CHESTNUT GLENN ASSISTED LIVING.

PRINTED: 07/08/2025 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 25446 Se cee 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 (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) CHESTNUT GLENN-ASSISTED LIVING BY AME A4777 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 interview and record review, the facility failed to ensure one resident (Resident #3), of seven sampled residents, received proper care as defined in the Individualized Service Plan (ISP) when staff failed to assess the resident following a fall and failed to assess a bruise of unknown origin. The facility census was 35. Review of the facility undated policy Incident/Accident Report Guidelines showed the following: -All resident incidents should be reported and documented as soon as possible on the | Incident/Accident Report form. The Director of Nursing (DON) conducts a post fall assessment; -When a resident has sustained an injury or is found on the floor presumably from a fall, staff members immediately evaluates the resident for severity of injury; -The DON should be notified; -The DON should direct staff to assure that the resident has appropriate and safe follow up medical care; -The resident's primary care physician should be notified by fax or phone, dependent on the status of the resident; -Family/Power of Attorney should be notified; -The Incident/Accident report form should be thoroughly and legibly completed by the staff member who was first on the scene; -A description of the occurrence should be noted in the resident's record; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE | Eecytiy Iz7)]a5 STATE FORM 6899 K14711 If continuation sheet 1 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 1 -Resident who sustained a confirmed fall should have narrative charting each shift along with vital signs for 72 hours post fall; -A completed report form should be forwarded to the DON; -A post fall assessment should be initiated by the staff member filling out the incident report and then forwarded to the DON for follow up and completion. This assessment form should be placed in the resident's chart. Review of the facility policy Change of Condition dated October 2015 showed the following: -The DON is responsible for completing an evaluation and recognizing and responding to changes in the residents’ condition that my indicate illness or a decline in functional status; -A significant change of status is a decline in a resident's status, physical, emotional or psychosocial condition that does not normally resolve itself without intervention by staff; -Evaluation should be conducted and documented by licensed nursing staff. Observations and concerns should be addressed as needed; -The resident's physician and legal representative should be notified of the condition change. 1. Review of Resident #3's Physician Order Sheet dated 5/8/25 showed the following: -Admitted 5/7/25; -Diagnoses of dementia, chronic obstructive pulmonary disease (COPD, a progressive lung disease which caused increased shortness of breath and typically worsened over time with chronic cough, wheezing and difficulty breathing), and Parkinson's Disease (a progressive disease of the nervous system that affected movement and mobility). Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 2 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 2 Review of the resident's Individual Service Plan (ISP), dated 5/8/25, showed the following: -Alert to person with long term memory loss; -Walked with a walker; -No recent history of falls; -No wounds or bruises; -Special medication awareness included anticoagulant medication (blood thinning medication); -Totally dependent on staff for personal care (bathing, oral care, hair care, shaving, and nail care). Review of the resident's fall risk evaluation, dated 5/12/25, showed the following: -One to two falls in the previous six months; -Cognitive impairment, mental status varied over the course of the day; -Ambulated with a walker; -One to two prescribed medications which potentially affected mobility (antidepressant, antipsychotic and high blood pressure medications); -Fall risk score of 4 indicating low fall risk. Review of the resident's Monthly summary, dated 6/9/25, showed the following: -No change in the resident's functional status; -Ambulated with a walker, with abnormal and unsteady gait; -Skin tear to left elbow on 6/5/25 when staff found the resident on the floor; -No falls. Review of the resident's medical record showed no documentation regarding the resident's fall on 6/5/25 including staff assessment of the resident including the resident's skin tear on the left elbow. Review of the resident's nurses' notes dated Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 3 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 3 6/13/25 showed staff documented the following: -At 1:59 P.M. the Memory Care Director of Nursing (DON) documented a late entry which occurred on 6/8/25. The DON arrived at the facility on 6/8/25 at approximately 8:30 A.M. The resident sat in his/her chair and was talkative. The DON palpated (touched) the resident's right and left sides without any complaints of pain. Staff informed the DON on 6/7/25 the resident had a bruise to his/her side. During an interview on 6/26/25 at 9:40 A.M. Level One Medication Aide (LIMA) A said on 6/8/25 staff noted a large purple bruise on the resident's left upper side below the arm pit area the size of his/her hand with fingers spread open. A raised lump was noted in the bruised area. The resident fell prior to 6/8/25 (unsure of the date but within the three days prior to hospital admission on 6/8/25) in another resident's room, crawled on the floor and staff assisted the resident off the floor. No assessment following the earlier fall was completed and he/she did not document the fall in the resident's medical record or complete a fall