CUBA VILLAGE MEMORY CARE.

PRINTED: 04/15/2626 ; ; FORM APPROVED Missouri Department of Health and Senior Service STATEMENT OF DEFICIENCIES {X14} PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 27071 eee 04/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY BD A VILLA CUB. GE MEMORY CARE CUBA, MO 68453 (X4} 4D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION {x8} 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) AA4756. 19 CSR 30-86.047(28)(I} Individual Service Pian - Signatures A4T5S _ The facility may admit or retain an individual for residency in an assisted living facility only ifthe individual does not require hospitalization or i skilled nursing placement as defined in this rule, and only if the facility: : () includes the signatures of an authorized representative of the facility and the resident or | . the resident's legal representative in the i . individualized service plan to acknowledge that _ the service plan has been reviewed and _ understood by the resident or legal _ representative; il | This regulation is not met as evidenced by: | Class i ' Based on interview and record review, the facility | _ staff failed to obtain signatures on individualized ' service plan ((iSP) a required assessment tool identifying the individual needs of the residents - and completed by qualified facility staff) to i acknowledge the plan had been reviewed and understood by the resident or their representative | for three of three sampled residents (Residents #1, #2 and #3). The facility census was 18. _ 1, Review of the facility provided policies showed _ they did not contain a policy for the review of _ ISPs. _ 2. Review of Resident #1's face sheet showed the resident admitted to the facility on 08/15/25. Review of the residant's ISP, dated 09/05/25, _ showed the record did not contain the signature _ of the resident or the resident's legal : ' representative. Missouri Department of Health and Senior Services ORATORY DIRECTOR'S OR PROVIGER/SUPPLIER REPRESENTATIVE'S SIGNATURE THLE Exepuh} (KB) DATE LA , fb. Sutcy) oie b-21-Le ORM 698 BOQ Hf continuation sheet 1 of 3 PRINTED: 04/15/2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 27071 B. WING 04/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA VILLAGE MEMORY CARE CUBA, MO 65453 (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) A4756| Continued From page 1 | 3. Review of Resident #2’s face sheet showed : the resident admitted to the facility on 02/03/26. Review of the resident's medical records showed | the records did not contain documentation of an — ISP or review of an ISP with the resident or his/her legal representative. | During an interview on 04/02/26 at 1:27 P.M., the | | resident said he/she moved to the facility a couple months ago and did not recall signing an ' ISP or meeting with staff to discuss services. 4. Review of Resident #3's face sheet showed ; the resident admitted to the facility on 02/06/26. Review of the resident's ISP, dated 02/06/26, showed the record did not contain the signature _ of the resident or the resident's legal representative. | 5. During an interview on 04/02/26 at 4:35 P.M., Licensed Practical Nurse (LPN) A said he/she could not locate documentation of aniSP being | | signed by or reviewed with Residents #1, #2 and _ : #3 or their representatives. The LPN said it is the — responsibility of the admitting nurse to complete | | the initial ISP on the day of admission and the full | | ISP should be completed and signed within five days of admission. During an interview on 04/02/26 at 5:00 P.M., the | | administrator said the facility nurse should review | ISP's with the resident representative and the : resident when it is clinically appropriate. The | administrator said he/she had became the interim | administrator in March 2026 and he/she did not ' know why the ISP's did not contain the signatures of the residents or their Missouri Department of Health and Senior Services STATE FORM i 9JQQ11 if continuation sheet 2 of 3 PRINTED: 04/15/2026 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 27071 BN ac 04/02/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (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 THEAPPROPRIATE =| —_—SCODAATEE DEFICIENCY) CUBA VILLAGE MEMORY CARE Continued From page 2 representatives. Missouri Department of Health and Senior Services STATE FORM saaa 9JQQ11 if continuation sheet 3 of 3 PLAN OF CORRECTION — : | Provider/Supplier | | sess Cuba Village Mernory Care | Street Address, : City, Zip: | 903 State Hwy DD Cuba, MO 65463 Sa oe ee nceactanesa i PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | Date of Survey: | 04/02/2026 ID PREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) | DATE This plan of correction (POC) is submitted as required under | State law. The submission of the POC does not constitute an i admission on the part of Cuba Village Memory Care (the i Facility) as to the accuracy of neither the surveyors’ findings, nor | the conclusions drawn there from. The Facility's submission of the POC does not constitute an admission on the part of the | 05/15/2026 Facility that the findings cited are accurate, that the findings constitute a deficiency, or the scope and severity regarding any deficiencies cited are correctly applied. This POC is intended to constitute the Facility’s credible letter alleging compliance. | Compliance has been and will be achieved by 05/15/2026. | The facility will ensure signatures are obtained on individual | service plans (ISP), a required assessment tool identifying the i _ A4756 individual needs of the residents and completed by qualified | 05/15/2026 =| | staff, to acknowledge the plan has been reviewed and understood by the resident and/or their representative. = aii ee eee eT ee DET TT enn T CE nae een ee od All residents are potentially at risk by this alleged deficient practice, _ | The Executive Director (ED) and Health and We i —— i 7 ness Director (HWD) will be in-serviced regarding the requirements of A4756 7 _ as it pertains to reviewing [SPs with residents and/or their | representatives, and obtaining signatures on the ISP by the | : | resident and/or their representative to acknowledge the plan has | 05/15/2026 | ' been reviewed and understood by the residents and/or their | representative. Inservice will be completed by Regional Director | of Operations (RDO) and record of completed in-service will be || keptin binder in BD's office. —— = | The HWD or her designee will review ISPs for residents 1, 2, { and 3 with the residents and/or their representative, and obtain | | | sSignature(s) from the residents and/or their representative to + 05/15/2026 | acknowledge the plan has been reviewed and understood by the residents 1, 2, and 3 will be kept in an ISP binder available to staff in the medication room. The HWD or her designee will audit ISPs for all residents to _ ensure each is signed by the resident and/or their representative to acknowledge the plan has been reviewed and understood by | the residents and/or their representative. Concerns will be | 08/15/2026 ' reported to ED and/or RDO, Regional Nurse Consultant (RNC). | . Signed copies of ISPs for ail residents will be kept in an ISP fo _______ binder available to staffin the medicationroom. ED and HWD will meet once weekly to discuss ISPs scheduled for completion that week. ED will ensure each resident scheduled for ISP completion and/or their representative signs the ISP to acknowledge the pian has been reviewed and understood by the residents and/or their representative. Documentation of ED/HWD weekly meetings and ED review for signatures by resident and/or their representative will be kept in the EDs office. Concerns will be reported to RDO, Regional Nurse Consultant(RNC). 05/15/2026 anes cpac Nes a a a ca 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.

