26 between 10:20 A.M. and 4:00 P.M., of the back of the dining reom, showed one ceiling tile with a large area of water damage. The area was brown in color, Observations on 01/06/26 between 11:00 A.M. and 4:00 P.M., of the basement near the therapy center room, showed two ceiling tiles missing Missouri Department of Health and Senior Services STATE FORM esea QZTE12 if continuation sheet 5 of 12 PRINTED: 07/30/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) BATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED R-C B. WING 04/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, Z1P CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA {A3201} | Continued From page 5 {A3201} which exposed the piping above and five other ceiling tiles covered in water damage which were dark brown in color and circle shaped. Observations on 01/06/26 between 11:10 A.M. and 4:00 P.M., in the basement by the stairs, showed the ceiling tiles near the sprinkler head, covered with water damage which was light brown in color and circle shaped. Observations on 01/06/26 between 1:28 P.M, and 4:00 P.M., of the second floor, showed one broken ceiling tile, above resident room 209. During an interview on 01/13/26 at 10:08 A.M., the Director of Administration said she did not know which part of the ceiling the Regulatory Auditors fooked at, but there was a flood on the fourth floor and a lot of the ceiling tiles were on back order. She was not aware of the ceiling tiles on the second floor or in the basement. During an interview on 1/13/26 at 10:10 A.M., the Administrator said she was not aware of the ceiling tiles having water damage. She did not know why the baseboards and doors were not fixed after the first visit. 3, Observations on 01/06/26 between 11:30 A.M. and 4:00 P.M., of the women's bathroom in the basement, showed the automatic faucet was connected but did not turn on when the sensor was triggered. During an interview on 01/06/26 at 3:45 P.M., Physical Therapist F said the faucet had been like that for over a month and he/she had to use the men's bathroom to wash his/her hands. He/she thought the management team knew the faucet was broken. Missouri Department of Health and Senior Services STATE FORM Bea QZTE12 If continuation sheet 6 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER {X2} MULTIPLE CONSTRUCTION A, BUILDING: PRINTED; 01/30/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C B. WING 01/13/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A3201} | Continued From page 6 *The higher the classification merited due to the extent of the violation. 19 CSR 30-86,032(23} Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. WU This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated 09/26/25. Class |I* Based on observation and interview, the facility failed to ensure resident rooms were kept clean and orderly when resident rooms were found with dried feces and urine, thick layers of dust, and debris under beds and in walkways. The census was 70. 4. Observations on 01/06/26 between 11:45 A.M. and 4:00 P.M., of resident room 319, showed the following: -Small black specs on the floor covering an area of approximately 3 feet wide from the side of the bed to the bathroom; -Dried feces in the base of the toilet in the bathroom; -Streaks of a yellowish film on the base of the step to the walk in shower in the bathroom; -Streaks of a yellowish build up in the bottom corners of the shower In the bathroom; -Black discoloration to the base of the sink cabinet, approximately 2 inches high, surrounding the base of the cabinet at the floor fine in the Missouri Deparment of Heaith and Senior Services STATE FORM cosa QZTE12 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD &E COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A3201} {A3224} 2/13/26 Whole house audit will be completed for leantiness 3/1/26 2/16/26 Education with housekeeping staff on ousekeeping schedule and expectations 2/17/26 All staff education will be completed on overall expectations for daily housekeeping needs 2/27/26 2. new housekeepers hired 2/27/26 Residents education will be completed on reporting housekeeping needs Weekly housekeeping audit will be completed by ED or esignee on 5 resident room and common areas if continuation sheet 7 of 12 PRINTED: 01/30/2026 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 R-C B. WING 01/43/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA | SAINT LOUIS, MO 63109 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 5) 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) | | i {A3224} | Continued From page 7 {A3224} bathroom; i -Dark yellow stains surrounding the base of the sink cabinet, approximately 4 inches wide, on the floor in the bathroom; ~Built up black substance in the corner, at the i back of the sink base cabinet on the wall in the bathroom. 2. Observations on 01/06/26 between 9:54 A.M. and 3:53 P.M., of resident room 419, showed the following: -In the bedroom: -Five empty soda cans on the counter; -Three used plates in the sink; -The floor around the kitchen sink and underneath the bed covered in dust, hair, food crumbs and white fuzz; -Between 1:00 P.M. and 3:53 P.M., the lunch meal tray was placed on the counter; -In the bathroom: -In the left side of the toilet bowl, a quarter size piece of feces; -The toilet bowl was covered in a splashed brown substance; -The toilet lid covered brown and yellow streaks; -On the floor around the toilet and in front of It, several spots of a dried yellow substance covered the area, During an interview on 01/06/26 at 10:01 A.M., the resident said it bothered him/her to use the toilet when it looked like that. He/she said the Housekeepers had not cleaned his/her room ina couple weeks at least. 3. Observations on 01/06/26 between 8:12 A.M. and 3:45 P.M., of resident room 412, showed the following: -Inside the bedroom: Missouri Department of Health and Senior Services STATE FORM 6808 QZTE12 If continuation sheet 8 of 12 § J Misscuri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 07594 NAME OF PROVIDER OR SUPPLIER {X2) MULTIPLE CONSTRUCTION A, BUILDING: . B, WING PRINTED: 01/30/2026 FORM APPROVED (X3} DATE SURVEY COMPLETED R-C 01/13/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (x4) ID SUMMARY STATEMENT GF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A3224} | Continued From page 8 -Several soda cans covered the windowsill; -The kitchen sink covered in dried brown liquid; -Inside the bathroom: -The toilet seat, lid, bow!, and the base of the toilet, completely covered in a dried yellow substance; -The floor around the toilet, covered in a dried, crusty, yellow substance; -Inside the tollet bowl, on the sides, several areas of dried feces; -The entire floor covered in ripped pieces of toilet paper and paper towels; -The sink completely covered in hair. During an interview on 01/06/26 at 8:15 A.M., the resident said the bathroom had been in the condition it was in for a while. He/she said it bothered him/her to use the restroom in the condition it was in. He/she said the Housekeepers did not want to come into his/her room and clean it. The resident said his/her bedroom and bathroom are “the worst" on the weekends when the Housekeepers do not come into his/her room. 4. Observations on 1/6/26 between 9:30 A.M. and 3:52 P.M., of combined resident rooms 404 and 406, showed the following: -In the bedroom: -Underneath the bed, the floor, covered in a thick fayer of dust, pieces of paper, hair and food crumbs; -The television stand covered in dust; -The kitchen sink filled with dirty dishes; -Inside the bathroom: ~The bathroom floor around the toilet, covered in black and brown dried splashes; -Inside of the toilet bowl, on the seat and lid were covered in a dried, brown substance, Missouri Department of Health and Sentor Services STATE FORM 6098 QZTE12 ID PROVIDER'S PLAN OF CORRECTION 8) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A3224} If continuation sheet 9 of 12 PRINTED: 01/30/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 07594 B. WING 01/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA {A3224} | Continued From page 9 {A3224} During an interview on 01/06/26 at 9:37 A.M., a resident said it had been a while since the Housekeepers had come to the room. The resident said he/she would like the Housekeepers to come more often than they do. During an interview on 1/6/26 at 9:40 A.M., another resident said he/she thought the Housekeepers did not come into his/her room often enough and said the bathroom's condition bothered him/her when he/she used it. During an interview on 01/06/26 at 9:34 A.M., the residents‘ family member said the room usually looked like that and he/she wished it was cleaner for his/her family members. 