incident report. He/She did not notify the DON, family or physician of the earlier fall. LIMAA thought LIMA C completed the assessment and documentation. Staff should assess a resident after a fall for injuries, obtain treatment and notify the DON of the fall. Staff should document the fall in the resident's medical record and complete a fall incident report. During an interview on 6/26/25 at 1:15 P.M. LIMA C said the resident fell on 6/5/25. LIMAC found the resident on the floor crawling with a skin tear to the left elbow. Later the resident said his/her back hurt. LIMA C did not see a bruise on the resident's left chest wall on 6/5/25, the bruise showed up later. LIMA C and LIMAA got the Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 4 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 4 resident off the floor following the 6/5/25 fall. LIMA C did not complete an incident report or document the 6/5/25 fall. The only injury was a skin tear to the left elbow. During an interview on 6/26/25 at 12:30 P.M. Caregiver B said on 6/6/25 the resident had a C-shaped skin tear on his/her left elbow. Caregiver B notified either the administrator or Memory Care DON of the skin tear. During interviews on 6/26/25 at 9:15 A.M. and 11:30 A.M. the Memory Care DON said the following: -She was not aware of any prior falls; -The resident had a bruise to the left side, under the left arm for a couple of days prior to transport to the ER on 6/8/25. The bruise was about the size of a person's hand with unknown cause. She was aware of the bruise and completed no investigation or assessment to determine the cause and no follow up assessments were completed; -Staff must have marked no falls in error on the resident's monthly summary, dated 6/9/25, as the resident had experienced falls; -Staff should assess a resident's condition following a fall, obtain medical treatment as indicated, document the fall in the resident's medical record, complete a fall incident report and notify the DON, family and physician. Staff should assess a bruise or injury of unknown origin immediately and attempt to determine the cause. The DON and staff should have ongoing assessments of any injury and document the assessments in the resident's medical record. During an interview on 6/26/25 at 11:30 A.M. the Administrator said the following: -Staff notified her, on an unknown date, the Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 5 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 5 resident was on the floor on his/her knees prior to the 6/8/25 fall. She asked staff if the resident had use of his/her legs and arms and instructed staff to help the resident up, check vital signs and completed an incident report. She instructed staff to notify the resident's family and physician; -Staff did not assess and document the resident's fall and skin tear and did not assess and document the resident's left chest wall bruise. Staff completed no follow up assessments or incident reports regarding either fall or the bruise; -Staff should have assessed the resident after each fall, assessed the resident's condition and obtained medical treatment. Staff should have documented the assessments and completed incident reports following each fall and following identification of a bruise of unknown origin. Staff should have notified the physician and the family of the resident's falls and left chest wall bruise. During an interview on 7/7/25 at 12:55 P.M. the resident's physician said she was not aware the resident fell 6/5/25 and was not aware the resident had a open hand size bruise on the left chest wall two days prior to the 6/8/25 fall and hospitalization. Staff had not notified her of the fall on 6/5/25 or the left chest wall bruise. She expected staff to monitor a bruise and notify her of the bruise and if the bruise became worse or larger. Staff should notify her of any change in the resident's condition and notify her of any falls or bruise or injury. Staff should assess and monitor the resident following a fall or injury and document the assessments in the resident's medical record. MO 00255520 Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 6 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 6 19 CSR 30-86.047(37) Appropriate Action & Notification In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the person listed in the resident ' s record as the legally authorized representative, designee or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medical examiner immediately upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home. I/II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to notify one resident's (Resident #3's) physician and family in a review of four residents, when the resident sustained a fall with a skin tear to the left elbow and failed to notify the physician and family when staff identified a bruise of unknown origin on the resident's left chest wall. The facility census was 35. Review of the facility undated policy Incident/Accident Report Guidelines showed the following: -All resident incidents should be reported and documented as soon as possible on the Incident/Accident Report form; -The DON should be notified; -The resident's primary care physician should be notified by fax or phone, dependent on the status of the resident; Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 7 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 7 -Family/Power of Attorney should be notified. Review of the facility policy Change of Condition dated October 2015 showed the following: -A significant change of status is a decline in a resident's status, physical, emotional or psychosocial condition that does not normally resolve itself without intervention by staff; -The resident's physician and legal representative should be notified of the condition change. 