GLENFIELD MEMORY CARE.

PRINTED: 08/28/2025 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 C 30372 B.WING 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 118 OHMES RD COTTLEVILLE, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GLENFIELD MEMORY CARE A4797 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 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 the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Wl This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure medication was administered per physician orders for one resident (Resident #1), in a review of four sampled residents. The physician prescribed morphine (opioid pain medication) and lorazapem (antianxiety medication) to be administered every eight hours. From 8/1/25 through 8/18/25 staff failed to Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Administrator 9/11/2025 STATE FORM bee QT8311 If continuation sheet 1 of 4 PRINTED: 08/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30372 B.WING 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 118 OHMES RD COTTLEVILLE, 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} GLENFIELD MEMORY CARE A4797 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 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 fo do so and the resident ‘s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if nota physician or a licensed nurse, shall be a certified medication technician or level | medication aide. il This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to ensure medication was administered per physician orders for one resident (Resident #1), in a review of four sampled residents. The physician prescribed morphine (opioid pain medication) and lorazapem (antianxiety medication) to be administered every eight hours. From 8/1/25 through 8/18/25 staff failed to Missouri Department of Health arid Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM B89 QT8311 if continuation sheet 1 of 4 PRINTED: 08/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {XT} PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30372 B.WING 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 118 OHMES RD COTTLEVILLE, 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} GLENFIELD MEMORY CARE A4797 Continued From page 1 administer the resident's scheduled 10:00 P.M. dose of morphine and lorazepam four times. The facility census was 15. Review of the facility's Medication Administration policy, dated 4/13/2020, showed the following: -Medication administration schedules are managed by QuickMar CareSuite program. This program was available on any facility computer or laptop in the building/ -Med Pass Rules: -Pass medication according to schedule in QuickMar CareSuite; -Make yourself familiar with the upcoming medication pass schedule; -Check QuickMar CareSuite regularly for scheduled medications, treatments, tasks, activities of daily living, etc.; -Chart missed medication, wasted medication, refused medications accurately and timely; -Report any problems to Licensed Practical Nurse (LPN), Registered Nurse (RN), Care Manager, or Administrator. 1. Review of Resident #1's face sheet, undated, showed the following: -The resident admitted on 6/20/24: -Diagnoses included Alzheimer’s dementia and anxiety; -He/She received hospice services. Review of the resident's physician orders, dated 7/30/25, showed the following: -Lorazepam (antianxiety) two milligrams {mg)/milliliters (mI give 0.25 mi by mouth every eight hours, scheduled at 6:00 A.M., 2:00 P.M., and 10:00 P.M.; -Morphine 100 mg/5 mi give 0.25 ml by mouth every twelve hours, scheduled for 8:00 A.M. and 8:00 PLM. Missouri Department of Health arid Senior Services STATE FORM 8895 QT8311 if continuation sheet 2 of 4 PRINTED: 08/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {XT} PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30372 B.WING 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 118 OHMES RD COTTLEVILLE, 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} GLENFIELD MEMORY CARE A4797 Continued From page 2 Review of the resident's physician orders, dated 8/4/25, showed the order for morphine was changed from administration every twelve hours (8:00 A.M. and 8:00 P_M.) to every eight hours (6:00 A.M., 2:00 P.M., and 10:00 P.M_). Review of the resident's medication administration record (MAR), dated August 2025, showed the following: -On 8/5/25 staff failed to administer the resident's 10:00 P.M. dose of lorazepam and morphine; -On 8/7/25 staff failed to administer the resident's 10:00 P.M. dose of lorazepam and morphine; -On 8/10/25 staff failed to administer the resident's 10:00 P.M. dose of lorazepam and morphine; -On 8/18/25 staff failed to administer the resident's 10:00 P.M. dose of lorazepam and morphine; -Staff failed to document the reason why the medications were not administered. During an interview on 8/26/25 at 7:17 A.M., LIMA C said the following: -Resident #1 was not having pain or anxiety that LIMA C observed; -He/She was confused about the resident's medication time and that was why he/she missed administering medications. During an interview on 8/19/25 at 12:23 P.M. and on 8/26/25 at 10:05 A.M., the administrator said her expectation was staff give medications per physician orders. Staff did not document why the medication was not given, it was just left blank. LIMA C was the staff member who worked when the 10:00 P.M. doses of medication were not administered to the resident. The facility stopped Missouri Department of Health arid Senior Services STATE FORM 8895 QT8311 if continuation sheet 3 of 4 PRINTED: 08/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {XT} PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30372 B.WING 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 118 OHMES RD COTTLEVILLE, 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} GLENFIELD MEMORY CARE A4797 Continued From page 3 having the nurse review the medication administration records weekly, because they did not have any issues at the time. She did not witness the resident have any signs or symptoms of pain or anxiety. She spoke with LIMA C on 8/26/25 about the missed doses of medication and LIMA C was confused because 10:00 P.M. was not a routine medication administration time and that was why LIMA C failed to administer the medications. MO257623 Missouri Department of Health arid Senior Services STATE FORM 8895 QT8311 if continuation sheet 4 of 4 P L A N O F C O R R EC T | O N Provider/Supplier Name: | Glenfield Memory Care Street Address, City, Zip: | 118 Ohmes Road, Cottleville, MO 63376 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | 26D2155841 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) co "Rane |ON DEFIECIENCY STATES FACILITY FAILED TO ENSURE MEDICATION WAS ADMINISTERED PER PHYSICIAN’S ORDERS FOR ONE RESIDENT. FACILITY PLAN OF CORRECTION: - ON 8/26/25: VERBAL COMMUNICATION FROM ADMINISTRATOR TO STAFF MEMBER WHO MISSED FOUR DOSES OF 10PM MEDICATION FROM 8/1/25- 8/18/25 WAS COMPLETED TO ASSESS FINDINGS AND PREVENT ANY FUTURE MISSING DOSES. ADMINISTRATOR HAS RESTARTED WEEKLY REVIEWS OF MEDICATION ADMINISTRATION RECORDS FOR ALL RESIDENTS. NURSE WILL BE RESPONSIBLE FOR COMPLETING REPORT AND 10/15/2025 REPORTING TO ADMINISTRATOR WEEKLY FOR THE MONTH OF SEPTEMBER AND OCTOBER. WEEKLY REPORTS WILL BE REEVALUATED BY END OF OCTOBER FOR POSSIBLE BIWEEKLY REPORTS TIMEFRAME IF NO MISSED MEDICATIONS ARE BEING FOUND WEEKLY. AT SEPTEMBER’S ALL STAFF MONTHLY MEETING, FACILITY’S MEDICATION POLICY WILL BE DISCUSSED AND REVISITED AMONG STAFF FOR EVERYONE’S BENEFIT AND TO AVOID ANY FURUTRE MISS COMMUNICATIONS. A4797 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.