5. Observations on 01/06/26 between 1:34 P.M. and 4:00 P.M., of resident room 417, showed the following: -Smail scraps of paper across the floor near the bed and chairs; | -Cat litter on the floor under the kitchenette sink by the front door of the recom. | During an interview on 01/6/26 at 1:35 P.M., the resident said he/she would like more help with cleaning his/her room and asked to have someone came in to help him/her clean. He/she said it had been quite some time since anyone had been in to clean his/her room. 6. Observations on 01/06/26 between 1:20 P.M. | and 3:56 P.M., of resident room 513, showed the following: -In the bedroom: ~Behind the recliner, the floor covered in a thick layer of dust; ~The trash can was full, and overflow laid on Missourl Department of Health and Senior Services STATE FORM 6898 QZTE12 If continuation sheat 10 of 12 PRINTED: 01/30/2026 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 R-C B. WING 04/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (X4}1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTICN SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA { j } i {A3224} | Cantinued From page 10 {A3224} the floor next to the trash can; -in the bathroom: -The toilet bow! covered in brown spots, both dried and wet; -The toilet seat covered in dried brown spots. During an interview on 1/6/26 at 2:16 P.M., the resident said his/her significant other had "raised hell" multiple times to the staff about the condition of his/her room and the staff started fo clean it and then would stop again. The resident said the last time his/her significant other "raised hell" was on Thanksgiving. 7, Observations on 01/06/26 between 9:39 A.M. and 4:00 P.M., of resident room 214, showed urine stains on the floor of the bathroom around the base of the toilet between the commode and sink base, 8. Observation on 01/06/26 at 9:00 A.M., of resident room 204, showed the the kitchen counter covered in to-go containers of various sizes, pieces of paper, and there was plastic wrap around the faucet. 9, Observations on 01/06/26 between 9:40 A.M, and 3:51 P.M., of resident room 415, showed the following: -In the bedroom: -Underneath the television stand, a thick layer of dust; | -On top of the television stand, a layer of dust; ~in the bathroom: -The toilet bow! covered in brown spots; -The toilet lid covered in a dried yellow substance; -The floor around the toilet had small black and brown spots and pieces of toilet paper. Missouri Department of Health and Sentor Services STATE FORM 6899 OQZTEi2 if continuation sheet 11 of 12 PRINTED: 01/30/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIERICLIA (X2} MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 07594 8. WING 01/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA {A3224} | Continued From page 11 {A3224} 10. During an interview on 01/13/26 at 10:11 A.M., the Director of Administration said last week she talked to the Housekeepers about her expectation of cleanliness in the resident rooms. She said as scon a resident would leave for the hospital, the room needed to be deep cleaned, and sheets stripped. During an interview on 01/13/26 at 10:13 A.M., the Administrator said she thought she needed to hire another Housekeeper to ensure the resident roams were clean. She said the rooms were not up to her expectations. She said the building was six floors and there were only three Housekeepers. She said the facility may need more Housekeepers than what they thought. She said it had been a while since she had gone behind a Housekeeper to ensure their work was completed. M0O00260087 *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senlor Services STATE FORM 6598 QZTE12 if continuation sheet 12 of 12 i i

PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY Missouri Department of Health and Senior Services COMPLETED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 03/21/2025 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 NAME OF PROVIDER OR SUPPLIER ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit | stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; _ 2. Atwo- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom | landing of the exit stairway, attendants ' work | area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during | emergency conditions that are located in the area of refuge and conspicuously posted adjoining the | | communication or intercom system; | 4. Asign at the entrance to the room that states " | AREA OF REFUGE IN CASE OF FIRE" and _ displays the international symbol of accessibility; | | 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or | has a fire protection rating of not less than twenty | (20) minutes with smoke seals and positive | latching hardware. These doors shall not be lockable; | 6. Asign conspicuously posted at the bottom of | | the exit stairway with a diagram showing each | location of the areas of refuge; | | 7. Emergency lighting for the area of refuge; and | | 8. The total area of the areas of refuge on a floor | shall equal at least twenty (20) square feet for | | each resident who is blind or requires the use of _a wheelchair or walker housed on the floor. |! (X86) DATE ead PKDI14 TATE FORM If continuation sheet 4 of 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 This regulation is not met as evidenced by: Based on observation and interview, the facility failed to post a sign at the bottom of each exit stairway with a diagram showing each location of the area of refuge. The census was 74. 1. Observation on 3/20/25 between 7:25 A.M. and 4:45 P.M., of the north stairway exit, showed no signs or diagrams posted at the bottom of each of the exit stairwells depicting the locations of the areas of refuge locations for each floor. The area of refuge was at the top of the stairs, for the second through seventh floors, through the exit door. 2. Observation on 3/20/25 between 7:40 A.M. and 4:45 P.M., of the west stairway exit, showed no signs or diagrams posted at the bottom of each of the exit stairwells depicting the locations of the areas of refuge locations for each floor. The area of refuge was at the top of the stairs, for the second through seventh floors, through the exit door. 3. During an interview on 3/20/25 at 3:33 P.M. the Regional Maintenance Supervisor said he was aware the signs needed to be in place but was not aware the signs had been removed and did not know when it had occurred. 4. During an interview on 3/20/25 at 3:50 P.M., the Administrator said she was not aware the diagrams had been removed from the bottom of the stairwell. The Administrator said she was aware of the need for the diagrams and why they were important for the safety of the residents. 19 CSR 30-86.032(2) Substantially Constructed & Maintained Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 2 The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to maintain the building in good repair. This had the potential to affect all residents. The census was 74. 1. Observation on 3/20/25 between 12:25 P.M. and 4:45 P.M., of the fourth floor, showed beige resident room doors 401, 402, 404, 405, 409, 410, 412 and 413, half-way down, covered with various black scuff marks and missing paint which exposed white paint and brown wood underneath. 2. Observation on 3/20/25 between 12:49 P.M. and 4:45 P.M., of the fifth floor, showed the following: -Beige resident room doors 502, 503, 504, 510, 512, 513, 516 and 518, half-way down, covered with various black scuff marks and missing paint which exposed white paint and brown wood underneath; -Resident room door 511, half-way down, covered with dried brown streaks; -A missing ceiling tile near resident room door 512. 3. Observation on 3/20/25 between 8:30 A.M. and 4:45 P.M., of the dining room, showed the following: -Several ceiling tiles covered with water stains; -Near the elevator, a white door that led to the Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 3 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 3 stairs, half-way down, covered with various black scuff marks; -The white door frame of the door to the kitchen, covered with black scuff marks. Above the kitchen door, to the left of the black clock, an approximate 2 foot long crack on the wall. 4. Observation 3/20/25 between 10:35 A.M. and 4:45 P.M., near the front desk, showed the following: -The corners of the white columns, covered with black scuff marks; -Between the bistro and the mailboxes, showed several black threshold sections which connected the carpet and the laminate floor, missing, which exposed threaded carpet; -Near the mailboxes, four ceiling tiles covered with brown water stains; -Half-way down the elevator white door frames, covered with black scuff marks. 5. Observation on 3/20/25 between 8:29 A.M. and 4:45 P.M., of the kitchen, showed the following: -The entrance on the left, near the bottom left corner of the wall, a missing white tile which exposed an approximate 3 inch by 3 inch hole; -Several areas of missing beige paint on the door frame which exposed white and brown paint underneath; -Near the steamer, on the ceiling, an approximate 3 ft by 2 ft white ceiling vent, covered with peeled paint which exposed light gray paint underneath. 