1. Review of Resident #3's Physician Order Sheet, dated 5/8/25, showed the following: -Admitted 5/7/25; -Diagnoses of dementia, chronic obstructive pulmonary disease (COPD, a progressive lung disease which caused increased shortness of breath and typically worsened over time with chronic cough, wheezing and difficulty breathing), and Parkinson's Disease (a progressive disease of the nervous system that affected movement and mobility). Review of the resident's Monthly summary dated 6/9/25 showed the following: -No change in the resident's functional status; -Ambulated with a walker, with abnormal and unsteady gait: -Skin tear to left elbow on 6/5/25 when staff found the resident on the floor. Review of the resident's medical record showed no documentation the resident fell and no documentation staff notified the resident's physician and family of the resident's fall and skin tear on 6/5/25. Review of the resident's nurses’ notes dated 6/13/25 showed at 1:59 P.M. the Memory Care Director of Nursing (DON) documented a late Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 8 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 8 entry which occurred on 6/8/25. The DON arrived at the facility on 6/8/25 at approximately 8:30 A.M. The resident sat in his/her chair and was talkative. The DON palpated (touched) the resident's right and left sides without any complaints of pain. Staff informed the DON on 6/7/25 the resident had a bruise to his/her side. Review of the resident's medical record showed no documentation staff identified a bruise to the resident's left side, assessed the cause of the bruise or notified the resident's physician or family of the resident's bruise. During an interview on 6/26/25 at 9:40 A.M. Level One Medication Aide (LIMA) A said the resident fell prior to 6/8/25 (unsure of the date but within the three days prior to hospital admission on 6/8/25) in another resident's room, crawled on the floor and staff assisted the resident off the floor. He/She did not notify the DON, family or physician of the earlier fall. Staff should notify the physician and the resident's family of a fall or injury. During an interview on 6/26/25 at 1:15 P.M. LIMA C said the resident fell on 6/5/25. LIMAC found the resident on the floor crawling with a skin tear to the left elbow. Later the resident said his/her back hurt. LIMA C did not see a bruise on the resident's left chest wall on 6/5/25, the bruise showed up later. LIMA C and LIMAA got the resident off the floor following the 6/5/25 fall. Staff should notify the resident's physician and family of a fall or injury. LIMA C thought the Memory Care DON notified the physician and family of falls and injuries. During interviews on 6/26/25 at 9:15 A.M. and 11:30 A.M. the Memory Care DON said the Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 9 of 11 PRINTED: 07/08/2025 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 C 25446 B. WING 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 9 following: -The resident had a bruise to the left side, under the left arm for a couple of days prior to transport to the ER. The bruise was about the size of a person's hand with unknown cause. She did not notify the resident's physician or family of the left chest wall bruise; -Staff should complete a fall incident report and notify the DON, family and physician. Staff should notify the resident's physician and family of any injury or bruise of unknown origin. During an interview on 6/26/25 at 11:30 A.M. the Administrator said the following: -Staff notified her, on unknown date, the resident was on the floor on his/her knees prior to the 6/8/25 fall. She asked staff if the resident had use of his/her legs and arms and instructed staff to help the resident up, check vital signs and complete an incident report. She instructed staff to notify the resident's family and physician; -Staff did not notify the resident's physician or family of the fall, the skin tear or the left chest wall bruise; -Staff should have notified the physician and the family of the resident's falls, skin tear and left chest wall bruise. During an interview on 7/7/25 at 12:55 P.M. the resident's physician said she was not aware the resident fell 6/5/25 and was not aware the resident had a hand print size bruise on the left chest wall two days prior to the 6/8/25 fall and hospitalization. Staff had not notified her of the fall on 6/5/25 or the left chest wall bruise. She expected staff to monitor a bruise and notify her of the bruise and if the bruise became worse or larger. Staff should notify her of any change in the resident's condition and notify her of any falls or bruise or injury. Missouri Department of Health and Senior Services STATE FORM 6899 K14711 If continuation sheet 10 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 25446 B. WING NAME OF PROVIDER OR SUPPLIER 121 KLONDIKE CROSSING CHESTNUT GLENN-ASSISTED LIVING BY AME SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 10 MO00025520 Missouri Department of Health and Senior Services STATE FORM ame K14711 (X2) MULTIPLE CONSTRUCTION CROSS-REFERENCED TO THE APPROPRIATE PRINTED: 07/08/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 06/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 11 of 11 PLAN OF CORRECTION Provider/Supplier Name Chestnut Glen -Assisted Living by Americare Street Address, City, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 25446 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE In response to 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Immediate Action: Regional Nurse Consultant will be provided training on or before 8/01/25 to Memory Care and Director of Nurses, Administrator on the following: 1.) Incident & Accident Reporting Guidelines a. Completing Incident Report b. Types of Incident including Injury of unknown Origin c. Notification to responsible party & Physician d. Updating ISP to include interventions to decrease future risk . Review and or update of Fall Risk Evaluation f. Follow up