CAPETOWN ASSISTED LIVING.

PRINTED. 10/26/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (11) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A BUILDING {X3} DATE SURVEY COMP ETED B. WING 23989 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADORESS CITY. STATE. ZIP CODE 2857 CAPE LACROIX ROAD CAPE GIRARDEAU, MO 63701 CAPETOWN ASSISTED LIVING (X41 SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION ixs) PREFIX (EACH DEFICIENCY MUST SE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A7035 19 CSR 30-87.030(33) Thawing Potentially Hazardous Foods | Potentially hazardous foods shall be thawed in refrigerated units at a temperature not to exceed forty-five degrees Fahrenheit (45°F): or under potable running water at a temperature of seventy degrees Fahrenheit (70°F) or below, with sufficient water velocity to agitate and float off loose food particles into the overflow; or ina microwave oven only when the food will be immediately transferred to conventional cooking | facilities as part of a continuous cooking process or when the entire, uninterrupted cooking process takes place in the microwave oven: or as part of the conventional cooking process. II/IIl This regulation is not met as evidenced by Class III Based on observation and interview, the facility failed to thaw frozen, uncooked pork in a safe manner, which was intended for use of the residents’ evening meal. This practice could potentially lead to food-borne illness and could affect all residents. The facility's census was 29. 1. Observation on 10/11/23 at 12:13 P.M. of the Memory Care kitchen showed: - One, 12 pound (Ib) pork tenderloin, defrosted and warm to the touch, in the kitchen sink; - No cold water running over the pork tenderloin or in the kitchen sink; - Using a digital thermometer, the pork tenderloin had an internal temperature of 66.5 degrees Fahrenheit (F). During an interview on 10/11/23 at 12:24 P.M., the Cook said he/she put the pork tenderloin in | | the sink, covered with water, at 6:00 A.M., this | morning. The cook said he/she had just let the Missoun Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDERAUPPLIE 145) DATE ‘S SIGNATURE lolx =a WGE91" i continuation sheet 1 of 3 STATE FORM Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPUERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23989 NAME OF PROVIDER OR SUPPLIER CAPETOWN ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A7035 Continued From page 1 water out before SLCR staff entered the kitchen. During an interview on 10/11/23 at 1:03 P.M., the Administrator said the cook is aware of proper defrosting procedures for meat, but will discuss it with him/her again. PRINTED. 10/26/2023 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A BUILDING (X3) DATE SURVEY COMPLETED B WING _ 10/11/2023 STREET ADDRESS. CITY. STATE, ZIP CODE 2857 CAPE LACROIX ROAD CAPE GIRARDEAU, MO 63701 PROVIDER'S PLAN OF CORRECTION ey (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO TKE APPROPRIATE DATE DEFICIENCY) ! A7035 | | | A7042 A7042 19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap Ice shall be dispensed only with scoops, tongs or other ice-dispensing utensils or through automatic self-service, ice-dispensing equipment. Ice-dispensing utensils shall be stored on a clean surface or in the ice with the dispensing utensil ' s handle extended out of the ice. Between uses, ice transfer receptacles shall be stored in a way that protects them from contamination. Ice storage bins shall be drained through an air gap. Ill This regulation is not met as evidenced by: Class lll Based on observation and interview, the facility failed to provide an air gap for the ice machine drain pipe to protect the ice from contamination in the case of backflow, potentially affecting all residents in the facility. The facility's census was 29. 1. Observation on 10/11/23 at 10:55 A.M. of the kitchen showed: - The ice machine drain tube touched the top of the drain in the floor; - Ablack, slimy substance around the end of the ice machine drain tube. During an interview on 10/11/23 at 1:03 P.M., the Administrator said the drain tube will be corrected Missouri Department of Health and Senior Services STATE FORM nay WGEQ"" I continuation shee 2 of 3 PRINTED. 10/26/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED ei oe 10/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADORESS CITY, STATE. ZIP CODE 2857 CAPE LACROIX ROAD CAPE GIRARDEAU, MO 63701 CAPETOWN ASSISTED LIVING (X4,10 SUMMARY STATEMENT OF OEFICIENCIES 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) A7042 Continued From page 2 A7042 and cleaned. } M ssouri Department of Health and Semor Services STATE FORM came WGES11 Hf continuubon shee: 30% 3 PLAN OF CORRECTION Provider/Supplier Name: Capetown Assisted Living by Americare Street Address, City, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 2857 Cape LaCroix Rd, Cape Girardeau, MO, 63701 23989 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 19 CSR 30-87.030(33) Thawing Potentially Hazardous Foods Potentially hazardous foods shall be thawed in refrigerated units at a temperature not to exceed forty-five degrees Fahrenheit (45°F); or under potable running water at a temperature of seventy degrees Fahrenheit (70°F) or below, with sufficient A7035 water velocity to agitate and float off loose food particles into the 11/10/2023 overflow: or in a microwave oven only when the food will be immediately transferred to conventional cooking facilities as part of a continuous cooking process or when the entire, uninterrupted cooking process takes place in the microwave oven; or as part of the conventional cooking process. II/III All residents that reside in our memory care are at risk for this deficient practice. All staff to be in-serviced by 11/10/2023 by Administrator and/or Designee on ensuring proper thawing of food process. Dietary Manager to ensure proper thawing of potentially hazardous foods five (5) days a week. Administrator and/or Designee to monitor proper thawing of potentially hazardous foods one (1) day a week. 11/10/2023 A7042 19 CSR 30-87 .030(40) Ice Store/Dispense, No Contamination, Air Gap ice shall be dispensed only with scoops, tongs or other ice- dispensing utensils or through automatic self-service, ice- dispensing equipment. Ice-dispensing utensils shall be stored on a clean surface or in the ice with the dispensing utensil ' s handle extended out of the ice. Between uses, ice transfer receptacles shall be stored in a way that protects them from contamination. Ice storage bins shall be drained through an air gap. Ill All residents that reside at this facility are at risk for this deficient practice. Maintenance fixed drain pipe last week along with being cleaned with no longer any black slimy substance on the pipe by 10/20/2023. Maintenance in serviced by 11/10/2023 by Administrator and/or Designee on ensuring that drain pipe from ice machine has an air gape between pipe and drain to prevent backflow. Maintenance will check weekly and after repairs are made to ensure there is an air gap between dishwasher pipe and drain and that there is not black slimy substance building up, and if 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.