6. Observation on 3/20/25 between 10:41 A.M. and 4:45 P.M., of the counselor's office, showed three ceiling tiles covered with extensive brown water stains and one missing ceiling tile which exposed pipes. 7. Observation on 3/20/25 between 10:45 A.M. Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 4 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 4 and 4:45 P.M., in the beauty/barber salon, showed five ceiling tiles covered with brown water stains and one ceiling tile missing which exposed pipes. 8. Observation on 3/20/25 between 10:52 A.M. and 4:45 P.M., of the Administrator's office, showed three ceiling tiles covered with brown water stains. 9. Observation on 3/20/25 between 10:43 A.M. and 4:45 P.M., near the clubroom, showed a ceiling tile covered with brown water stains. 10. Observation on 3/20/25 between 12:15 P.M. and 4:45 P.M., of the hallway behind the counselors office, showed three ceiling tiles covered with brown water stains and one ceiling tile missing which exposed wires. 11. During an interview on 3/20/25 at 1:25 P.M., the Maintenance Regional Director (MRG) and the Maintenance Assistant said a resident flooded their bathroom a couple of weeks ago, by accident and the water leaked down to the bottom floors. He is aware there were missing thresholds. They started peeling and getting caught on resident's wheelchairs, so he decided to pull them up. The Maintenance Assistant said everyday he painted but new scuff marks would appear a few hours later. The MRG said he and his staff do their jobs but they need assistance with support. The MRG said he reached out to the owner about support for dealing with those issues. 12. During an interview on 3/21/25 at 11:35 A.M., the Administrator said she did not know about the scuff marks on the doors, door frames and in the dining room and the missing thresholds. She said Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 5 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 she was aware of the water stained ceiling tiles and missing ceiling tiles. An incident happened where the water line to the sprinkler system was cut which caused the pooling of the water in different areas. *The higher classification merited due to the extent of the violation. 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 This regulation is not met as evidenced by: Based on interview and record review, the facility failed to complete a community based assessment (CBA) semiannually for five of six sampled residents (Residents #3, #6, #1, #5 and 2). The census was 74. 1. Review of Resident #3's medical record, showed the following: -Admit date 2/29/24; -Diagnoses included high blood pressure, Alzheimer's disease, and incontinence; -Most recent semi-annual CBA dated 6/12/24: -No documented semi-annual CBA completed by Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 6 12/12/24. 2. Review of Resident #6's medical record, showed the following: -Admit date 3/25/23; -Diagnoses included high blood pressure and acid reflux; -Most recent semi-annual CBA dated 6/21/24; -No documented semi-annual CBA completed by 12/21/24. 3. Review of Resident #1's medical record, showed the following: -Admit date 3/25/23; -Diagnoses included high blood pressure and atrial fibrillation (irregular heart beat); -Most recent semi-annual CBA dated 6/24/24; -No documented semi-annual CBA completed by 12/24/24. 4. Review of Resident #5's medical record, showed the following: -Admit date 4/12/23; -Diagnoses included high blood pressure and depression; -Most recent semi-annual CBA dated 6/24/24: -No documented semi-annual CBA completed by 12/24/24. 5. Review of Resident #2's medical record, showed the following: -Admit date 3/21/22; -Diagnoses included dementia with Lewy Bodies, muscle weakness and difficulty walking; -Most recent semi-annual CBA dated 7/4/24: -No documented semi-annual CBA completed by 1/4/25. 6. During an interview on 3/21/25 at 11:35 A.M., the Administrator said she was aware the CBA Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 7 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 needed to be done semi-annually or with a change of condition. The Administrator said she has been flooded with things needing to be done and this must have slipped by. 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. I/II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to provide proper care for a resident, as defined in their individualized service plans for one resident who required the use of a CPAP machine when sleeping (Resident #20). The census was 74. Review of Resident #20's medical record, showed: -Admit date 4/20/20; -Diagnoses included congestive heart disease, toxic encephalopathy (brain disease), acute respiratory failure, anxiety, and heart disease congestive heart failure, type two diabetes, obesity, kidney failure and high blood pressure. Review of the resident's ISP dated 2/13/25, showed: -Special Medication Assistance; -Oxygen Assistance; -Goal: Oxygen therapy will be administered as requested or ordered; -Interventions: needs assistance with positioning and applying his/her CPAP machine when he/she is sleeping. Staff need to ensure he/she is Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 8 wearing it while in bed. Review of photos of resident's CPAP machine, showed the following: -Photo #1 of resident's CPAP machine taken by family member on 3/2/25, showed a note which read "when CPAP placed on pt must press button to turn on"; -Photo #2 of resident's CPAP machine taken by family member on 3/2/25, showed the usage report for the last seven days. The usage report indicated zero days used in the past seven days. During an interview on 3/20/25 at 3:50 P.M., Care Giver (CG) N said he/she would put the resident down for bed each night and would help position the CPAP for the resident. CG N said he/she did not think the CPAP required to be manually turned on each night. During an interview on 3/20/25 at 4:59 P.M., Medication Technician (MT) C said he/she did recall seeing the CPAP being used by the resident but could not remember if the CPAP was turned on. During an interview on 3/20/25 at 4:49 P.M., the Administrator said the staff members were informed the resident needed the CPAP at night and were aware of how important it was for the CPAP to be used by the resident. The Administrator was not aware the CPAP was not being turned on when it was in use. M0O00250493 19 CSR 30-86.047(46) Safe & Effective Medication System Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 9 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Il This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to ensure all staff members completed a safe and effective medication pass when Level One Medication Aide (LIMA) A dropped a medication on the floor, picked it up and gave it to a resident and when LIMA A did not watch residents consume their medication before walking away, for two of two observed residents during the morning medication pass (Residents #7 and #8). The census was 74. Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 10 1. Observation on 3/20/25 at 9:45 A.M., of the morning medication pass, showed LIMAA gave Resident #7 his/her medication and walked around the corner and down the hall while the resident sat on the bench by the medication cart. The resident was still taking his/her medication when LIMA A walked down the hall. LIMAA did not watch the resident take his/her medication. While the resident was still taking his/her medication, he/she dropped a small, white pill on the floor and as it bounced, LIMAA came back around the corner and accidentally kicked the pill further across the room. LIMAA picked the pill off the floor, handed it to the resident and the resident consumed the pill. 2. Observation on 3/20/25 at 10:07 A.M., showed LIMAA entered Resident #8's room and gave the resident his/her medication. The resident looked in the medication cup, took out the Benefiber, (used to treat constipation), tablet and placed it on his/her nightstand. LIMAA asked the resident if he/she was going to take the tablet, and the resident said he/she would take it later. LIMAA shrugged and said "okay" and left the room and did not watch the resident take all of his/her medications. 3. During an interview on 3/20/25 at 11:00 A.M., LIMAA said he/she did not remember dropping a pill, accidentally kicking the pill, picking it up and giving it to the resident. He/she said if he/she did do that, it was probably because he/she was nervous. LIMAA said it was not okay to give medication that had been dropped on the floor. 