assessments and documentation 2.) Change of Condition Guidelines a. What constitutes a change in condition b. Notification to responsible party & Physician ORit/aces c. Completing Community Based Assessment with Change of Condition d. Updating ISP to include interventions to decrease future risk/decline e. Review and or update to Risk evaluations f. Follow up assessments and documentation Director of Nursing will provide staff education in-servicing on or before 8/01/2025 on the following items: 1.) Incident & Accident Reporting Guidelines 2.) Entering all Incident Reports in Point Click Care 3.) Documentation on incident in resident progress notes 4) Initial Service Plan & Plan of Care/ISP policy and procedure 5.) Fall Follow Up Protocol 6.) Fall Follow Up-Checkoff Sheet 7.) Change of Condition policy and procedure 121 Klondike Crossing, St. Peters MO 63376 oO A4778 All resident Monthly Summaries reviewed and updated to reflect resident status and needs, Community Based assessment completed on any resident with identified change in condition. All resident ISP reviewed and updated to reflect needs and services required including appropriate interventions to decrease the risk of falls. All residents Fall Risk evaluations reviewed and updated if indicated to reflect residents’ risk for falls. Ongoing Compliance: Director of Nursing will ensure ongoing compliance through reviewing 24-hour communication log during or prior to morning meeting and providing follow up on any and all incidents, accidents and or change in condition. Follow up will include but is not limited to: 1. Physical Assessment of resident is completed when indicated 2. Assuring that all documentation, evaluations, assessments incident report and progress notes are complete 3. Assuring physician was/is notified 4. Notification to responsible party and or legal representative & Physician 5. ISP is updated with appropriate interventions to decrease future risks or decline 6. Review of Community Based Assessment and updated if resident has experienced a change in condition 7. Capturing all incident accidents and or change of condition in Monthly Summary Completion Date: 08/01/2025 In response to 19 CSR 30-86.047(37) Appropriate Action Immediate Action: Regional Nurse Consultant will be provided training on or before 8/01/25 to Memory Care and Director of Nurses, Administrator on the following: 1.) Incident & Accident Reporting Guidelines Completing Incident Report Types of Incident including Injury of unknown Origin Notification to responsible party and or legal representative & Physician Updating ISP to include interventions to decrease future risk Review and or update of Fall Risk Evaluation Follow up assessments and documentation 2.) Change of Condition Guidelines a. What constitutes a change in condition 08/01/2025 Notification to responsible party & Physician Completing Community Based Assessment with Change of Condition d. Updating ISP to include interventions to decrease future risk/decline e. Review and or update to Risk evaluations f. Follow up assessments and documentation Ongoing Compliance: Director of Nursing will ensure ongoing compliance through reviewing 24-hour communication log during or prior to morning meeting and providing follow up on any and all incidents, accidents and or change in condition. Follow up will include but is not limited to: Complete Physical Assessment of Resident Proper Notification to: a. Resident physician b. Resident legal representative/responsible party 3. Completion of Documentation: Incident report Progress Note Risk Evaluations updated Post Fall follow up if indicated Review and updated Community Based Assessment if indicated and or monthly summary f. ISP updated with interventions to decrease future risk 290m Completion Date: 08/01/2025 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.

PRINTED: 08/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2)} MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED 25446 8. WING : 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 CHESTNUT GLENN-ASSISTED LIVING BY AME (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4797 19 CSR 30-86.047(46) Safe & Effective Medication System | The administrator shall develop and Amplement a i safe and effective system of medication contro! 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 ihe resident's physician so authorizes. All | individuals who administer medication shall be | trained in medication administration and, if not a i physician or a licensed nurse, shall be a certified | | | i medication technician or level | medication aide. Wil This regulation is not met as evidenced by: Class il Based on observation, record review, and interview, the facility failed to ensure the implementation of a safe and effective system of medication control and use when a Level One Mscication Aide (LIMA) failed to follow standard nursing procedures in the administration of meaication for three residents (Residents #1, #2, anid #3) of eight residents sampled. The facility Missouri Departrnent of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE Ge Orern Nommdo 0 Frewtive Diractoe — Harfay _ STATE FORM 8899 FHE614 If continuation shest 1 of 8 PRINTED: 08/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 25446 B, WING 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 (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 THEAPPROPRIATE | DATE i DEFICIENCY) i CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 1 census was 29. Review of the Level One Medication Aide student guide revision dated November, 1993, Lesson Plan 12 Unit IV for preparation, administration, and documentation of oral medications showed the following: -Review and verify medication administration records with physician's order according to facility policy; -Organize medications in the order of administration; -Check medication record and remove that container of medication from the bin; -Pour medication into medication cup: -Check medication record and label again; -Continue same procedure until this resident's medications for that time period are prepared; -Identify resident; -Hand medication to resident with a glass of water if needed; ~Report and record essential information. Review of the Level One Medication Aide student guide revision dated November, 1993, Lesson 13 Unit IV for recording and reporting administration | of medication showed the Level One Medication | Aide should administer medications to the proper | resident at the appropriate date, time, and method of administration. 