AUBURN CREEK ASSISTED LIVING.

PRINTED 04/24/2025 Missoun Department of Health and Semo: Semces FORM APPROVED STATEMENT OF DEF ICIENCIES tT ‘ ) PROVIDER SuemriER Cita AND PLAN OF CORRECTION IDENTIFICATION NUMBER JX MULTIPLE CONSTRUCTION & BU DING -__ 8 MING OO STREET ADORESS city SYATE 76 CODE (X23) DATE SURVEY COMPLETES 19892C 94/48/2025 NAME OF PROVIDER OR SUPPLIER AUBURN CREEK-ASSISTED LIVING BY AMERICaRE «2810 BEAVER CREEK prive CAPE GIRARDEAU, MO 63701 SUMMARY STATEMENT OF DEFICIENCIES Porras SPREE iD PROVIDER'S PLAN oF CORRECTION rs TAG REGULATORY OR LSC IDENTIE YING INE ORMATICNy "ae cmos nee to INE APPRODH TE “pte “ Tr DEFICIENCY) A6724 19 CSR 30-86 047(19) TB Screen Residants & Staff The facility shall screen residents and staf for tuberculosis as required for long-term care faculties by 19 CSR 20-20 100 i ‘ This regufatian 1s not met as evidenced by | Class I Baséd on interview and record review, ihe facitity failed to screen for Tuberculosis (TB) (a lung disease characterized by fever Cough. and drfficulty in breathing and @asily spread to others) In 2 timely manner as required by State of Missoun regulation 19 CSR 20-20.100 for two residents (Resident #1 and #2) out of three Sampled residents This affects alt facitity residents through the increased nsk of exposure ta tuberculosis The facility's census was 36 Review of the Department of Heaith and Senor Sernices (DHSS) Division of Communrty ana Public Health regulation regarding communicable diseases (19 CSR 20-20 100} showed ; ~ Long-term care facilities shall screen their residents and staff for TB using the Mantoux method punfied protein derivative (PPD) five tuberculin unit (TU) test Each facility shalt be responsible far ensunng that all test results are completed and that documentation 1s maintained for all residents. employees and volunteers - Each facrtity shall be responsible for ensuring that ai! test results are compieted and that documentation 1s maintained for all residents. employees. and volunteers. ~ Long-Term Care Residents Within one (1) month pnor to or one (1) week after admission ai residents new to long-term care are required to have the initial test of a Mantoux PPD two (2)}-Step tuberculin test If the initial test 1s ences ita pee S SIGNATURE Messoun Ogpartmant of Heath and Seno LABORATORY ORECT, -74-2025 U coninyanon smoot 1 of 2 Ped Sasi STATE FORM PRINTED: 04/90/2025 FORM APPROVED Missourt Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (%2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER ne BUNCING COMPLETED 198926 B WING. 04/18/2025 NAME OF PROVIDER OR SUFFLIER STREET ADORESS CITY STATE ZIP CODE 2910 BEAVER CREEK DRIVE CAPE GIRARDEAU, MOQ 63701 (%S$} 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 4x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SROULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION! caiainidaiaieas ose TO THE APPROPRIATE DATE EFICIENCY} AUBURN GREEK-ASSISTED LIVING BY AMER! A4724 Continued From page 1 negative, zero to nine millimeters (0-9 mm). the second test. which can be given after admission, should be given one to three (1-3) weeks later. Documentation of chest X ray evidence ruling out tuberculosis disease within one (1) month prior to admission, along with an evaluation to rule out signs and symptoms compatible with infectious tuberculosis, may be accepted by the facility on an interim basis until the Mantoux PPD two (2)-step test is completed. Record review for Resident #1 showed: - An admission date of 03/26/25: - No dacumentation of a TB test being administered. Record review for Resident #2 showed: - An admission date of 04/08/25: - No documentation of a TB test being administered During an interview on 04/18/25 at 12.30 P.M. Facility Staff (FS) A said he/she failed to follow-up on TB tests for new residents. Missoun Department of Health and Senior Services STATE FORM ga39 $¥8511 Hf contnualon sheet 2 af 2 PLAN OF CORRECTION eee Provid lier ' oe aapeiee : Auburn Creek- Assisted Living by Americare : ! SE t a lg aa | 2910 Beaver Creek Drive Cape Girardeau. MO 63701 ' City, Zip: ao Date of Survey: | 04/18/2025 : fd eee — ase ae lg eee PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ' 498920 , IOPREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | COMPLETION , __ | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} | = DATE 19 CSR 30-86.047 (19) TB Screen Residents & Staff | A4724 | The facility shall screen residents and staff for tuberculosis as 519/25 required for long-term care facilities by 19 CSR 20-20.100 II "The facility will ensure to screen for Tuberculosis (TB) (a lung | ! | disease characterized by fever. cough. and difficulty in breathing , ‘and easily spread to others) in a timely manner as required by | State of Missoun regulations 19 CSR 20-20 100 i tee J $$ All residents who resided at the communities are considered at | nsk for this déficient practice | Resident #1 received their first step TB test on 4/18/25 which | | was read on 4/21/25 with the results being negative Second | step TB test was administered on 4/25/25 | . Resident #2 recetwved ther first step TB test on 4/18/25 which | Was read on 4/21/25 with the results being negative Second step TB test was administered on 4/25/25. | Support Nurse completed audit of resident TB test records on 4/21/25 to ensure that all residents who feside at the community have received their 1%! and 2° step TB test upon admission and | _annually thereafter | | Administrator and or designee will in-service the ALF and Arbors | _ Director of Nursing on ensuring that residents are screened for | ‘ | TB within one (7) month pnor or one (1) week after admission. 1 : and second step given within 1-3 weeks later Director of Nursing or designee will audit resident TB records ' monthly ensuring that all new residents receive their 2 step TB | test and that annual screening are completed when due on other | residents a , ! Director of Nursing will report continued compfiance to ‘ | : | Administrator monthly on the DON monthiy report . The Adrninistrator signing and dating the first page of the CMS-2567/State Form is indicating thelr approval of the plan of correction being submitted on this form.