4. During an interview on 3/20/25 at 11:46 A.M., the Director of Clinical Compliance and Success (DCCS) said staff should not give residents Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 11 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 medication that was dropped on the floor. She said LIMAA should have watched the residents consume all medication before walking away. 5. During an interview on 3/20/25 at 12:36 P.M., the Administrator said it was not okay to drop medication on the floor, pick it up and give it to the resident. She said medication dropped on the floor is considered unusable and unusable medication should be destroyed. She said the staff should watch the residents take all of their medication before walking away. 19 CSR 30-86.047(47)(A) Physicians Orders Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to follow physician's orders when staff failed to administer mediation to a resident when the resident's blood glucose fell below 60 for one resident (Resident #20). The facility also failed to follow physician's orders when staff did not administer medication, for four residents (Residents #14, #15, #16 and #17), observed in the morning medication pass, and failed to administer medication within the administration window time for five residents (Residents #13, #12, #11, #9 and #8), observed during the morning medication pass. The facility also failed to follow physician's orders when blanks were Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 12 found in medication administration records (MARs) for two of two reviewed residents (Residents #19 and #5). The census was 74. Review of the facility's "Medication Service" policy dated 9/27/21, showed medications may be given up to one hour before or up to one hour after the prescribed time to accommodate resident schedules unless otherwise indicated by the physician. 1. Review of Resident #20's medical record, showed: -Admit date 4/20/20; -Diagnoses included congestive heart disease, toxic encephalopathy (brain disease), acute respiratory failure, anxiety, and heart disease congestive heart failure, type two diabetes, obesity, kidney failure and high blood pressure. Review of the resident's physician orders sheet (POS) dated 2/12/25, showed an order for Gvoke hypo pen 2 (rescue pen used to treat very low blood sugar) Inject 1 milligram (mg)/.2 milliliters (ml), inject as needed as directed per package instructions for blood glucose less than 60. Review of the resident's blood glucose report for February 2025 showed the following: -On 2/25/25 at 7:55 P.M., blood glucose level 47 mg/dl reading taken by medication technician (MT) C; -On 2/26/25 at 8:26 A.M., blood glucose level 38 mg/dl, reading taken by MT A; -On 2/27/25 at 12:47 A.M., blood glucose level 29 mg/dl, reading taken by MT K. Review of the resident's electronic medication administration record (EMAR) dated February 2025, showed the resident's prescription for Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 13 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 13 Gvoke hypo pen was not administered from the day it was prescribed on 2/12/25 until the resident passed on 2/27/25. During an interview on 3/20/25 at 4:59 P.M., MT C said he/she tested the resident's blood glucose and saw the low reading. The MT said he/she then got the resident a cup of juice and later retested the blood glucose and saw the level was up so he/she did not do anything else. MT C said he/she did not think to notify the Director of Nursing (DON) or hospice of the low blood glucose because the level went back up. MT C said he/she did not know the resident had an order to administer Gvoke if the resident's reading was below 60. MT C said he/she did not recall ever seeing an order for Gvoke. MT C said if there was an order he/she would need to notify the Nurse so he/she could administer the injection. MT C said he/she only used the PRN page of the EMAR when a resident requested one of the PRN medications. During an interview on 3/21/25 at 10:15 A.M., MT A said he/she did not remember testing the blood glucose on the resident but said he/she must have because it was charted. MT A said it is standard procedure to just give the resident some juice or a piece of candy to raise the blood glucose. MT A said when the blood glucose came back up, he/she did not do anything else because it was in the acceptable range. MT A said he/she never reported the low blood sugar to the Nurse or hospice, but did chart it in the resident's chart. MT A said he/she never saw an order for the resident for Gvoke in the EMAR. MT A said if he/she had seen the order, then he/she would have called the Nurse on duty to administer it to the resident. MT A said he/she only used the PRN page of the EMAR when a resident requested Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 14 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 14 one of the PRN medications and he/she did not review it as a part of a normal medication pass. During an interview on 3/20/25 at 12:17 P.M., MT K said the resident's blood glucose was low so he/she gave the resident some juice and retested later. When the retest was done, the blood glucose was up so he/she did not do anything else. MT K said he/she never notified the Nurse or hospice of the low blood sugar. MT K said he/she did not see an order for Gvoke in the EMAR. MT K said he/she only used the PRN page of the EMAR when a resident requested one of the PRN medications. During an interview on 3/20/25 at 4:03 P.M., the Administrator said she was also functioning as the facility DON in February. The Administrator said he/she did not review the glucose report for the resident daily and the staff should have reported the low blood glucose readings to her. The Administrator said he/she was initially unable to locate the prescription for Gvoke in the resident's EMAR by looking at the primary page, which care staff would use to pass medication. The Administrator said the order for Gvoke was located on the PRN page of the EMAR. The Administrator said the staff should be checking the PRN page on the EMAR when passing medications to confirm all medications are being passed but they appear to not be doing this. 2. Review of Resident #14's medical record, showed the facility admitted the resident on 3/30/12, with diagnoses which included Alzheimer's disease, epilepsy (Seizure disorder) and anxiety disorder. Review of the resident's POS dated 3/20/25, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 15 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 15 -Famotidine (used to treat stomach ulcers), 20 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Levetiracetam (used to treat seizures), 750 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Lisinopril (used to treat high blood pressure), 10 mg. Give one tablet by mouth one time daily at 8:00 A.M.; -Memantine, (used to treat memory loss), 28 mg. Give one capsule by mouth one time at 8:00 A.M.; -Metoprolol (used to treat high blood pressure), 100 mg. Give one tablet by mouth daily at 8:00 A.M.; -Preservision capsules (helps reduce the risk of vision loss). Give one capsule by mouth two times daily at 8:00 A.M. and 5:00 P.M. Observation on 3/20/25 at 11:30 A.M., showed LIMA A failed to administer Resident #14's morning medication due to the residents being out of the facility on an outing. 3. Review of Resident #15's medical record, showed the facility admitted the resident on 12/25/24, with diagnoses which included dementia with Lewy Bodies. Dementia with psychosis, diabetes, high blood pressure and depression. Review of the resident's POS dated 3/20/25, showed the following: -Clonazepam (used to control seizures), 0.5 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Furosemide (used to treat high blood pressure), 20 mg. Give one tablet by mouth every other day at 8:00 A.M.; -Levothyroxine (used to treat hypothyroidism, a Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 16 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 16 condition where the thyroid gland does not produce enough thyroid hormone), 88 microgram (mcg). Give on tablet by mouth two times daily with meals at 8:00 A.M. and 5:00 P.M.; -Quetiapine (used to treat depression), 25 mg. Give one tablet by mouth in the morning at 8:00 A.M.; -Rivastigmine (used to treat memory loss), 3 mg. Give one capsule by mouth two times daily at 8:00 A.M. and 5:00 P.M. Observation on 3/20/25 at 11:30 A.M., showed LIMA A failed to administer Resident #15's morning medication due to the residents being out of the facility on an outing. 4. Review of Resident #16's medical record, showed the facility admitted the resident on 1/3/25, with diagnoses which included Alzheimer's disease and rheumatoid arthritis (chronic, inflammatory autoimmune disease that primarily affects the joints). Review of the resident's POS dated 3/20/25, showed the following: -Aspirin (used as a blood thinner), 81 mg. Give one tablet by mouth one time daily at 8:00 A.M.; -Atorvastatin (used to lower cholesterol), 40 mg. Give one tablet by mouth one time daily at 8:00 A.M.; -Duloxetine (used to treat depression), 20 mg. Give one capsule by mouth one time daily at 8:00 A.M.; -Levothyroxine, 100 microgram (mcg). Give one tablet by mouth one time daily at 8:00 A.M; -Losartan (used to treat high blood pressure), 50 mg. Give one tablet by mouth one time daily at 8:00 A.M.: -Metoprolol, 25 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 17 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 17 -Metoprolol, 50 mg. Give one tablet by mouth two times daily with 25 mg to equal 75 mg at 8:00 A.M. and 5:00 P.M. Observation on 3/20/25 at 11:30 A.M., showed LIMAA failed to administer Resident #16's morning medication due to the residents being out of the facility on an outing. 