5 i t 1. Review of Resident #1's face sheet showed the following: -Admission date of 8/8/21: -Diagnoses included Parkinson's disease (nervous system disorder characterized by tremors and slowing of movement). Review of the resident's Physician Order Sheets (POS) for July, 2024 showed orders for the | Missouri Department of Health and Senior Services STATE FORM 6899 FHF6141 If continuation sheet 2 of 8 PRINTED: 08/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 25446 B. WING ____. 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID | PROVIDER'S PLAN OF CORRECTION FOxs) 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 = —sDATE | DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME Continued From page 2 following: -Carbidopa-levodopa (medication used to treat Parkinson's disease), 25-100 mg (milligrams), two tablets by mouth daily at breakfast, afternoon, | and bedtime; | -Mirapex (used to treat Parkinson's disease), 0.25 / mg, one tablet by mouth daily in the morning and in the afternoon. -LIMAA opened the electronic medication administration record (eMAR) for the resident; -The eMAR showed that the resident was due for | administration of carbidopa-levodopa, 25-100 mg, . two tablets at noon and Mirapex, 0.25 mg, one tablet at noon; -He/She opened the locked medication cart to remove the resident's medication strip-pack from the box labeled for the resident; -He/She was not able to locate the resident's medication strip-pack for noon medications on 7/31/24 in the medication cart; -He/She administered the resident's noon medications with the resident's breakfast medications in error. Observation on 7/31/24 at 12:17 P.M. showed: : | Review of the resident's eMAR notes for 7/31/24 at 12:17 P.M. showed the following: -LIMAA administered carbidopa-levodopa, 25-100 mg, two tablets at 7:00 A.M. that were scheduled for administration at 12:00 P.M.; -LIMAA administered Mirapex, 0.25 mg, one tablet at 7:00 A.M. that was scheduled for administration at 12:00 P.M. 2. Review of Resident #2's face sheet showed the following: -Admission date of 1/19/24; -Diagnoses included osteoporosis (low bone density). Missouri Department of Health and Senior Services STATE FORM 6890 FHF611 {f continuation sheet 3 of 8 PRINTED: 08/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 25446 B. WING 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 (Xa) ID SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION | (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD 8E | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | CROSS-REFERENCED TO THEAPPROPRIATE | DATE DEFICIENCY) CHESTNUT GLENN-ASSISTED LIVING BY AME A4797| Continued From page 3 Review of the resident's POS for July, 2024 showed orders for acetaminophen, 325 mg, two tablets by mouth daily at morning, afternoon, and | bedtime. Observation on 7/31/24 at 12:19 P.M. showed: -LIMAA opened the eMAR for the resident; -The resident's eMAR showed the resident was due for administration of acetaminophen (medication to treat pain), 325 mg, two tablets per day at noon; -He/She opened the locked medication cart to remove the resident's labeled medication strip-pack from the box; -He/She was not able to locate the resident's medication strip-pack for noon medications on 7/31/24 in the medication cart; -LIMAA said he/she had administered the resident's noon medications with the resident's breakfast medications. | Review of the resident's eMAR notes for 7/31/24 at 12:21 P.M. showed LIMAA had administered acetaminophen, 325 mg, two tablets at 7:00 A.M. | that were scheduled for administration at 12:00 | P.M. } 3. Review of Resident #3's face sheet showed the | following: -Admission date of 11/27/23, -Diagnoses included Alzheimer's disease, bipolar disorder (mental illness characterized by extreme mood swings between depression and mania), gastro-esophageal reflux disease, and irritable bowel syndrome (digestive disorder). Review of the resident's POS for July, 2024 showed the following orders: -Docusate 100 mg, one capsule by mouth one Missouri Department of Health and Senior Services STATE FORM 6899 FHF611 If continuation sheet 4 of 8 PRINTED: 08/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 25446 B. WING 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING CHESTNUT GLENN-ASSISTED LIVING BY AME SAINT PETERS, MO 63376 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION i (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL i (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) i Continued From page 4 time a day; -Dicyclomine 10 mg, one capsule by mouth two times a day; -Memantine 10 mg, one tablet by mouth two times a day; -Risperidone 0.5 mg; one tablet by mouth in the morning and at bedtime. Observation on 7/31/24 at 12:29 P.M. showed: -LIMAA reviewed the eMAR and determined that | no other residents were scheduled for administration of medication at noon; -He/She opened the locked medication cart to review the medication strip-pack boxes for each of the ten memory care residents; -The resident's labeled medication strip-pack box | contained a strip-pack dated 7/31/24 for breakfast | administration containing one 100 mg capsule of | docusate, one 10 mg capsule of dicyclomine, one 10 mg tablet of memantine, and one 0.5 mg tablet of risperidone. -He/She reviewed the resident's eMAR which showed she had administered docusate 100 mg, dicyclomine 10 mg, memantine 10 mg, and risperidone 0.5 mg during the 7:00 A.M. medication pass; -He/She had documented the medication was administered during the breakfast medication pass when it had not been administered, -He/She reported the medication errors to the Director of Nursing (DON). 