GLENDALE GARDENS MEMORY CARE.

PRINTED: 04/15/2025 FORM APPROVED STATEMENT OF DEFICIENCIES 0X1) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 17054D B.WING 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GITY, STATE, ZIP CODE 1300 SOUTH MAIN CLINTON, MO 64735 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES. i PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL ‘ {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ARBORS AT GLENDALE GARDENS-MEM CAR! 19 CSR 30-86.047(13)(B) EDL Inquiry Prior to allowing any person who has been hired in @ full-time, part-time, or temporary position io have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shail, prior to sending a temporary employee to a facility: {B) Make an inquiry to the department, as , provided in section 660.315, RSMo, as to | whether the person is listed onthe EDL. Each | | facility shall maintain documents verifying that the | | EDL checks were requested, the date of each such request, and the nature of the response } received for each such request. The inquirymay | be made through the department's website; il/tit | This regulation is not met as evidenced by: i Class II* Based on interview and record review, facility staff failed to document a check of the employee disqualification list (EDL - a list of individuais unable to work in long-term care settings) for two | staff(Certified Nurses Aide {CNA)AandLevel | One Medication Aide (LIMA B)) of four sampled newly hired staff members prior to the staff member beginning employment with resident contact. The facility census was 13. ' Review of the facility policy titled "Employee Disqualification List/Abuse Registry," dated 05/10, | showed the following: -All employees are expected to not have been | placed on the Employee Disqualification List by ; Missouri Department of Health and Senior | Services; | “Go online to www.dhss.mo.gov/EDL/ and follow prompts to obtain verification that the employee is nae Ati rea nn ert rencontre er crn rer ha A MY KOREN AOU 99 NE sr pemeRaEMRALLAE t Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER- RERRESENTATIVE'S SIGNATURE ICUs ae UES JON IEL adi MOLD STATE FORM if continuation sheet 1 of 3 PRINTED: 04/15/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 17054D B. WING 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1300 SOUTH MAIN CLINTON, MO 64735 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) ARBORS AT GLENDALE GARDENS-MEM CAR| Continued From page 1 clear on the EDL list; -Once verification is obtained, print and place in the yellow employee file if hired; -Check the Employee Disqualification list on a quarterly basis to ensure no current employees have been added to the list. 1. Review of CNAA's personnel record showed the following: -Hire and start date of 10/07/24: -The file did not contain an EDL check before start date; -Staff documented an EDL check completed on 12/31/24 during the quarterly EDL check of all employees. 2. Review of LIMA B's personnel record showed the following: -Hire and start date of 09/30/24; -The file did not contain an EDL check before start date; -Staff documented an EDL check completed on 12/31/24 during the quarterly EDL check of all employees. 3. During an interview on 04/08/25, at 4:35 P.M., the Director of Nursing (DON)/Interim Executive Director (ED) said the following: -He/She became the interim ED about two months ago; -The ED is usually responsible for completing EDL checks on prospective employees; -The former ED left in September of 2024 and there were a few other interim EDs between September of 2024 and February of 2025; -A new bookkeeper has been hired and he/she may be responsible for EDL checks going forward. *The higher class merited due to the extent of the Missouri Department of Health and Senior Services STATE FORM 6899 PLPP11 If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 17054D WINS NAME OF PROVIDER OR SUPPLIER 1300 SOUTH MAIN ARBORS AT GLENDALE GARDENS-MEM CAR| CLINTON, MO 64735 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 violation. Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 3 of 3 PLPP11 PLAN OF CORRECTION Provider/Supplier Name: The Arbors at Glendale Gardens Assisted Living by Americare Street Address, 1300 S. Main St. City, Zip: Clinton, MO 664735 Date of Survey: April 8, 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The filling of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the summary Statement of Deficiencies date April 9, 2025 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. Administrator and/or designee will verify that any individual is not listed on the Employee Disqualification List(Abuse Registry nana prior to being hired for any type of position at the facility. This Ongoing verification will be printed and placed in the employee's file. An audit was completed of all current employee files to ensure the EDL is documented. Any that weren't documented were 4/18/2025 checked immediately to verify that they were not on the Employee Disqualification List/(Abuse Registry. Administrator and/or designee will review the list of quarterly additions to the Employee Disqualification List to verify that none of our current employees have been added to this list affer being Ongoing hired. After reviewing, this document will be signed and placed in file/binder. 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.