5. Review of Resident #17's medical record, showed the facility admitted the resident on 8/28/18, with diagnoses which included hoarding behavior and depression. Review of the resident's POS dated 3/20/25, showed the following: -Preservision capsule. Give one capsule by mouth one time daily at 8:00 A.M.; -Sertraline (used to treat depression), 100 mg. Give two tablets by mouth one time daily at 8:00 A.M.; -Tylenol, 325 mg. Give two tablets by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Vitamin B-12, 1000 mcg. Give one tablet by mouth one time daily at 8:00 A.M.; -Vitamin D-3. Give one tablet by mouth one time daily at 8:00 A.M. Observation on 3/20/25 at 11:30 A.M., showed LIMAA failed to administer Resident #17's morning medication due to the resident was out of the facility on an outing. 6. Review of Resident #13's medical record, showed the facility admitted the resident on 6/26/23, with diagnoses which included high blood pressure, prostate cancer and urinary incontinence. Review of the resident's POS dated 3/20/25, Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 18 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 18 showed the following: -Eliquis (used to treat blood clots), 5 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Entresto (used to treat chronic heart failure), 24-26 mg. Give on tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Magnesium Oxide (used to treat heartburn), 400 mg. Give two tablets by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Metformin (used to treat diabetes), 500 mg. Give one tablet by mouth two times daily with meals at 8:00 A.M. and 5:00 P.M.; -Methocarbamol (used to treat pain and stiffness), 500 mg. Give 1/2 tablet by mouth three times daily at 8:00 A.M., 5:00 P.M. and 8:00 P.M.; -Pain relief tablet, 500 mg. Give two tablets by mouth every six hours at 8:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M.; -Pregabalin (used to treat nerve pain), 150 mg. Give one capsule by mouth every 12 hours at 8:00 A.M. and 5:00 P.M.. Observation on 3/20/25 at 11:01 A.M., showed LIMA A administered the morning medication to the resident two hours and one minute past the window of administration time. 7. Review of Resident #12's medical record, showed the facility admitted the resident on 5/1/18, with diagnoses which included anxiety, seizure disorder, cognitive impairment, depression, high blood pressure and former poly drug use. Review of the resident's POS dated 3/20/25, showed the following: -Divalproex (used to treat seizures), 250 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 19 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 19 -Docusate sodium (used to treat constipation), 100 mg. Give one capsule by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Ziprasidone (used to treat symptoms of mental disorders), 80 mg. Give one capsule by mouth in the morning with food at 8:00 A.M. Observation on 3/20/25 at 10:52 A.M., showed LIMA A administered the morning medication to the resident one hour and 52 minutes past the window of administration time. 8. Review of Resident #11's medical record, showed the facility admitted the resident on 5/20/24, with diagnoses which included depression, anxiety and osteoporosis (a bone disease that causes a decrease in bone density and strength, making bones more fragile and susceptible to fractures). Review of the resident's POS dated 3/20/25, showed an order for propranolol (used to treat high blood pressure), 10 mg. Give one tablet by mouth daily two times daily at 8:00 A.M. and 5:00 P.M. Observation on 3/20/25 at 10:47 A.M., showed LIMA A administered the morning medication to the resident one hour and 47 minutes past the window of administration time. 9. Review of Resident #9's medical record, showed the facility admitted the resident on 2/22/21, with diagnoses which included bipolar disorder, high blood pressure, anxiety disorder, chronic pain, obesity and constipation. Review of the resident's POS dated 3/20/25, showed the following: -Clonazepam, 0.5 mg. Give one tablet by mouth Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 20 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 20 two times daily at 8:00 A.M. and 5:00 P.M.; -Gabapentin (used to treat pain), 400 mg. Give one capsule by mouth three times daily at 8:00 A.M., 2:00 P.M. and 8:00 P.M.; -Lamotrigine (used to treat epilepsy), 100 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.; -Tramadol (used to treat pain), 50 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M.. Observation on 3/20/25 at 10:34 A.M., showed LIMAA administered the morning medication to the resident one hour and 34 minutes past the window of administration time. 10. Review of Resident #8's medical record, showed the facility admitted the resident on 4/14/23, with diagnoses which included chronic heart failure, high blood pressure and cardiomyopathy (a group of diseases that affect the heart muscle, making it difficult for the heart to pump blood effectively). Review of the resident's POS dated 3/20/25, showed an order for Eliquis, 5 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M. Observation on 3/20/25 at 10:07 A.M., showed LIMAA administered the morning medication to the resident one hour and seven minutes past the window of administration time. 11. Review of Resident #19's medical record, showed the facility admitted the resident on 9/26/24, with diagnoses which included Parkinson's disease, depression, migraine and arthritis. Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 21 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 21 Review of the resident's POS dated 1/1/25, showed the following: -Atorvastatin, 40 mg. Give one tablet by mouth one time daily; -Carbidopa and levodopa (used to treat Parkinson's disease), 25-100 mg. Give 1/2 tablet by mouth three times daily; -Cyclobenzaprine (used to help relax muscles), 10 mg. Give one tablet by mouth at bed time; -Gabapentin, 600 mg. Give one tablet by mouth one time daily; -Preservision. Give one capsule by mouth one time daily; -Propranolol, 80 mg. Give one capsule by mouth one time daily; -Refresh eye drops. Instill one drop into each eye two times daily; -Supplement, vitamin D3. Give one tablet by mouth one time daily; -Venlafaxine (used to treat depression and anxiety), 75 mg. Give one capsule by mouth one time daily. Review of the resident's MAR dated 2/1/25, showed the following: -On 2/7/25, the evening dose of carbidopa and levodopa was not administered to the resident with no documentation as to why; -On 2/20/25, vitamin D3 was not administered to the resident with no documentation as to why; -On 2/21/25, vitamin D3 was not administered to the resident with no documentation as to why; -On 2/28/25, the evening dose of refresh eyes was not administered to the resident with no documentation as to why. Review of the resident's MAR dated 3/1/25, showed the following: -On 3/3/25, the evening dose of carbidopa and levodopa was not administered to the resident Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 22 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 22 with no documentation as to why; -On 3/3/25, cyclobenzaprine was not administered to the resident with no documentation as to why; -On 3/7/25, atorvastatin was not administered to the resident with no documentation as to why; -On 3/7/25, the morning dose of carbidopa and levodopa was not administered to the resident with no documentation as to why; -On 3/7/25, the afternoon dose of carbidopa and levodopa was not administered to the resident with no documentation as to why; -On 3/7/25, gabapentin was not administered to the resident with no documentation as to why; -On 3/7/25, vitamin D3 was not administered to the resident with no documentation as to why; -On 3/10/25, atorvastatin was not administered to the resident with no documentation as to why; -On 3/10/25, the evening dose of carbidopa and levodopa was not administered to the resident with no documentation as to why; -On 3/10/25, gabapentin was not administered to the resident with no documentation as to why; -On 3/10/25, Preservision was not administered to the resident because the resident was out of the facility; -On 3/10/25, the morning dose of refresh eyes was not administered to the resident because the resident was out of the facility; -On 3/12/25, the evening dose of carbidopa and levodopa was not administered to the resident with no documentation as to why; -On 3/12/25, cyclobenzaprine was not administered to the resident with no documentation as to why; -On 3/13/25, atorvastatin was not administered to the resident with no documentation as to why; -On 3/13/25, gabapentin was not administered to the resident with no documentation as to why; -On 3/13/25, Preservision was not administered Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 23 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 23 to the resident because the resident was out of the facility. 