4. Observation of medication pass conducted by LIMAA on 7/31/24 at 12:40 P.M. showed the following: -The DON reviewed the medication errors with LIMAA at the medication cart; i -She instructed LIMAA to hold all medications for | Residents #1 and #2 until telephone consultation with the residents’ physician; Missouri Department of Health and Senior Services STATE FORM 6899 FHF6141 If continuation sheet 5 of 8 PRINTED: 08/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 25446 B.WING 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING CHESTNUT GLENN-ASSISTED LIVING BY AME SAINT PETERS, MO 63376 (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 i DATE ! DEFICIENCY) i Continued From page 5 -She instructed LIMAA to go ahead and administer Resident #3's medications since the resident was not at risk of double-dosing of any of the scheduled medications; -LIMAA removed the resident's medication strip-pack from the medication cart drawer and placed it on the top of the cart; -LIMAA set up a paper medication cup on the top of the cart; -LIMAA picked up the medication strip-pack and attempted to open the strip-pack by tearing the package; -LIMAA placed the corner of the medication strip-pack in his/her mouth and tore open the medication pack with his/her teeth; -The DON stopped LIMAA from further contamination of the resident's medications; -DON supervised LIMAA with destruction of the contaminated medications and proper administration of replacement medications for Resident #3. 4. Review of Resident #3's eMAR notes for 7/31/24 at 3:05 P.M. showed the following: -Docusate 100 mg, one capsule, administration documented in error at 7:00 A.M. and actually administered at 12:40 P.M.; -Dicyclomine 10 mg, one capsule, administration documented in error at 7:00 A.M. and actually administered at 12:40 P.M.; -Memantine 10 mg, one tablet, administration documented in error at 7:00 A.M. and actually administered at 12:40 P.M.:; and -Risperidone 0.5 mg; one tablet, administration documented in error at 7:00 A.M. and actually administered at 12:40 P.M. 5. During interview on 7/31/24 at 11:30 A.M., LIMAA said the following: -He/She had conducted the breakfast medication Missouri Department of Health and Senior Services STATE FORM 6899 FHE611 If continuation sheet 6 of 8 PRINTED: 08/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED 8. WING 25446 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 CHESTNUT GLENN-ASSISTED LIVING BY AME (x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x8) 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 THEAPPROPRIATE =—=——DATE DEFICIENCY) Continued From page 6 pass at 7:00 A.M.; -He/She did not compare the resident medication | strip-packs to the eMAR during the breakfast medication pass and gave Residents #1 and #2 | medications that were not yet due for administration; -He/She had not been aware that Resident #1 had received double-doses of two medications during the breakfast medication pass; i -He/She documented administration of Resident | | | | #3's medications without preparing the medications from the strip-packs and administering the medications to Resident #3. During interview on 7/31/24 at 11:40 P.M., the DON said the following: -It was her expectation that all staff responsible for medication administration would follow proper | nursing techniques utilizing the five key elements of medication administration; i -She identified the five key elements as verifying | the correct resident, correct medication, correct | j dosage, correct time, and correct route of administration; -She expected staff to follow proper nursing | techniques to keep resident medications sanitary | and to not use their teeth to open medication | ! strip-packs. During interview on 7/31/24 at 5:47 P.M., the Administrator said the following: -It was her expectation that all staff responsible for medication administration would follow proper nursing techniques utilizing the five key elements | of medication administration; | -It was her expectation that staff would administer | medications according to physician orders, -It was her expectation that staff would administer | medications in a sanitary manner to prevent contamination of resident medications. Missouri Department of Health and Senior Services STATE FORM 6899 FHF611 If continuation sheet 7 of 8 PRINTED: 08/15/2024 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 25446 B. WING ____________ 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING CHESTNUT GLENN-ASSISTED LIVING BY AME SAINT PETERS, MO 63376 (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) Missouri Department of Health and Senior Services STATE FORM 6899 FHF614 if continuation sheet 8 of 8 PLAN OF CORRECTION Chestnut Glen Assisted Living Provider/Supplier Name: ore Address, | 421 Klondike Crossing St. Peters, Mo 63376 ity, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 25446 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the fact alleged or the conclusion set forth in the statement of deficiencies. The plan of correction is prepared and executed because state laws require it. This provider maintains that the alleged deficiencies do not individually, or collectively, jeopardize the health and safety of its residents; nor are they of such character as to limit this provider's capacity to render adequate care, Furthermore, the provider asserts that it is in substantial compliance with the regulations governing the operation and licensure of assisted living facilities, and this pian of correction, in its entirety constitutes this providers allegation of compliance. Completion dates are provided for procedural processing purposes and correlates with most recent contemplated or accomplished corrective action. These dates do not necessarily correspond chronologically to the date the facility was in compliance with the requirement of participation or that corrective action was necessary. 