PRINTED: 09/02/2025 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 Cc 27071 EWING 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST 86 PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ARBORS AT VICTORIAN PLACE OF CUBA, MEM CAR 19 CSR 30-86,047(35) Protective Oversight Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. Ill This regulation is not met as evidenced by: Class I] Based on observation, interview, and record review, facility staff failed to provide 24-hour protective oversight for one resident (Resident #1), who stated he/she was having suicidal ideations. The facility cansus was 24, 1, Review of the facility's Suicide Threat Precautions policy, dated 06/10/19, showed staff are directed as follows: -All communities should take appropriate precautionary steps to monitor a resident who has made a suicide threat known; -A resident who is contemplating suicide may not always make their intentlons known, in this case appropriate steps should be taken to prevent such actions; -lf a suicide threat is made community should put oné on one Supervision in place for that resident as soon as possible, the resident should not be left alone for any length of time; -Notify the physician, Director of Operations {DOP), and Registered Nurse-Certifled (RNC); -lIf determined that discharge for psychiatric evaluation is necessary, facilitate the transfer as soon as possible via ambulance to the nearest Emergency Room (ER) or psychiatric community Missour Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM be 4RHY11 PRINTED: 09/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 5. WING 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (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} ARBORS AT VICTORIAN PLACE OF CUBA, MEM CAR Continued From page 1 that will accept the resident. 2. Review of Resident #1's medical record showed the resident admitted to the facility on 8/7/25. Reviewed showed the resident diagnoses of schizoaffective disorder (a mental health condition characterized by a combination of schizophrenia and mood disorders}, Attention-Deficit Hyperactivity Disorder ((ADHD) a mental disorders of not able to focus, impulsivity, and hyperactivity), and chronic pain syndrome. Review of the resident's progress notes, dated 8/7/25, showed staff documented a fire occurred at the resident's primary community and the resident was safely relocated to another community with casework onsite to provide counseling or trauma support. Review of the resident's progress notes, dated 8/14/25, showed staff documented the resident has been increasingly agitated and verbally aggressive, throwing things, resident is his/her own person and stated, "| am leaving and | am going to find the closest bridge", staff called 911 based on the verbal threat of selfharm and EMS arrived, resident refused to be transported. Observation on 08/14/25 at 2:55 P.M., showed the resident in his/her room. Observation showed staff did not checked on the resident. Observation on 08/14/25 at 3:20 P.M., showed the resident in his/her room. Observation showed staff did not checked on the resident. Observation on 08/14/25 at 3:43 P.M., showed the resident remained in his/her room. Observation showed staff did not check an the | resident. Observation showed Level 1 Medication Missouri Department of Health and Senior Services STATE FORM enna 4RHY 44 If continuation sheel 2 of 5 PRINTED: 09/02/2025 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 fe: BING 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 303 HIGHWAY DD CUBA, MO 65453 (%4) 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) ARBORS AT VICTORIAN PLACE OF CUBA, MEM CAR Continued From page 2 Aide (LIMA) A at the nurse's station at the other end of the hail and the resident not visible. Observation on 08/14/25 at 4:00 P.M., the resident went outside to smoke unassisted. Observation showed LIMA B sat at the nurse's station at the end of the hall on his/her phone and the resident not visible. During an interview on 08/14/25 at 2:30 P.M., the Regional Vice President (VP) said he/she oversees the current and previous facility the resident had been in. The Regional VP said after the previous facility had a fire, they moved all the residents to other facilities. The Regional VP said the resident's case worker has made daily visits to help the resident transition to the new facility. The Regional VP said the resident has had increased behaviors such as verbal aggression and anxiety each day since moving. The Regional VP said the resident came up to his/her office around 11:00 A.M. today saying he/she was going to leave and find a bridge. The Regional VP said 911 was called and an ambulance came but the resident refused treatment. The Regional VP said he/she placed the resident on every 15-minute checks for suicide precautions and the resident's safety at that time and educated the staff to complete these. During an interview on 08/14/25 at 2:30 P.M., the resident's case worker said he/she has known the resident a long time. The case worker said he/she has been visiting the resident daily since the fire and today was as bad as he/she has ever seen the resident's mood. During an interview on 08/14/25 at 2:55 P.M., the resident said after his/her parent passed away and his primary facility residence recently caught Missouri Department of Health and Senior Services STATE FORM e39e ARHY 11 It continuation sheet 3 of § PRINTED: 09/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: (43) DATE SURVEY COMPLETED .¢) 08/14/2025 27071 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD c c ARBORS AT VICTORIAN PLACE OF CUBA, MEM CAR CUBA, MO 66453 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 3 on fire where he lost most of his/her belongings. The resident said he/she spoke to the prior facility's Administrator about his/her depression and all of the loss he/she had incurred over the past several weeks. The resident said he/she did tell staff today he/she was going to "go find a bridge” but he/she said he/she does not have a plan to kill himselffherself. The resident said, "I'm just not ok with anything right now". The resident said he/she was seeing a psychiatric doctor at his/her previous facility but has not seen one since he/she moved. During an interview on 08/14/25 at 4:00 P.M., LIMA B said he/she had been at the facility all day and was aware of the resident being on every 15-minute checks for suicide precautions. LIMA B said he/she or LIMA A are responsible to complete every 15-minute checks, LIMA B said he/she thought LIMA A was doing the checks, and he/she has not done any 15-minute checks on the resident. LIMA B said he/she did not know where the resident was or when he/she had seen the resident last. During an interview on 08/14/25 at 4:01 P.M., LIMA A said he/she had been at the facility all day and was not aware of the resident being on every 15-minute checks for suicide precautions. LIMAA said he/she or LIMA B are responsible to complete every 15 minute checks, LIMAA said he/she has not checked on the resident every 15-minutes because he/she was doing laundry. LIMA A said he/she was not sure when he/she saw the resident last. During an interview on 08/14/25 at 4:05 P.M., the Regional VP said LIMA's working the floor are responsible for completing every 15-minute checks on the resident. The Regional VP said Missouri Departmant of Health and Senior Services STATE FORM 8866 4RHY 11 If continuation sheet 4 of 5 PRINTED: 09/02/2025 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 IDENTIFICATIGN NUMBER: A. BUILDING: COMPLETED C B. WING 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (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 Tas REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ARBORS AT VICTORIAN PLACE OF CUBA, MEM CAR Continued From page 4 he/she was not aware the staff were not completing the checks every 15 minutes. The Regional VP said he/she is responsible to oversee the staff and ensure the 15-minute checks are being completed. The Regional VP said he/she did not know where the resident was or when he/she saw the resident last. MO00257898 Missouri Department of Health and Senior Services STATE FORM aaa 4RHY11 If continuation sheet 5 of 6 PLAN OF CORRECTION | Provider/Supplier A Name; rbors at Victorian Place of Cuba Memory Care Street Address, ; : City, Zip: 903 Highway DD, Cuba, MO 65453 Date of Survey: 08/14/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 27071 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE In response to 19 CSR 30-88.047 Protective Oversight Immediate Action: LIMA A & B as well as all other staff on duty were immediately provided education by the Director of Nurses on policy and procedures