12. During an interview on 3/20/25 at 11:00 A.M., LIMAA said passing on two medication carts is hard. He/she said there was not enough time to pass all the resident's medications because sometimes it was "too hard" to "track the resident down" in the facility to administer the resident's medication. LIMA A did not know he/she could not pass medication past the window of administration time. He/she did not know to call the resident's physician and family members when a resident did not get their medication due to them being out of the facility. 13. Review of Resident #5's medical record, showed the facility admitted the resident on 4/12/23, with diagnoses which included high blood pressure, depression, muscle hypertonicity (where muscles remain contracted or stiff for prolonged periods) and stroke. Observation on 3/20/25 at 10:28 A.M., of the fourth floor, near the elevators, showed Certified Medication Technician (CMT) N administer medications to the resident, one hour and 28 minutes late. Review of the resident's Physician orders dated 3/2/25, showed an order for famotidine (used to treat stomach ulcer) tablet 20 mg. Give one tablet by mouth two times daily at 8:00 A.M. and 5:00 P.M. During an interview on 3/20/25 at 1:52 P.M., CMT N said he/she administered the resident's medication late because CMT N was late arriving to work. He/she was supposed to be at work at 7:00 A.M. but did not arrive until 8:00 A.M. and Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 24 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 24 the facility probably did not have anyone to cover for him/her. 14. During an interview on 3/20/25 at 11:46 A.M., the Regional Director of Clinical Compliance and Success said if a medication is ordered for 8:00 A.M., the medication should be given between 7:00 A.M. and 9:00 A.M. She said LIMAA should have let a supervisor, or a Nurse know before passing medication to residents after 9:00 A.M. She said if there are "X's" in the MAR, it means the resident is out of the facility. 15. During an interview on 3/20/25 at 11:30 A.M., the Administrator said there should be a time on all medications and the facility did not use a liberal medication pass. She said LIMAA should not have been passing morning medication out past 9:00 A.M. She said LIMAA should have destroyed the unusable medication, called the resident's physician and their family members and told them the resident did not get their morning medications. She did not know there were blanks in some resident's MARs and that residents went without medications when leaving the facility. *The higher the classification merited due to the extent of the violation. M000251343 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, Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 25 of 36 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 6543 CHIPPEWA ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA SAINT LOUIS, MO 63109 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 25 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) residents or major fraction of twenty-five (25) during the night shift. I/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 1 3 p.m. to 9 p.m. (Evening)* 1 9 p.m. to 7 a.m. (Night)* 1 3-15 3-20 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 II 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 39 of 74 residents who resided in the facility. The census was 74. Review of the facility's list of resident code status’, showed 39 residents with a full code status resided in the facility. Review of the facility's March 2025 schedule, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 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 26 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 26 -On 3/3/25, from 7:00 A.M. to 8:30 A.M. and from 5:00 P.M. to 7:00 P.M., no CPR trained person on shift; -On 3/6/25, from 7:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 3/7/25, from 7:00 A.M. to 8:30 A.M. and from 5:00 P.M. to 7:00 P.M., no CPR trained person on shift; -On 3/12/25, from 7:00 A.M. to 8:30 A.M., no CPR trained person on shift; -On 3/13/25, from 7:00 A.M. to 8:30 A.M. and from 5:00 P.M. to 7:00 P.M., no CPR trained person on shift; -On 3/16/25, from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 3/17/25, from 7:00 A.M. to 8:30 A.M., no CPR trained person on shift; -On 3/18/25, from 7:00 A.M. to 8:30 A.M., no CPR trained person on shift; -On 3/19/25, from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift. During an interview on 3/21/25 at 1:58 P.M., the Director of Clinical Compliance and Success said she did not know there were days without coverage, but she did know the facility needed CPR coverage at all times. During an interview on 3/21/25 at 1:57 P.M., the Administrator said when she first started, she thought there could have been an issue with the CPR coverage according to the schedule and she knew to have CPR coverage at all times. *The higher the classification merited due to the extent of the violation. A6005) 19 CSR 30-87.020(5) Toxic Material Storage Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 27 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 27 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 unlocked areas accessible to residents and in an unlocked cleaning cart, for one of one day of observation. This had the potential to affect all residents. The census was 74. 1. Observation on 3/20/25 between 2:00 P.M. and 3:00 P.M., of resident room 417, in the open closet next to the apartment door, showed two full 19 ounce (0z) spray cans of Lysol. The 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." 2. Observation on 3/20/25 between 7:45 A.M. and 12:25 P.M., of the fourth floor north area of refuge, showed an unlocked cleaning cart containing the following: -One full 12.5 oz spray can of Behold furniture polish. The precautionary statement read, "Caution the intentional missus by deliberately concentrating and inhaling its constants may be Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 28 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 28 harmful or fatal. Avoid contact with eyes."; -Two full 19 oz spray cans of Clorox disinfecting spray. The precautionary statement read, "Hazardous to humans and domestic animals. Causes mild eye irritation. Do not spray in eyes, on skin, or on clothing."; -One full bottle of Goo gone grout and tile cleaner. The precautionary statement read, Caution: Eye irritant, do not swallow. Do not get in eyes, do not get on skin or clothing. Keep out of the reach of children."; -One 1/2 full 19 oz spray can of Radiance furniture polish. The precautionary statement read, "Caution the intentional misuse by deliberately concentrating and inhaling its contents may be harmful or fatal. Avoid contact with eyes."; -One full 32 oz bottle of Liquid Plumr. The precautionary statement read, "Danger: keep out of the reach of children and pets. Injures eyes, skin and mucous membranes on contact. Harmful if swallowed." 3. During an interview on 3/20/25 at 11:30 A.M., the Administrator said cleaning products should always remain locked up and away from residents when not being used. Cleaning carts should always remain locked when being stored and should not be stored in the areas of refuge where residents have access to them. Residents should not have cleaning chemicals stored in their rooms. 19 CSR 30-87.020(28) Backflow Requirements The potable water system shall be installed to preclude the possibility of backflow. Devices shall be installed to protect against backflow and back siphonage at all fixtures and equipment where an Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 29 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 29 air gap at least twice the diameter of the water supply inlet is not provided between the water supply inlet and the fixture 's flood level rim. A hose shall not be attached to a faucet unless a backflow prevention device is installed. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure the ice machine water drainage hose had a gap between the tubing and the drain. The census was 74. Observation on 3/20/25 between 8::55 A.M. and 12:15 P.M., of the kitchen, showed a drainage hose extended out of the back of the ice machine, down the back of the ice machine and into the drain, in the floor. There was no air gap. During an interview on 3/20/25 at 12:20 P.M., the Dining Director said she had only been in her position approximately a month plus there was all new kitchen staff members. She said she was aware there needed to be an air gap but did not know there was no air gap. During an interview on 3/21/25 at 11:30 A.M., the Administrator said she has been in her position since September and she took a walk-through the kitchen but did not extensively look at everything. She was aware an air gap was required but did not know there was no air gap. 