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that ail resident's medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians’ instructions using acceptable nursing techniques. The facility shalt employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident’s condition and AA4797 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 @ 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 shail be trained in medication administration and, if not a physician or a SYSTEMIC CHANGES Provide education to all staff that are responsible for medication administration to follow proper nursing techniques utilizing the 9/42/2024 contamination of resident medications. MONITORING | Director of Nursing/designee will compiete random weekly 9/12/2024 medications. Director of Nursing/Regional Support Nurse will ensure that the LIMAs will receive bi-annual training and will provide training on licensed nurse, shall be a certified medication technician or level 1 medication aide. IDENTIFICATION OF OTHERS | fp [| five key elements of medication administration. Provide education to all staff that are responsible for medication audits observing medication administration techniques by utilizing the five key elements of medication administration and 9/12/2024 an annual basis, per company policy. The Administrator signing and dating the first page of the CMMS-2567/State Form is indicating their approval of Ail residents have the potential to be affected. 9/12/2024 administration to follow sanitary guidelines to prevent proper sanitary guidelines to prevent contamination of resident the plan of correction being submitted on this form.

PRINTED: 05/10/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED ee B. WING 25446 of — 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 CHESTNUT GLENN-ASSISTED LIVING BY AMERICAR (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2210 19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check Fire Extinguishers. (D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure check. II/III This regulation is not met as evidenced by: Class III: Based on record review and interview, the facility failed to document monthly pressure checks on all fire extinguishers. The facility census was thirty-three (33). This affected thirty-three (33) of thirty-three (33) residents. Record review showed no documentation was provided for the annual maintenance or monthly pressure checks for the fire extinguishers located in the kitchen of Terrace 2 and also in the Glenn of the common area. During an interview on 5-7-24 at 12:33 P.M., the maintenance director said the fire extinguisher company placed some loaner extinguishers in the facility while theirs are being hydro-tested. 19 CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults Complete Fire Alarm Systems. (G) Upon discovery of a fault with the complete fire alarm system, the facility shall correct the | fault. I/II This regulation is not met as evidenced by: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIE! REPRES| \TIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MOEB11 If continuation sheet 1 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 CHESTNUT GLENN-ASSISTED LIVING BY AMERICAR (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Class II Based on observation and interview, the facility failed to correct a fault with the complete fire alarm system. The facility census on 5-7-24 was thirty three (33). This deficiency affects thirty three (33) of thirty three (33) residents. Observation showed the fire alarm with a trouble signal on the panel. The trouble signal showed it located at D-4 smoke. During an interview on 5-7-24 at 1:39 A.M. the maintenance director said the fire alarm company has been notified and will be there today. 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to ensure protection from hazards by storing unnecessary combustible materials in any part of the building. The facility census was thirty three (33). This affected thirty three (33) of thirty three (33) residents. Observation showed several furnace rooms with combustibles being stored next to the furnace and blocking access to the furnaces. Observation showed mechanical rooms with Missouri Department of Health and Senior Services STATE FORM 6899 MOEB11 PRINTED: 05/10/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/07/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 CHESTNUT GLENN-ASSISTED LIVING BY AMERICAR (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 combustibles being stored blocking access to the electrical panels. Observation showed combustible items being stored in the sprinkler room blocking access to the sprinkler system in the event of an emergency or maintenance of the system. During an interview on 5-7-24, at 1:30 P.M. the Maintenance Director said he/she would relocate the items to storage rooms or get rid of them. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on observation and interview the facility failed to maintain the sprinkler system in accordance with NFPA 13 (1999 Edition). The facility census was thirty three (33) and this affected thirty three (33) of the thirty three (33). Observation in the Activities Room and the storage room by Resident Room C-1, showed items located on the top shelf in the closets interfering with the operation of the sprinkler heads. these items were located within eighteen (18") inches of the bottom of the sprinkler head. Observation showed several items being stored Missouri Department of Health and Senior Services STATE FORM 6899 MOEB11 PRINTED: 05/10/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/07/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 5 PRINTED: 05/10/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 (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) CHESTNUT GLENN-ASSISTED LIVING BY AMERICAR Continued From page 3 in the sprinkler room blocking access to the sprinkler system. Interview on 5-7-24 at 12:25 P.M. the maintenance director said they would remove the items and do training to educate the staff and residents. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class Ill Based on record review and interview the facility failed to properly maintain the buildings electrical Missouri Department of Health and Senior Services STATE FORM 6899 MOEB11 If continuation sheet 4 of 5 PRINTED: 05/10/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 121 KLONDIKE CROSSING SAINT PETERS, MO 63376 (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) CHESTNUT GLENN-ASSISTED LIVING BY AMERICAR Continued From page 4 wiring to not cause a safety or fire hazard. The facility census was thirty three (33). This deficiency affects thirty three (33) of thirty three (33) residents. Observation showed in resident room #B-2 a three way plug adapter being used. During an interview on 5-7-24 at 1:20 P.M. the maintenance director said he would remove and replace with approved power strips. Missouri Department of Health and Senior Services STATE FORM 6899 MOEB11 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Chestnut Glen Assisted Living Name: Street Address, E - 121 Klondike Crossing St. Peters, Mo 63376 City, Zip: Date of Survey: 05/07/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the fact alleged or the conclusion set forth in the statement of deficiencies. The plan of correction is prepared and executed because state laws require it. This provider maintains that the alleged deficiencies do not individually, or collectively, jeopardize the health and safety of its residents; nor are they of such character as to limit this provider's capacity to render adequate care. Furthermore, the provider asserts that it is in substantial compliance with the regulations governing the operation and licensure of assisted living facilities, and this plan of correction, in its entirety constitutes this providers allegation of compliance. Completion dates are provided for procedural processing purposes and correlates with most recent contemplated or accomplished corrective action. These dates do not necessarily correspond chronologically to the date the facility was in compliance with the requirement of participation or that corrective action was necessary. 19CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check Fire Extinguishers. (D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a month pressure check. SYSTEMIC CHANGES ° All fire extinguishers will have pressure checks completed monthly and documented accordingly. Tags attached 6/14/2024 to the fire extinguishers will provide documentation of monthly inspections completed. 6/14/2024 MONITORING 2 Maintenance Director/Administrator/designee will check fire extinguishers monthly to ensure inspection completed and documentation related to monthly pressure checks in place. 19CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults Complete Fire Alarm Systems. (G) Upon discovery of a fault with the complete fire alarm system, the facility shall correct the fault. SYSTEMIC CHANGES ¢ Fire Alarm Company came out to community that day and replaced smoke detector. e Maintenance Director will address any faults with fire orrHenes alarm panel, correct immediately if possible, contact fire alarm company as needed to assist in correcting MONITORING e Maintenance Director/designee will monitor fire alarm panels for faults, after hours care staff will contact Maintenance Director/designee as needed. Fire Alarm 6/14/2024 company instructed to contact Maintenance Director/designee when fire alarm fault is detected within system. 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage of Protection from Hazards (B)The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. SYSTEMIC CHANGES e Mechanical rooms/closets in the Glen, Terrace 1, and Terrace 2 will be cleaned and organized to ensure that access to the gas furnace, gas water heater, sprinkler 6/14/2024 controls, and electrical panels are not blocked. Combustible items and other large items to be moved away from gas furnaces and gas water heaters. MONITORING e Maintenance Director/designee to inspect Mechanical rooms/closets in the Glen, Terrace 1, and Terrace 2 6/14/2024 monthly and as needed to ensure continued compliance. 19 CSR 30.86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems (B) Facilities that have a sprinkler system installed prior to August 1, 2007 shall inspect, maintain, and test these systems in accordance with the requirement that were in effect for such facilities on August 27, 2007 SYSTEMIC CHANGES 6/14/2024 e Resident room closets/Activity room closet will have 6/14/2024 items removed from the top shelf providing 18 inches of clearance from the bottom of the sprinkler heads. MONITORING e Maintenance Director/designee will inspect resident room closets/Activity room closet to ensure no items are stored above the 18 inches of clearance from the bottom of the sprinkler heads. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, NFPA Inc., incorporated for reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities 6/14/2024 shall have wring inspected every two years by a qualified 6/14/2024 electrician. SYSTEMIC CHANGES e Maintenance Director removed three way plug adapter 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. from resident room. MONITORING e Maintenance Director/designee will inspect all resident rooms monthly to ensure only approved power Strips are being used.