for providing protective oversight for residents who are suicidal or displaying any behaviors that places them or others at risk for harm. Education included procedures for completing documented 15-minute visual checks. in the event that the resident is visiting with visitors, staff is to continue the visual check without invading the privacy of ihe resident. Staff member responsible for 15-minute checks will complete documentation indicating 15-minute check are completed. Off Duty staff were provided education on 15-minute checks upon the arrival to their next scheduled shift. A4776 Resident #1 was evaluated by Dr. an 8/15/2025 and determined that the resident was not a threat to others or self and was able to be removed from 15-minute checks. Resident #1 later on 8/18/25 transferred to in , Missouri. or one on one services. Ongoing Compliance: Administrator will conduct ongoing education to all current and new hire staff on completing 15-minute protective oversight check on any resident displaying or making threats of suicide in- servicing will include which staff member on duty is assigned the task and to complete documentation of the 15-minute visual checks. All training to be conducted on or before 09/08/2026 and then ongoing for newly hired staff and no less than annual for current staff. Administrator and or designee in absence of will assure ongoing compliance through review of 15-minute check documentation and assignment sheets for 15-minute checks or one on one services. Com letion Date: 09/08/2025 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.

PRINTED: 07/11/2024 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 B.WING 07/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (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) ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L A2237| 19 CSR 30-86.022(8)(B) Exit-Directional Indicators Exit Signs. (B) Directional indicators showing the direction of travel shall be placed in corridors, passageways, or other locations where the direction of travel to reach the nearest exit is not apparent. I/II] This regulation is not met as evidenced by: Class III Based on observation and interview during the fire inspection process, the facility had confusing exit signs which had illuminated directional arrows in inappropriate locations. The facility census was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Observation on revealed an exit sign with a directional arrow indicating a turn to the courtyard, which is not an exit. During the exit interview on July 10, 2024 at 1330 the administrator stated she would have the maintenance man stated he would cover the misleading arrow. 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. |/Il This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM If continuation sheet 1 of 4 PRINTED: 07/11/2024 FORM APPROVED STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B.WING 07/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (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) ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L Continued From page 1 Based on observation and interview during the fire safety inspection process, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Observation revealed a missing escutcheon ring in furnace room 6/7. Observation revealed a missing escutcheon ring in the linen closet directly across from furnace room 6/7. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the building During the exit interview on July 10, 2024 at 1315 the administrator advised she would have maintenance replace the missing escutcheon rings. 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. Il This regulation is not met as evidenced by: Class Il Based on observation and interview during the fire safety inspection process, the facility failed to ensure all emergency lighting was operational. The facility census was eleven (11). This deficiency affects eleven (11) of eleven (11) Missouri Department of Health and Senior Services STATE FORM ats 8GV411 If continuation sheet 2 of 4 PRINTED: 07/11/2024 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 BOMING) 07/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EAGH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L Continued From page 2 residents. Observation revealed an emergency light failed to illuminate while depressing the test button in the sprinkler riser room. During the exit interview on July 10, 2024 at 1320, the administrator stated she would have maintenance make the repair. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. I/II This regulation is not met as evidenced by: Class Ill Missouri Department of Health and Senior Services STATE FORM 6299 8GV411 If continuation sheet 3 of 4 PRINTED: 07/11/2024 Missouri Department of Health and Senior Services FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (x4) ID 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) ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L Continued From page 3 Based on observation and interview during the | fire inspection process, the facility failed to ensure the facility's electric wiring was properly maintained. The facility census was eleven (11). This deficiency affects eleven (11) of eleven (11) | residents. Observation revealed an emergency light hanging by it's wires next to room 13. Observation revealed an electrical outlet hanging by it's wires in the laundry room next to room 5. During the exit interview on July 10, 2024 at 1325 the administrator stated she would have maintenance make repairs. Missouri Department of Health and Senior Services STATE FORM som 8GV411 COMPLETED 07/10/2024 (x8) COMPLETE DATE If continuation sneet 4 of 4 PLAN OF CORRECTION siiilsiiaiaaa niet Arbors at Victorian Place of Cuba Name: Street Address, | 903 Hwy DD Cuba, Missouri 65453 City, Zip: Date of Survey: 07/10/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Exit Sign showing an exit pointing towards the courtyard between the buildings will have the Arrow blackened out so it does not point to this enclosed courtyard. The missing escutcheon ring in the linen closet across from furnace room 6/7 will be replaced The Missing escutcheon ring missing in furnace room 6/7 will be replaced. Maintenance will incorporate checking escutcheon rings in every 7/26/2024 location during his monthly safety inspections. This will be 7/26/2024 ongoing throughout the year. Emergency Lighting- battery powered in the sprinkler riser room will be replaced and functioning correctly. Maintenance will ensure that all emergency lighting is in proper 7/26/2024 working order during his monthly safety inspections throughout A2237 Electrical Wiring, maintained, inspected A2269 Maintenance will repair this loose emergency Light and ensure A3214 that it is mounted correctly and in proper functioning order. Maintenance will ensure that all electrical wiring is maintained COMPLETION DATE the year 7/26/2024 and inspected during his monthly safety inspections throughout

PRINTED: 05/31/2024 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 c 27071 cilia 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (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) ARBORS VICTORIAN PL CUBA, MEM CARE A‘ A4724 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II | This regulation is not met as evidenced by: Class II Based on interview and record review, tacility staff failed to ensure the required two step tuberculosis ((TB) a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered timely for two (Level One Medication Aide (LIMA) A and Certified Nursing | Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) two (2}-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test | should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two years. Review of the facility's Policy for Employee TB Testing, undated, showed: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 4 teliv STATE FORM gag P| 14 If continuation sheet 1 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4724 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. 