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 30 of 36 PRINTED: 04/07/2025 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 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA SAINT LOUIS, MO 63109 (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 HILLS ASSISTED LIVING AND MEMORY CA Continued From page 30 This regulation is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure all kitchen staff wore hairnets properly during preparation and service of food. This had the potential to affect all residents. This census was 74. 1. Observation on 3/20/25 between 7:45 A.M. and 9:30 A.M., of the kitchen, showed Dietary Server F with a ponytail and no hair net, in and out of the kitchen waiting for the cook to plate breakfast food which consisted of hashbrowns, sausage links, toast, eggs and pancakes, then he/she took the plates to the dining room and served the residents. 2. Observation on 3/20/25 between 7:55 A.M. and 9:15 A.M., of the kitchen, showed Dietary Server G with a goatee which was approximately 1-2 inches long and no beard restraint, in and out of the kitchen waiting for the cook to plate breakfast food and then he/she took plates to the dining room and served the residents. 3. Observation on 3/20/25 between 11:35 A.M. and 12:15 P.M., of the kitchen, showed Dietary Server H with beard which measured approximately 4-5 inches and had a bandanna which partially covered his/her beard. Hair from the beard poked out of the top of the bandanna and he/she had to keep adjusting it because the bandanna kept slipping down. 4. During an interview on 3/20/25 at 12:20 P.M., the Dining Director said she did not know kitchen staff who have beards were required to were beard nets. She said they do not have beard nets and she did not think there was a hairnet policy. She was aware staff required hairnets. The Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 If continuation sheet 31 of 36 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 6543 CHIPPEWA SAINT LOUIS, MO 63109 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 31 Dining Director was not sure why all staff did not have one on. 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to ensure all food was properly stored and protected from potential contamination. This had the potential to affect all residents. The census was 74. Observation on 3/20/25 between 8:01 A.M. and Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 (X2) MULTIPLE CONSTRUCTION PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 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 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 32 4:00 P.M., of the kitchen, showed the following: -Under the center preparation (prep) island, inside the cooler, raw chocolate chip cookies, a large container of grated parmesan cheese, a bowl of sliced cucumbers and a bowl of salad mix all sat uncovered and a tray of sliced tomatoes partially covered. The outer edges of the cooler doors, near the screws, covered with black and brown dirt; -On top of the center preparation island, near the steamer, an opened 10 pound (Ib) container of barbeque sauce which read for for best flavor, refrigerate after opening and a 3 1/2 lb carton of instant potatoes, a large bag of tortilla chips and a 5 lb box of biscuit mix uncovered; -An opened 12 ounce (oz) bottle of spicy brown mustard which read refrigerate after opening, sat on top of the steamer; -Underneath the steamer, on the shelf, an opened 32 oz bottle of lemon juice which read refrigerate after opening; -Underneath the grill, an opened 32 oz bottle of lemon juice. During an interview on 3/20/25 at 12:20 P.M., the Dining Director said she was not aware of the uncovered food items inside the cooler underneath the center preparation island. She was aware all food should be covered, labeled and dated. During an interview on 3/21/25 at 11:35 A.M., the Administrator said she did not know there were food items left out and uncovered. She was aware food items were to be covered and dated. *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 33 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (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 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily The food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens shall be cleaned at least once a day, except that this shall not apply to hot oil-cooking equipment and hot oil-filtering systems. The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure the six-burner grill, several rectangular baking trays and cooking utensils were clean. This had the potential to affect all residents. The census was 74. Observation on 3/20/25 between 9:07 A.M. and 4:00 P.M., of the kitchen, showed the following: -Near the oven, a silver, metal, multi-shelf rack with several cooking utensils, covered with dried crusted food debris; -The top of the grill, covered with black, burnt, crusted food and crumbs; -Throughout the kitchen, multiple large, long, silver baking trays, the outside and around the rim, covered with thick, dried, black, burnt, food crust. During an interview on 3/20/25 at 12:20 P.M., the Dining Director said they did a deep clean last Thursday which included the oven, fryer, grill, stove, walls, shelves and scrubbed the floor. The Dining Director said she was not aware the grill, the baking trays or the cooking utensils were dirty. She said staff do not use the grill because none of the meals call for use of the grill. Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 34 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 34 During an interview on 3/21/25 at 11:35 A.M., the Administrator said she was aware food-contact utensils are to be cleaned. She did not know they were not. 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 kept clean when multiple non-food contact surfaces were covered in food debris and sticky substances. The census was 74. Observation on 3/20/25 between 7:35 A.M. and 4:00 P.M., of the kitchen, showed the following: -The two compartment oven handles, covered with grease. Inside and on the bottom of each oven, several areas of black, burnt, dried food debris; -The entire outside of the grill, covered with thick layers of dried grease. The right knob on the grill missing which exposed a silver metal piece and the middle knob was partially broken. The partial middle knob and the knob on the left were sticky to the touch; -The backsplash behind the flat-top, covered with dried black burnt food residue. All three knobs were missing; -The top of the stove, covered with thick, brown and black dried food crumbs. Underneath the stove, near the three grease drip trays, covered with dried, thick, burnt, black food crumbs. Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 35 of 36 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 ST LOUIS HILLS ASSISTED LIVING AND MEMORY CA (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63109 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 35 Underneath the stove, at the top of the oven door, covered with dried black food crumbs. Between the top of the stove and the knobs and surrounding the knobs, covered with thick layers of dust and burnt food residue; -The outside of the deep fryer, covered with thick layers of dried grease; -The right side of the center preparation table, near the steamer, covered with thick layers of dried food residue; -The bottom shelf of the silver metal cart the steamer sat on, covered with food crumbs; -Underneath the flat-top, the bottom shelf, long sliver baking tray lined with beige parchment paper, held several cooking and cleaning utensils. The tray was filled with black and brown dried burnt food crumbs; -The pipes on the right side of the steamer, covered with dried food drippings and dirt; -The handles to the refrigerator, sticky to the touch. During an interview on 3/20/25 at 12:20 P.M., the Dining Director said they did a deep clean last Thursday which included the oven, fryer, grill, stove, walls, shelves and scrubbed the floor. The Dining Director said she was aware some of the appliances needed to be replaced or the burnt black crust needed to be cleaned but she had not reported it yet. She was not aware of the grease surrounding the appliances. The Dining Director said the there was a lot wrong with the kitchen and she has it on a list. During an interview on 3/21/25 at 11:35 A.M., the Administrator said she was aware non-food contact utensils and appliances were to be cleaned. She did not know they