HARTMANN VILLAGE ASSISTED LIVING.

PRINTED: 12/10/2024 FORM APPROVED epariment of Health and Senior Service STATEMENT OF DEFICIENCIES (x4) PROVIDE R/SUPPLIERICLIA (X2} MULTIPLE CONSTRUCTION (X93; DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILOING COMPLETED C B.WING 41/22/2024 NAVE OF PROVIDER OR SUPPLIER STREET AQORESS. CITY, STATE, ZIP CODE 81S RANKIN MILL LANE BOONVILLE, MO 65233 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION CxS (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) HARTMANN VILLAGE-ASSISTED LIVING BY AMERIC, A7019 19 CSR 30-87.030(17) Food Stored in Identifying Containers Uniess its identity is unmistakable, bulk food, such as cooking oil, syrup, salt, sugar or flour nat stored in the product container or package in which it was obtained, shalt be stored in a container identifying the food by common name. in This regulation is not met as evidenced by: Class Hi Based on observation, interview, and record review, the facility staff failed to property store open food to prevent cross contamination and outdated usage. The census was 20. 1. Review of the facility's Food Starage and Safety Policies, dated 9/10/19, showed stalf are directed to contain, store, label, and date ‘ everything property. 2. Observation on 11/22/24 at 10:41 A.M. of the " pantry showed: -Two large plastic bags with zip closure of ‘ chocolate cake mix undated: -A large plastic container with a blue lid of a powdered sugar type substance, debris on the fid, a white measuring one cup in the substance dated 9/26/24, unlabeled: _ -A large plastic container with a bive tid of a flour type substance, debris on the lid and a plastic cup with handle in the flour, undated and unlabeled: -A large plastic container with a clear lid of a sugar, debris on the lid, a white measuring half a cup in the substance, undated, and unlabeled: -A large plastic bag with zip clesure of a five-pound bag of combread mix, undated; -Five plastic bags with zip cosures of pasta Missouri Department of Health and Senior Services LABGRATORY-DIREC TOR'S OR P IDER/SUPRER REPRESENTATIVE'S SIGNATURE YE Ue ; STATE FORM TITLE (RG OATES “ 377111 it coltinuanbn sheot ¢ of 4 PRINTED: 12/10/2024 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 Cc B. WING 11/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 615 RANKIN MILL LANE BOONVILLE, MO 65233 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD 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) HARTMANN VILLAGE-ASSISTED LIVING BY AMERIC: A7019 Continued From page 1 noodles, undated and unlabeled. 3. Observation on 11/22/24 at 11:00 A.M., showed the refrigerator in the kitchen bottom of the doors and bottom of the refrigerator contained debris. 4. Observation on 11/22/24 at 11:05 A.M., showed the freezer contained: -A large plastic bag of cinnamon rolls, undated and unlabeled; -A large plastic bag of shredded potatoes, undated and unlabeled; -A large plastic bag of chicken, undated and unlabeled; -A large plastic bag of cookie dough, undated and unlabeled; -Three large plastic bag of bread sticks, undated and unlabeled; -A large plastic bag of waffles open, unsealed, undated and unlabeled; -Debris on the bottom of freezer. During an interview on 11/22/24 at 11:15 A.M., the dietary manager said when pre-packaged food is open and not all is used staff are to put the food in a bag or container, seal, date and label. The dietary manager said when there are leftovers, the leftovers should be put in containers sealed, dated, and labeled. The dietary manager said there should not be measuring cups in the powdered sugar, flour, and sugar and could not say why they are there. The dietary manager said the cooks are responsible for food being stored properly. The dietary manager said he/she tries to check ever moming when he/she comes in to work. The dietary manager said he/she can not say why the food is not stored properly. Missouri Department of Heaith and Senior Services STATE FORM a8 377111 li continuation sheet 2 of 4 PRINTED: 12/10/2024 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 Cc 26026 B.WING 41/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 615 RANKIN MILL LANE BOONVILLE, MO 65233 (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) HARTMANN VILLAGE-ASSISTED LIVING BY AMERIC, A7019 Continued From page 2 MO00245026 19 CSR 30-87 .030(64) Grills/Griddles/Microwaves/Other-Clean Daily The food-contact surfaces of grills, griddies 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 shail be kept free of encrusted grease deposits and other accumulated soil. lil This regulation is not met as evidenced by: Class {I Based on observation, interview, and record review, the facility staff failed to maintain kitchen equipment in a clean and sanitary manner. The census was 20. 1. Review of the facility's Kitchen Services policy, undated, showed all meals are to be prepared, distributed, and served under sanitary conditions. Review of the facility's Opening and Closing Checklist, undated, showed staff are directed at the end of the shift to complete the daily cleaning schedule. Review of the facility's Monthly Deep Cleaning Schedule, undated, showed staff are to clean ovens weekly. 