1] This regulation is not met as evidenced by: Class II Based on interview and record review, tacility staff failed to ensure the required two step tuberculosis ((1B) a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered timely for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test fo determine if you have tuberculosis) two (2)-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two years. Review of the facility's Policy for Employee TB Testing, undated, showed: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) DATE STATE FORM sao SKYW11 If continuation sheet 4 of 15 NAME OF PROVIDER OR SUPPLIER ARBORS AAT24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 27071 VICTORIAN PL CUBA, MEM CARE AS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 -It is the Administrator's responsibility to assure the TB test is administered and results read prior to an employee beginning employment, and to assure annual testing is completed; -To assure that employees have been tested for Tuberculosis prior to working and do not have active disease along with annual surveillance in order to be in compliance with state regulations; -All prospective employees will have the first TB test administered prior fo day 1 of employment. The TB test result may be read on the first day of employment; -lf an employee is unable to have the Tuberculin test administered because of a documented history/positive PPD test, a Chest x-ray is required, the report must state that evidence of active pulmonary disease has been ruled out. A copy of the Chest x-ray report which has been performed within the last 6 months is acceptable. Otherwise the facility will send the prospective employee to have a Chest x-ray completed, prior fo beginning employment; -The second TB test is required for new employees and will be administered 7-21 days after the initial test. 1. Review of LIMAA's personnel file showed a hire date of 1/29/2024. Review showed the L1MA received his/her first step TB administered on 1-29-2024 and read on 1-31-2024. Review showed staff documented he/she recieved the second TB step administered on 4-16-2024 (78 days past the initial test). 2. Review of CNA B's personnel file showed a hire date of 3/25/2024. Review showed the CNA's received his/her first step TB on 3-25-2024. Review showed the file did not contain documentation of the results of the first test or Missouri Department of Health and Senior Services STATE FORM {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 6899 CROSS-REFERENCED TO THE APPROPRIATE SKYW11 PRINTED: 05/31/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 05/16/2024 STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} lf continuation sheet 2 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4724 Continued From page 2 documentation of the second TB test. 3. During an interview on 5/6/2024 at 1:34 P_M., the administrator said he/she is responsible to ensure the TB tests are completed timely and in the employees personel file. The administrator said he/she was responsible for the administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(20\(K) Personnel Record - orientation training The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (K) Documentation of what the employee was instructed on during orientation training; III This regulation is not met as evidenced by: Class Ill Based on interview and record review facility staff failed to provide orientation training for two staff members (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. The facility staff did not provide a policy in regards to job responsibilities training. 2. Review of LIMAA's personnel record showed a hire date of 03/25/2024. Review showed the record did not contain documentation of orientation training . Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 3 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4735 Continued From page 3 3. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of orientation training . During an interview on 5/16/2024 at 1:34 P_M., the administrator said he/she is responsible to ensure all required training was received to all of his/her staff members. The administrator said he/she was responsible for all the training of his/her staff. The administrator said he/she was responsbile for both administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(62)}(A) Orientation - job responsibilities Prior to or on the first day that anew employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (A) Job responsibilities; I/II This regulation is not met as evidenced by: Class Ill Based on interview and record review facility staff failed to provide job responsibilities training for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members The facility census was 11. 1. The facility staff did not provide a policy in regards to job responsibilities training. 2. Review of LIMAA's personnel record showed Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 4 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4846 Continued From page 4 a hire date of 03/25/2024. Review showed the record did not contain documentation of job responsibilities training. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of job responsibilities training . During an interview on 5-16-2024 at 1:34 P_M., the administrator said he/she is responsible to ensure all required training was received to all of his/her staff members. The administrator said he/she was responsible for all the training of his/her staff. The administrator said he/she was responsbile for both administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(62)(B) Orientation - emergency response procedures Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (B) Emergency response procedures; Hi/lll This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to provide emergency response training for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B). of three sampled staff members. The facility census Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 5 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4847 Continued From page 5 was 11. 1. The facility staff did not provide a policy in regards fo emergency response training. 2. Review of LIMAA's personnel record showed a hire date of 03/25/2024. Review showed the record did not contain documentation of emergency response training. 3. Review of CNAB's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of emergency response training. During an interview on 5-16-2024 at 1:34 P_M., the administrator said he/she is responsible to ensure that all required training was received to all of his/her staff members. The administrator said he/she was responsible for all the training of his/her staff. The administrator said he/she was responsbile for both administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(62)(C) Orientation - infection control/handwashing Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (C) Infection control and handwashing procedures and requirements; II/II This regulation is not met as evidenced by: Class Ill Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 6 of 15 PRINTED: 05/31/2024 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 Cc 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4848 Continued From page 6 Based on interview and record review facility staff failed to provide infection control/handwashing training for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. The facility staff did not provide a policy in regards fo infection control/handwashing training. 2. Review of LIMAA's personnel record showed a hire date of 03/25/2024. Review showed the record did not contain documentation of infection control/handwashing training . 3. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of infection control/nandwashing training. During an interview on 5-16-2024 at 1:34 P_M., the administrator said he/she is responsible to ensure that all required training was received to all of his/her staff members. The administrator said he/she was responsible for all the training of his/her staff. The administrator said he/she was responsbile for both administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(62)(E) Orientation - resident A4850 dignity Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 7 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD ‘ ARBORS VICTORIAN PL CUBA, MEM CARE As CUBA, MO 65453 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} A4850 Continued From page 7 the following: (E) Preservation of resident dignity; I/II] This regulation is not met as evidenced by: Class Ill Based on interview and record review facility staff failed to provide dignity training for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. The facility staff did not provide a policy in regards fo resident dignity training . 2. Review of LIMAA's personnel record showed a hire date of 03/25/2024. Review showed the record did not contain documentation of resident dignity training. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of resident dignity training. During an interview on 5-16-2024 at 1:34 P_M., the administrator said he/she is responsible to ensure that all required training was received to all of his/her staff members. The administrator said he/she was responsible for the resident dignity training. The administrator said he/she was responsbile for both administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(62)(H) Orientation - resident A4853 rights/property Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 8 of 15 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ARBORS A4B53 Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 27071 VICTORIAN PL CUBA, MEM CARE AS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (H) Instruction regarding the rights of residents and protection of property; H/I! This regulation is not met as evidenced by: Class Ill Based on interview and record review facility staff failed to provide resident rights/property training for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. The facility staff did not provide a policy in regards fo resident rights/property training. 2. Review of LIMAA's personnel record showed a hire date of 03/25/2024. Review showed the record did not contain documentation of resident rights/property training. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of resident rights/property training. During an interview on 5-16-2024 at 1:34 P_M., the administrator said he/she is responsible to ensure that all required training was received to all of his/her staff members. The administrator said he/she was responsible for the resident right/property training. The administrator said he/she was responsbile for both administrative Missouri Department of Health and Senior Services STATE FORM {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 6899 CROSS-REFERENCED TO THE APPROPRIATE SKYW11 PRINTED: 05/31/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 05/16/2024 STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} lf continuation sheet 9 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4853_ Continued From page 9 duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(62)(l) Orientation - resident mental illness Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (1) Instruction regarding working with residents with mental illness; {I/II This regulation is not met as evidenced by: Class Ill Based on interview and record review facility staff failed to provide resident mental illness training for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. The facility staff did not provide a policy in regards fo mental illness training. 2. Review of LIMAA's personnel record showed a hire date of 03/25/2024. Review showed the record did not contain documentation of resident mental illness training. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of resident menial illness training. Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 10 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4854 Continued From page 10 During an interview on 5-16-2024 at 1:34 P.M, the administrator said he/she is responsible to ensure that all required training was received to all of his/her staff members. The administrator said he/she was both responsible for the administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(62)(J) Orientation-person centered care/social model Prior to or on the first day that anew employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (J) Instruction regarding person-centered care and the concept of a social model of care, and techniques that are effective in enhancing resident choice and control over his or her own environment. {IH This regulation is not met as evidenced by: Class Ill Based on interview and record review facility staff failed to provide training on person centered care for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. The facility staff did not provide a policy in regards to person centered care training. 2. Review of LIMAA's personnel record showed Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 if continuation sheet 11 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4855 Continued From page 11 a hire date of 03/25/2024. Review showed the record did not contain documentation of person centered care training. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of person centered care training. During an interview on 5-16-2024 at 1:34 P_M., the administrator said he/she is responsible to ensure that all required training was received to all of his/her staff members. The administrator said he/she was responsible for the administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr in addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer ' s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer ' s disease and related dementias as follows: (A) For employees providing direct care fo such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer's disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 12 of 15 PRINTED: 05/31/2024 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: COMPLETED A. BUILDING: Cc 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A4856 Continued From page 12 routine for residents based on their needs, and understanding and dealing with family issues; and HII This regulation is not met as evidenced by: Class Ill Based on interview and record review facility staff failed to provide Alzheimer's/dementia training for two (Level One Medication Aide (LIMA) A and Certified Nursing Aide (CNA) B) of three sampled staff members. The facility census was 11. 1. The facility staff did not provide a policy in regards to Alzheimer's/dementia training. 2. Review of LIMAA's personnel record showed a hire date of 03/25/2024. Review showed the record did not contain documentation of Alzheimer's/dementia training. Review of CNA B's personnel record showed a hire date of 01/29/2024. Review showed the record did not contain documentation of Alzheimer's/dementia training. During an interview on 5-16-2024 at 1:34 P_M., the administrator said he/she is responsible to ensure that all required training was received to all of his/her staff members. The administrator said he/she was responsible for the administrative duties and Director of Nurse duties for a few months and some tasks may not be complete as they should. 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 13 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 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 VICTORIAN PL CUBA, MEM CARE As A8004 Continued From page 13 Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/tll This regulation is not met as evidenced by: Class Ill Based on record review and interview, the facility staff failed to ensure the resident or legally authorized representative's individual rights and responsibilities were renewed annually for three (Resident #1, #2, and #3) out of three sampled residents. The facility census was 11. 1. Review of Resident #1's medical record showed: -Date of admission 05/04/2024: -Review showed the record did not contain the rights and responsibilities of the residents were reviewed annually after admission by the resident or the resident's legal representative. 2. Review of Resident #2’s medical record showed: -Date of admission 02/28/2022; -Review showed the record did not include the rights and responsibilities of the residents were reviewed annually after admission by the resident or the resident's legal representative. 3. Review of Resident #3's medical recard showed: Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 14 of 15 PRINTED: 05/31/2024 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 27071 B.WING 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 903 HIGHWAY DD CUBA, MO 65453 (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} ARBORS VICTORIAN PL CUBA, MEM CARE As A8004 Continued From page 14 -Date of admission 11/03/2017; -Review showed the record did not include the rights and responsibilities of the residents were reviewed annually after admissionby the resident or the resident's legal representative. During an interview on 5-16-2024 at 1:34 P.M_, the administrator said he/she was not aware the resident's rights were not reviewed and signed annually by the resident or the resident's designee. The administrator said he/she is responsible to ensure this is completed. Missouri Department of Health and Senior Services STATE FORM 5899 SKYW 11 If continuation sheet 15 of 15 lier Name: Street Address, City, Zip: Date of Survey: LE ID PREFIX TAG A4724 Provider/Supp The Arbors at Victorian Place of Cuba the past two years. PLAN OF CORRECTION 903 Highway DD Cuba, MO 65453 5/16/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCED TO THE APPROPRIATE DEFICIENCY 19 CSR 30-86.047 (19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities 19 CSR 20-20.100 I General requirement for Tuberculosis testing for employees in Long-term care facilities shall screen their employees for tuberculosis using Mantoux method purified in Long Term Care Facilities, 19 CSR 20-20.100 reads as follows: - Long