PRINTED: 04/10/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A c ND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19892C B. WING 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2910 BEAVER CREEK DRIVE CAPE GIRARDEAU, MO 63701 (%4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL j (EACH CORRECTIVE ACTION SHOULD BE j COMPLETE TAG: REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DATE ' DEFICIENCY) AUBURN CREEK-ASSISTED LIVING BY AMERICARE A2269: 19 CSR 30-86.022(11)(B) Sprinkler System _ Maintenance/Testing i 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. AI _ This regulation is not met as evidenced by: . Class tl Based on record review and interview on March : 26, 2024 the facility failed to maintain the facility sprinkler system in accordance with NFPA 25, | 1998 edition. The facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Record review shows a stated deficiencies for the sprinkier system of the main building under section 13.3.2.1.3 (tamper switch) with the following technician response: does not give a supervisory alarm at the panel. Record review shows a stated deficiencies for the sprinkler system of the main building under section 13.3.3.5.2 (tamper switch) with the following technician response: does not give a supervisory alarm at the panel. Record review shows a stated deficiencies for the sprinkler system of the main building under section 13.2.8.2 (electric bell) with the following technician response: failed to operate. not hooked up. During an interview on March 26, 2024 at 10:20 A.M., the Administrator stated the repairs have been approved, however the sprinkler company Missourt Department of Health and Senior Services LABORATORYJDJRECTOR'S TITLE + 1 4 dust 442-202 STATE FORM gage iDKV11 If continuation sheet 1 of 2 PRINTED: 09/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA {X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19892C B.WING 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 2910 BEAVER CREEK DRIVE CAPE GIRARDEAU, MO 63701 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} AUBURN CREEK-ASSISTED LIVING BY AMERI A2269 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/l This regulation is not met as evidenced by: Class Il Based on record review and interview on March 26, 2024 the facility failed to maintain the facility sprinkler system in accordance with NFPA 25, 1998 edition. The facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Record review shows a stated deficiencies for the sprinkler system of the main building under section 13.3.2.1.3 (tamper switch) with the following technician response: does not give a supervisory alarm at the panel. Record review shows a stated deficiencies for the sprinkler system of the main building under section 13.3.3.5.2 (tamper switch) with the following technician response: does not give a supervisory alarm at the panel. Record review shows a stated deficiencies for the sprinkler system of the main building under section 13.2.8.2 (electric bell) with the following technician response: failed to operate. not hooked up. During an interview on March 26, 2024 at 10:20 A.M., the Administrator stated the repairs have been approved, however the sprinkler company Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) DATE STATE FORM sao IDKV 1414 If continuation sheet 1 of 2 PRINTED: 09/12/2024 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 19892C B.WING 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 2910 BEAVER CREEK DRIVE CAPE GIRARDEAU, MO 63701 (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} AUBURN CREEK-ASSISTED LIVING BY AMERI A2269 Continued From page 1 has not been back to make the repairs. Missouri Department of Health and Senior Services STATE FORM 5899 IDKV141 if continuation sheet 2 of 2 PLAN OF CORRECTION | Provider/Supplier Warns Auburn Creek Assisted Living by Americare Street Address, cree, 2G 2910 Beaver Creek Drive Cape Girardeau, MO 63701 ity, Zip: Date of Survey: 03/26/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a momen peer ee | ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 19 CSR 30-86.022(11)(B) Sprinkler System eend Maintenance/Testing ichaaieie Sprinkler System (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 The facility will ensure to maintain the sprinkler system in accordance with NFPA 25 1998 edition. All residents are considered at risk for the deficient practice. —— Sprinkler company has repaired the issued noted on the inspection the tamper switch is now giving the supervisor alert on panel as required in section 13.3.2.1.3. af Sprinkler company has repaired the issued noted on the inspection and the electric beil has been replaced in accordance ; ! with section 13.2.8.2. Administrator and/or designee will in-service maintenance supervisor on ensuring that any issues that are identified by | sprinkler company on their inspections are brought to the Administrator immediately and corrected. Maintenance supervisor will review inspections completed by sprinkler company & Fire Alarm company after they occur to ensure that sprinkler system remains compliant in accordance to NFPA 1998 edition and report completed inspections for the |_month to Administrator on monthly maintenance report.