3. Observation on 11/22/24 at 10:47 A.M., showed the table's bottom shelf in the kitchen contained debris. Missouri Department of Health and Senior Services STATE FORM ane 377111 \f continuation sheet 3 of 4 PRINTED: 12/10/2024 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 Cc 26026 ____—_———— 11/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 615 RANKIN MILL LANE BOONVILLE, MO 65233 (X4) 1D 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) HARTMANN VILLAGE-ASSISTED LIVING BY AMERIC, A7066 Continued From page 3 5 Observation on 11/22/24 at 10:50 A.M., showed the two kitchen stove ovens contained: -A build-up of grease on the oven door, racks, and bottom of oven; -One oven contained two with pieces of foil in the grease build up. 6. During an interview on 11/22/24 at 11:15 A.M., the dietary manager said there is a cleaning schedule to be filled out daily and it is tumed in daily but the facility has been out of forms for about a week. The dietary manager said he/she thinks it have been five months since the ovens were cleaned and was aware of the conditions of the ovens. The dietary manager said everyone is responsible for cleaning the kitchen. The dietary manager said he/she didn't know why the ovens were not cleaned. The dietary manager said he/she could not locate any of the completed cleaning forms. During a telephone interview on 11/22/24 at 11:48 A.M., certified medication aide (CMA) A said there is a duty roster between shifts on cleaning the kitchen. CMAA said the day shift usually cleans the ovens. CMAA said he/she only works in the kitchen when needed. MO00245026 Missouri Department of Health and Senior Services STATE FORM 8899 377111 if pontinuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: Hartmann Village Street Address, City, Zip: 7 615 Rankin Mill Ln, Boonville Mo 65233 Date of Survey: 11-22-2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A7019 The filing of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the summary of the statement of deficiencies dated 11/22/2024 by the Missouri Department of Health and Senior Services. This plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. In response to 19 CSR 30-87.30 (17) Food Stored in identifying Containers Immediate Action: 1. All dry food storage bins were immediately emptied and cleaned. All undated, unlabeled food was discarded 2. Allrefrigerators and freezers were inspected and cleaned. All undated, unlabeled food removed and discarded. 3. in-services completed with all current Food and Nutrition Department employees in the following issues: 12-30-2024 Proper Cleaning and Sanitizing of food bins Proper Cleaning of Refrigerators and Freezers Proper label and dating Kitchen cleaning list, completing and signing Education given to counsel employees responsible for failing to properly clean, label and date food bins. Education completed by Administrator on or before 12/30/2024. 4. All staff to complete Food Handling Course on Relias 5. Registered Dietitian consultant to audit quarterly and include on report 6. Kitchen Daily Cleaning Roster posted and staff inserviced on completing task and documenting who performed task with date and initials mOODLY Ongoing Compliance: The Administrator or designee in the absence of will assure __ongoing compliance through. wn Having Dietary ‘Manager inspect Refrigerators. freezers, food bins and lids daily for food debris and cleaned as needed. Having Dietary manager inspect kitchen for cleanliness weekly Having Dietary Manager posting Kitchen Cleaning Roster for dietary staff to complete daily and weekly cleaning responsibilities. Educating Dietary Manager to review Registered Dietitian consultant quarterly audit and immediately | address all issues or concerns identified by the Dieticians Audit report. Provide education and training on kitchens sanitation to all new dietary employees. Administrator wili assure Dietary Manager receive Food Safe Course/ Certification on or before 01/31/2025 Administrator or designee in the absence of will perform o-weekly inspection of kitchen, refrigerators, freezers, food bins and lids for food debris and cleaned Completion Date: All items .o be completed by 12/30/2024 with exception of Dietary Manager Food Safe Certification which will be completed by 1/31/2025 _ _ A7066 In response to 19 CSR 30-87 30 (64) Grils/Grcdies/Microwave/Other Clean Daily Immediate Action: 1, y a Ongoing Compliance: Administrator or designee for in absence of will assure ongoing coraphiance through the following: 4. cganed properly i1-service completed with all Food and Nutrition Dept =mployees. a Proper Cleaning of Food Service Equipment, Service areas, counters. table tops and storage shelves Cleaning list completing and signing. © Education given to counsel employees responsible for failing to maintain kitchen in a clean and sanitary manner. All staff to complete Food Handling Course on Relias faily cleaning roster posted and staff inserviced on completing task and documenting who performed task wth date and initials. oT Si] kitchen equipment, surfaces, tables and shelving was | | | = Jucating Dietary Manager to inspect for cleanliness of | ritchen, refrigerators, kitchen equipment, storage | shelves, grills, microwave, stoves, ovens and other | vetary areas weekly. « ducating Dietary Manager to review Registered | Mretitian Consultant to audit quarterly and include on | feport and immediately address all issues or concerns ‘dentified by the Dieticians Audit report. | 12/30/2024 3. Administrator or designee of in the absence of will do bi- weekly inspect for cleanliness of kitchen, refrigerators, kitchen equipment, storage shelves, grills, microwave, stoves, ovens and other dietary areas weekly. 4. Administrator will review Dietary Cleaning Rosters bi- weekly to assure dietary staff are aware of daily, weekly and or biweekly duties for maintaining a clean and sanitary kitchen 5. Administrator will provide education to all newly hired dietary employees on kitchens sanitation, kitchen cleaning rosters for all surfaces and equipment. 6. Administrator will complete re-education for staff when any deficient practices is identified in bi-weekly | inspections and or in the Dietary Consultant Audit | report. | 7. Dietary Manager to have Food Safe Course/ Certification on or before 01/31/2025 | Completion Date: | All items to be completed by 12/30/2024 with exception of | Dietary Manager Food Safe Certification which will be completed by 1/31/2025 ! a a < Y | | 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.