term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD- a Skin test to determine if you have tuberculosis) two (2)- step tuberculin test within one month prior to starting employment; - Itis the responsibility of the facility to maintain documentation of each employee’s tuberculin status; - Ifthe initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within COMPLETION DATE 7/112024 The facility will ensure the required two step tuberculosis (TB) screening test are administered timely in accordance with general requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20- 20.100. All residents are considered at risk for this deficient practice LIMA A has received required two step tuberculosis screening test on Shp/zy & b)i}lay both subsequent tests were negative for TB C.N.A B has received required two step tuberculosis screening test on SliyJay & lila both subsequent tests were neg Administrator and or designee has completed an audit of all employee personnel filed ensuring that all employees have received required two-step tuberculosis screening test and annual testing has been completed. Regional Nurse Consultant and or Designee will in-service Administrator and nurse on Tuberculosis screening test ensuring that the first TB test is be administered prior to day 1 of employment and second test administered 7-21 days after the initial test. As well as annual surveillance thereafter. Regional Nurse Consultant and or designee will in-service Administrator and nurse on if an employee is unable to have the TB test because of a documented history/positive PPD test, a chest x-ray is required. A copy of the chest x- ray report performed within the last 6 months is acceptable as long as it states that the evidence of active pulmonary disease has been ruled out. The Nurse or designee will review TB records of new hires to ensure that Two-step TB test have been given in accordance to state regulations monthly. The nurse or designee will review employee TB records monthly and ensure that any annual screens are completed in accordance to state regulations. The nurse or designee will report continued compliance on TB testing for both 2 step testing for new hires and annual testing compliance to the Administrator monthly on DON report. 19 CSR 30-86.047(20)(K) Personnel Record-orientation training. the administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following (K) Documentation of 7/1/24 what the employee was instructed during orientation training. The facility will provide orientation training for all staff members. All residents are considered at risk for this deficient practice. LIMA A has received the proper orientation and orientation documentation has been updated in his/her personnel record. C.N.A B A has received the proper orientation and orientation documentation has been updated in his/her personnel record Administrator and or designee has audited all employee personnel records to ensure that all employees have orientation documentation completed in their file. Regional Director of Operations and or designee will in- service Administrator by 6/20/24 on ensuring that orientation documentation is completed on all employees and records of employee orientation are kept in employee personnel records. Administrator and or designee will perform quarterly audits of employee files to ensure that orientation documentation has be completed and placed in employee personnel records. Administrator and or Designee will report continued compliance to Regional Director of Operations monthly on Administrator monthly report. 19 CSR 30-86.047(62)(A) Orientation- job responsibilities Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following (A) Job responsibilities The facility will provide job responsibilities training for all employees. This training will be at least two (2) hours and appropriate to employee’s job function. All residents are considered at risk for this deficient practice. LIMA A has received job responsibility training and the signed documentation of that training has been added to employee personnel file. C.N.A B has received job responsibility training and the signed documentation of that training has been added to employee personnel file. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have signed job responsibilities in their employee personnel records. Regional Director of Operations and or designee will in- service Administrator by 6/24/24 on ensuring that all employees on first day that a new employee works in the facility he/she will receive job responsibility training and 7/1/24 those records will be placed in the employees personnel file. Administrator and or designee will audit all new hires files monthly to ensure that job responsibility training has been completed and records of training is in the employee personnel file. Administrator will report continued compliance to Regional Operation Director Monthly on Administrator monthly report. 19 CSR 30-86.047(62)(B) Orientation emergency response procedures. Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following (B) Emergency procedures. The facility will ensure to provide emergency response training to all employees prior to or on the first day the A4847 7/1/24 LIMA A has received emergency response training and record of that training has been added to employees personnel file. C.N.A B has received emergency response training and record of that training has been added to employees personnel file. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have emergency response training in their employee personnel records. Regional Director of Operations will in-service Administrator or Designee by 6/24/24 on ensuring that all new employees prior to or on first day that a new employee works in the facility he/she will receive orientation on emergency response procedures and copy’s of that training personnel record. Administrator and or designee will audit all new hires files monthly to ensure that emergency response training has been completed and records of training is in the employee personnel file. Administrator will report continued compliance to Regional Operation Director Monthly on Administrator monthly report 19 CSR 30-86.047 (62)(C) Orientation — Infection control/ handwashing A4848 Prior to or on the first day that a new employee works in 7/1/24 the facility he shall receive orientation of at least two (2) hours appropriate to his or her job function. The facility will ensure to provide infection control/handwashing training to new employees prior to or on the first day that a new employee. All residents are considered at risk for this deficient practice LIMA A has been trained on infection control/handwashing and the documentation has been added to employee’s personnel records. C.N.A B’s has been trained on infection control/handwashing and the documentation has been added to employee’s personnel records. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have infection control/handwashing training in their employee personnel records. Regional Director of Operations will in-service Administrator or Designee by 6/24/24 on ensuring that all new employees prior to or on first day that a new employee works in the facility he/she will receive orientation on infection control/hand washing and copies of that training has been placed in employees personnel record. Administrator and or designee will audit all new hires files monthly to ensure that handwashing training has been completed and records of training is in the employee personnel file. Administrator will report continued compliance to Regional Operation Director Monthly on Administrator monthly report 19 CSR 30-86.047 (62)(E) Orientation- Resident dignity Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include the following: E) Preservation of resident dignit The facility will ensure to provide dignity training prior to or on the first day that a new employee works in the facility and copies of that training will be placed in employee personnel file. All residents are considered at risk for this deficient | practice 7/1/24 LIMA A has been trained on resident dignity training and the documentation has been added to employee’s personnel records. C.N.A B’s has been trained on resident dignity training and the documentation has been added to employee’s personnel records. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have resident dignity training in their employee personnel records. Regional Director of Operations will in-service Administrator or Designee by 6/24/24 on ensuring that all new employees prior to or on first day that a new employee works in the facility he/she will receive orientation on Resident dignity training and copies of that training has been placed in employees personnel record. Administrator and or designee will audit all new hires files monthly to ensure resident dignity training has been completed and records of training is in the employee personnel file. Administrator will report continued compliance to Regional Operation Director Monthly on Administrator 19 CSR 30-860.47 (62)(H) Orientation — resident rights/property Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include the following: (H) Instruction regarding the rights of residents and protection of property. The facility will provide resident rights/property training for all new employees prior to or on the first day that new employee works in the facility. All residents are considered at risk for this deficient practice LIMA A has been trained on resident rights/property and the documentation has been added to employee’s personnel records. C.N.A B’s has been trained on resident rights/property and the documentation has been added to employee’s personnel records. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have been trained on resident rights/property and copy of training is in their employee personnel records. A4853 7/1/24 Regional Director of Operations will in-service Administrator or Designee by 6/24/24 on ensuring that all new employees prior to or on first day that a new employee works in the facility he/she will receive orientation on resident rights/property and copies of that training has been placed in employees personnel record. Administrator and or designee will audit all new hires files monthly to ensure resident right/property training has been completed and records of training is in the employee personnel file. Administrator will report continued compliance to Regional Operation Director Monthly on Administrator monthly report 19 CSR 30-86.047 (62)(1) Orientation- resident mental illness Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (I) Instructions regarding working with residents with mental illness The facility will ensure to provide resident mental illness training prior to or on the first day that a new employee works in the facili All residents are considered at risk for this deficient practice LIMA A has been trained on resident mental illness and the documentation has been added to employee’s personnel records. C.N.A B’s has been trained on mental illness and the documentation has been added to employee’s personnel records. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have been trained on mental illness and copy of training is in their employee personnel records. Regional Director of Operations will in-service Administrator or Designee by 6/24/24 on ensuring that all new employees prior to or on first day that a new employee works in the facility he/she will receive orientation on mental illness and copies of that training has been placed in employees personnel record. Administrator and or designee will audit all new hires files monthly to ensure mental illness training has been completed and records of training is in the employee personnel file. A4854 7/1/24 Administrator will report continued compliance to Regional Operation Director Monthly on Administrator monthly report 19 CSR 30-86.047 (62)(J) Orientation-person centered care/social model Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least AA855 two (2) hours appropriate to his or her job function. This shall include at least the following: (J) Instruction regarding person-centered care and the concept of a social model of care, and techniques that are effective in enhancing resident choice and control over his or her own environment. The facility will ensure to provide training on person centered care prior to or on first day that a new employee works in the facili 7/1/24 All residents are considered at risk for this deficient practice LIMA A has been trained on person-centered care and the concept of a social model of care and techniques and the documentation has been added to employee’s personnel records. C.N.A B’s has been trained on person-centered care and the concept of a social model of care and techniques and the documentation has been added to employee’s personnel records. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have been trained on person-centered care and the concept of a social model of care and techniques and copy of training is in their employee personnel records. Regional Director of Operations will in-service Administrator or Designee by 6/24/24 on ensuring that all new employees prior to or on first day that a new employee works in the facility he/she will receive orientation on person-centered care and the concept of a social model of care and techniques and copies of that training has been placed in employees personnel record. Administrator and or designee will audit all new hires files monthly to ensure person-centered care and the concept of a social model of care and techniques training has been completed and records of training is in the employee personnel file. Administrator will report continued compliance to Regional Operation Director Monthly on Administrator 19 CSR 30-86.047 (63)(A) Alz/Dementia Training-Direct Care Staff, 3 hours In addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer’s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer’s disease and related dementias as follows: (A) For employees providing direct care to such persons, A4856 the orientation training shall include at least (3) hours of 7/1/24 training including at a minimum an overview of mentally confused residents such as those having Alzheimer’s disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues. The facility will provide Alzheimer’ s/dementia training for employees providing direct care to such persons, the orientation training shall include at least (3) hours of training. All residents are considered at risk for this deficient practice LIMA A has been trained on Alzheimer’s/Dementia and the documentation has been added to employee’s personnel records. C.N.A B’s has been trained on Alzheimer’s/Dementia and the documentation has been added to employee’s personnel records. Administrator and or Designee will complete employee personnel audit by 6/24/24 and ensure that all employees have been trained on Alzheimer’s/Dementia and copy of training is in their employee personnel records. Regional Director of Operations will in-service Administrator or Designee by 6/24/24 on ensuring that all new employees prior to or on first day that a new employee works in the facility he/she will receive orientation on Alzheimer’s/Dementia and copies of that training has been placed in employees personnel record. Administrator and or designee will audit all new hires files monthly to ensure Alzheimer’s/Dementia training has been completed and records of training is in the employee personnel file. Administrator will report continued compliance to Regional Operation Director Monthly on Administrator 19 CSR 30-880.10 (4) Resident Rights- Admission/Annual Review. Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual’s rights and 7/1/24 responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his next of kin, legally authorized representative or designee, either in a group session or individually. The facility will ensure the resident or legally authorized representative’s individual rights and responsibilities are renewed annually for all residents that reside in the communi All residents are considered at risk for this deficient practice. Resident #1’s resident rights have been reviewed with resident and or his/her next of kin, legally authorized Resident #2’s resident rights have been reviewed with resident and or his/her next of kin, legally authorized representative or designee. Resident #3’s resident rights have been reviewed with resident and or his/her next of kin, legally authorized representative or designee. Regional Nurse Consultant and or designee will complete audit of all resident health records to ensure that resident rights have been completed upon admission and annually thereafter on all residents that reside at the community by 6/24/24. Regional Nurse Consultant and or designee will in-service Administrator and nurse on resident rights being completed upon admission and annually with resident and or his/her next of kin, legally authorized representative or designee. Nurse and or designee will monitor for continued compliance by completing quarterly audits of residents health record to ensure that resident rights have been reviewed upon admission and annually thereafter with resident and or his/her next of kin, legally authorized representative or designee. a Administrator monthly on monthly DON report. 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.