were not. Missouri Department of Health and Senior Services STATE FORM 6899 PKDI11 PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6543 CHIPPEWA PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 36 of 36 PLAN OF CORRECTION Bae t an seas St. Louis Hills Assisted Living and Memory Care Street Address, City, Zip: 6543 Chippewa Street, St. Louis Missouri63109 Date of Survey: 03/21/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE AREA OF REFUGE REQUIREMENTS -Director of Maintenance will ensure that there is accurate signage posted at the bottoms of each of the exit stairways with diagrams showing the locations of each Area of Refuge. A2228 19 - Hard plastic magnetic paper covers purchased to ensure CSR30- signage and diagrams remain intact and easily visible to staff 06/01/2025 86.022 and residents. - The Director of Maintenance and maintenance team will conduct daily stairway audits x 1 week then weekly audits x 8 weeks. -The Director of Maintenance will then monitor and document stairway signage monthly while conducting monthly fire alarms. SUBSTANTIALLY CONSTRUCTED & MAINTAINED -The maintenance team has conducted a walk through with the Owner and operations team. The Maintenance team will ensure there are no missing tiles throughout the community, and all damaged tiles be replaced. All internal doors will be cleaned and painted so there is no chipped paint or visible wood. Any visible A3201 19 cracks in the walls will be assessed, then filled and new paint applied. All missing or damaged thresholds will be replaced. CSR 30- : ; - : ; - The Director of Maintenance or designee will continue to do 86.032 : . : aa ee semi-monthly inspections of interior walls, interior doors, floors, etc to ensure the community is being maintained properly. - The Executive Director or designee will do monthly inspections of interior landscape to ensure the building is maintained and safe for staff and residents. COMMUNITY BASED ASSESSMENT- SEMI-ANNUALLY A470 19 | -Audit of all charts completed on 4/11/2025, 49 charts are found CSR 30- . : : 06/01/25 86.047 to be out of compliance. Compliance will be made by 05/01/25 06/01/25 -Executive Director and Regional Compliance Director will conduct at least 5 audits weekly over the course of 8 weeks to ensure all residents have current Community Based Assessments. -Executive Director moving forward will ensure that a Community Based Assessment or designee is completed for every resident upon admission, semi-annually or when a significant change of condition is documented, these assessments will be maintained electronically through Allis. PROPER CARE PER INDIVIDUAL SERVICE PLAN -Executive Director or designee will ensure that all residents have a current Individual Service Plan developed, outlining resident’s current needs and preferences. All community staff will be in-serviced on what an Individualized Service Plan is, expectations of care to be completed per ISP, when and how to document refusal’s of care. -Executive Director or designee will conduct at least 2 weekly spot checks of care and document findings, and provide education when needed. -Executive Director or designee will conduct 5 ISP audits weekly for 8 weeks then 1 ISP audit weekly ongoing. A4777 19 CSR 30- 86.047 06/01/2025 and provided for review. PHYSICIANS ORDERS FOLLOWED -Executive Director will in-service all staff licensed to administer medications on proper medication administration and the importance of following physician’s orders. -Executive Director will complete chart audits and ensure all residents who are insulin dependent have guidelines to follow if resident becomes hypo/hyperglycemic, staff will be in-serviced AAT798 19 on monitoring for s/s of hypo/hyperglycemia. CSR 30- -Regional Compliance Director has met with Guardian 06/01/25 86.047 Pharmacy and will begin the transition to a liberal medication pass time. - Executive Director or designee will observe 1 medication pass weekly for 8 weeks. -Executive Director or designee ongoing will observe 1 medication pass twice monthly, staff will be educated as needed MEDICATION ADMINISTRATION -Executive Director will in-service all staff licensed to administer medications on proper medication administration and the AA797 19 importance of following physician’s orders. CSR 30- -Executive Director or designee will observe 1 medication pass 06/01/25 86.047 weekly for 8 weeks. , -Executive Director or designee ongoing will observe 1 medication pass twice monthly, staff will be educated as needed documentation of observations and training will be completed documentation of observations and training will be completed and provided for review. -Business office Manager or designee will collect CPR certification upon hire if applicable. TOXIC MATERIAL STORAGE -Executive Director will hold an all-staff meeting, all staff members will be in-serviced on poisonous and toxic materials, and storage of chemicals, A005 19 -The Director of Maintenance will make sure there is a space for CSR 30- all housekeeping carts to be kept, this area will be locked and 06/01/2025 87.020 only accessible to staff. -Executive Director will have a move-in ready list for all new admission’s listing what chemicals/cleaning supplies are acceptable to have in apartments. -Executive Director or designee will perform walk through to STAFFING ROTATION, RESIDENT CARE & FIRE SAFETY -Executive Director will ensure that an adequate number of staff are CPR certified, all shifts will have at least 1 person who is A4841 19 an CSR 30- GPS canned. 06/01/2025 86.047 -CPR class is currently scheduled for 04/16/2025 , -Business office Manager or designee will do quarterly audits of at least 10 employee charts to ensure CPR remains active. ensure proper storage of chemicals, audits will be completed daily x 1 week then weekly x 8 weeks, then monthly ongoing. BACKFLOW REQUIREMENTS The Director of Maintenance has installed a hook that the ice machine water drainage hose hangs on so there is a gap A6028 19 between the tubing and the drain to protect against backflow CSR 30- and back siphonage. 06/01/2025 87.020 -The Director of Maintenance or designee will ensure going forward that devices are installed and effective to protect against backflow, - The Director of Maintenance or designee will conduct daily audits x 1 week then weekly ongoing. CLEAN CLOTHING, HAIR RESTRAINTS -The Director of Dining Services has completed an in-service with all dining staff on the use and importance of wearing hair A7003 19 restraints to prevent contamination of food. All other staff outside CSR30- of the dining room staff will be in serviced on the use of hair 06/01/2025 87.030 restraints upon entering the kitchen. -The Director of Dining Services, or designee will perform daily audits x 1 week on at least 2 staff members then 1 staff member weekly going forward rotating between all 3 meals, and will maintain documentation of these audits for review. FOOD-PROTECTED, TEMP, NEED TO CONTACT DHSS A7015 19 -The Director of Dining Services will in-service all Dining staff on the importance of proper food storage to protect against CSR 30- : voc sag : 06/01/2025 87 030 potential contamination that could affect all residents. : - The Director of Dining or designee will ensure weekly audits are completed x 8 weeks showing food is properly stored and dated to prevent any potential contamination. - The Dining Director or designee will complete monthly inspections to ensure all food is stored and dated properly, and education to be provided upon hire, quarterly and as needed. GRILLS/GRIDDLES/MICROWAVES/OTHER CLEAN DAILY -The Director of Dining Services will immediately in-service all dining staff on the importance of ensuring that all food contact surfaces and all cooking equipment be kept free of encrusted grease, deposits and other accumulated soil. Kitchen will be inspection ready on 06/01/2025 -The Director of Dining Services will provide daily cleaning schedules/checklist of all cooking equipment and contact surfaces. Staff will be provided with both weekly and monthly deep cleaning schedules for all food contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens. -Director of Dining Services or designee on-going will complete monthly inspections of cooking equipment and food contact surfaces to ensure compliance of this rule. NONFOOD CONTACT SURFACES, CLEANED AS NEEDED A7066 19 CSR 30- 87.030 06/01/2025 -The Director of Dining Services will in-service all dining staff of cleanliness and the importance of keeping all surfaces free of any food debris or sticky substances. Kitchen will be inspection ready on 06/01/2025 -Director of Dining or designee will create a daily checklist for staff to ensure all non-food contact surfaces are kept cleaned. -Director of Dining Services or designee will complete monthly inspections go forward to ensure compliance of this rule. A7067 19 CSR 30- 87.030 06/01/2025 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.