PRINTED: 09/14/2023 a 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 27071 B. WING 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID 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 on DEFICIENCY ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L A2237| 19 CSR 30-86.022(8)(B) Exit-Directional Indicators Exit Signs. (B) Directional indicators showing the direction of travel shall be placed in corridors, passageways, or other locations where the direction of travel to reach the nearest exit is not apparent. II/II This regulation is not met as evidenced by: Class Ill | Based on observation and interview during the fire inspection process on September 11, 2023, the facility had confusing exit signs which had illuminated directional arrows in inappropriate locations. The facility census on September 11, 2023 was eight (8). This deficiency affects eight (8) out eight (8) residents. Observation on September 11, 2023 at 1328 revealed an exit sign with a directional arrow at the automatic fire door an the northeast wing, indicating a turn that was not there. Observation on September 11, 2023 at 1333 _ revealed an exit sign with a directional arrow at exit door three (3), indicating a turn that was not there Observation on September 11, 2023 at 1334 revealed an exit sign with a directional arrow at at the automatic fire door on the southeast wing, indicating a turn that was not there. During an interview on September 11, 2023 at 1430 the maintenance man stated he would cover the misleading arrows. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PAOVIDER/SUPPLIER REPRESENFATIVE’S SIGNATURE (%6) DATE STATE FORM epsa E5GD11 If continuation sheet 1 of 6 PRINTED: 09/14/2023 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 27071 —$—$$ 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 903 HIGHWAY DD CUBA, MO 65453 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE ae TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L 19 CSR 30-86.022(8)(B) Exit-Directional Indicators Exit Signs. (B) Directional indicators showing the direction of travel shall be placed in corridors, passageways, or other locations where the direction of travel to reach the nearest exit is not apparent. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire inspection process on September 11, 2023, the facility had confusing exit signs which had illuminated directional arrows in inappropriate locations. The facility census on September 11, 2023 was eight (8). This deficiency affects eight (8) out eight (8) residents. Observation on September 11, 2023 at 1328 revealed an exit sign with a directional arrow at the automatic fire door on the northeast wing, indicating a turn that was not there. Observation on September 11, 2023 at 1333 revealed an exit sign with a directional arrow at exit door three (3), indicating a turn that was not there Observation on September 11, 2023 at 1334 revealed an exit sign with a directional arrow at at the automatic fire door on the southeast wing, indicating a turn that was not there. During an interview on September 11, 2023 at 1430 the maintenance man stated he would cover the misleading arrows. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM Sone E5GD11 If continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 27071 NAME OF PROVIDER OR SUPPLIER 903 HIGHWAY DD ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L CUBA, MO 65453 (x4) ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL Continued From page 1 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/II| This regulation is not met as evidenced by: Class III Based on observation and interview during the fire inspection process on September 11, 2023, revealed the facility failed to ensure oxygen storage shall be in accordance with NFPA 99, 1999 Edition. The facility census on September 11, 2023 was eight (8). This deficiency affects eight (8) out eight (8) residents. Observation on September 11, 2023 at 1340 revealed no "Oxygen in Use" signage on the door of room eighteen (18). During an interview on September 11, 2023 at 1445 the maintenance man stated he would place the appropriate signage. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (X2) MULTIPLE CONSTRUCTION A. BUILDING: E5GD11 PRINTED: 09/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/11/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE ae CROSS-REFERENCED TO THE APPROPRIATE If continuation sheet 2 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 27071 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 903 HIGHWAY DD CUBA, MO 65453 ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 Class III Based on observation and interview during the fire inspection process on September 11, 2023 the facility failed to maintain the building in good repair. The facility census on September 11, 2023 was eight (8). This deficiency affects eight (8) out eight (8) residents. Observation on September 11, 2023 at 1311 revealed a ceiling penetration in furnace room three (3). Observation on September 11, 2023 at 1312 revealed a wall penetration behind the front door in the kitchen. Observation on September 11, 2023 at 1326 revealed a wall penetration in the southeast laundry room. Observation on September 11, 2023 at 1331 revealed a missing escutcheon ring in furnace room six/seven (6/7). Observation on September 11, 2023 at 1334 revealed a hanging escutcheon ring in the peak of the lobby. Observation on September 11, 2023 at 1343 revealed a wall penetration in the northwest laundry room. Observation on September 11, 2023 at 1349 revealed a wall penetration in furnace room ten/eleven (10/11). Observation on September 11, 2023 at 1352 Missouri Department of Health and Senior Services STATE FORM 6899 ID PREFIX E5GD11 PRINTED: 09/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/11/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE If continuation sheet 3 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 27071 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 903 HIGHWAY DD CUBA, MO 65453 ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 3 revealed a wall penetration in the southwest laundry room. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. Observation on September 11, 2023 at 1402 revealed damaged panic hardware to the front door of the building. While it is currently functional, it will only continue to deteriorate and may stop functioning. During an interview on September 11, 2023 at 1415 the maintenance stated he knew about the holes, caused by recent water leaks, and that he is in the process of repairing them. He further stated he would repair or replace the front door panic hardware. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of Missouri Department of Health and Senior Services STATE FORM 6899 ID PREFIX E5GD11 PRINTED: 09/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/11/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE If continuation sheet 4 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 27071 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 903 HIGHWAY DD CUBA, MO 65453 ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 4 the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire inspection process on September 11, 2023 the facility failed to ensure the facility's electric wiring was properly maintained. The facility census on September 11, 2023 was eight (8). This deficiency affects eight (8) out eight (8) residents. Observation on September 11, 2023 at 1330 revealed a water heater with exposed wire nuts in furnace room six/seven (6/7). Observation on September 11, 2023 at 1336 revealed a relocateble power tap plugged into another relocateable power tap in the IT room. Observation on September 11, 2023 at 1338 revealed a water heater with exposed wire nuts in furnace room eight/nine (8/9). Observation on September 11, 2023 at 1349 revealed a water heater with exposed wire nuts in furnace room ten/eleven (10/11). Observation on September 11, 2023 at 1400 revealed a relocateble power tap plugged into another relocateable power tap in the Missouri Department of Health and Senior Services STATE FORM 6899 ID PREFIX E5GD11 PRINTED: 09/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/11/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE ae CROSS-REFERENCED TO THE APPROPRIATE If continuation sheet 5 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 27071 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 903 HIGHWAY DD CUBA, MO 65453 ARBORS VICTORIAN PL CUBA, MEM CARE ASSTD L SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 5 administrator's office. During an interview on September 11, 2023 at 1500 the maintenance man stated he would replace the broken exit sign, remove relocateable power tap daisy chains, and ensure all wiring is properly enclosed. Missouri Department of Health and Senior Services STATE FORM 6899 ID PREFIX E5GD11 PRINTED: 09/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/11/2023 STREET ADDRESS, CITY, STATE, ZIP CODE (X5) COMPLETE DATE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier —- Arbors Victorian Place-Cuba ciy.zp ©|903 Highway DD Cuba, Mo 65453 Date of Survey: September 11, 2023 t L 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 Maintance Director will change out the Exit face plate. Maintance Director will check all Exit 10-15-2023 signs on our environmental score card quarterly. Maintance Director will place oxygen in use sign up on Rm 18. Maintance Director will check all rooms using score cards quarterly. Maintance Director will repair ceiling and walls of holes. Maintance Director will replace hanging and missing escutcheon rings. Maintance Director will check on ceiling, walls using score cards quarterly. Maintance Director will replace door hardware to propery be secure. Maintance Director will check door structures quarterly using score cards. Maintance Director will fix all exposed wire nuts in each furnace room. remove the relocateable power tap in both. Maintance Director will check quarterly using score cards. 10-15-2023 10-15-2023 10-15-2023 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.