CAREGIVERS INN.

PRINTED: 04/08/2024 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: GOMPLETED Cc 15342D 8, WING 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 (%4) iD SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION {(X8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE GOMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CAREGIVERS INN A4704| 19 CSR 30-86.047(6) Operator/Administrator Responsibilities The following Is the Plan of Correction The operator shall be responsible to assure for Caregivers inn regarding the compliance with all applicable laws and statements of deficiencies dated regulations. The administrator shall be fully 03/26/2024. This Plan of authorized and empowered to make decisions Correction is not to be construed regarding the operation of the facility and shall be as an admission of or agreement held responsible for the actions of all employees, with the findings and conclusions The administrator ' s rasponsibilities shall include in the statement of deficiencies, or oversight of residents to assure that they receive any related sanction or fine. care as defined in the individualized service plan. Rather, It ls submitted as INI confirmation of our ongoing efforts to comply with statutory and This regulation is not met as evidenced by: regulatory requirements. In this Class II* document, we have outlined | specific actions In response to | Based on interview and record review, the facility identified issues. We have not | administrator failed to assure compliance with all provided a detailed response to applicable laws and regulations. The facility each allegation or finding, nor have census was 16. we identified mitigating factors. We remain committed to the delivery of | 1. Review of 10 employes files on 3/26/24 at quality health care services and | 3:00 P.M. showed: will continue to make changes and | -Eight out of 10 records reviewed had no Criminal improvement to satisfy that Back Check (CBC) requested or received; objective. The following corrective -Eight out of 10 records reviewed had no actions have been implemented to Employee Disqualification List (EDL) reviewed ensure our continued commitment prior to employment; . ; to the quality of care to our -Five out of 10 records reviewed did not have TB residents. tests given prior to employment; -Four out of 10 records of staff who held a licanse had not verification of the licensure status; -10 out of 10 records had no written or signed statement by a physician for the ability to work in long-term care facility or limitations. During an interview on 4/5/24 at 2:30 P.M. the administrator said the following: -Employes files should contain the application, the letter from the Family Care Safety Registry Missourl Department of Health and Senior Services LABORATORY DIRECTOR'S OR PRQVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {X6) DATE 2 6898 FHFD11 if continuation sheet 4 of 31 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER (X1} PROVIDER/SUPPLIERI/CLIA IDENTIFICATION NUMBER: 15342D CAREGIVERS INN (x4) ID PREFIX TAG (X2) MULTIPLE CONSTRUCTION PRINTED: 04/08/2024 FORM APPROVED (X93) DATE SURVEY COMPLETED G 03/26/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4704| Continued From page 1 Missour Deparment of Health and Senior Services STATE FORM (FCSR), the background check, EDL checks, TB test information, a ID such as a driver's license and Social Security card; -He does net know why this information was in available; -He was unaware that a physician statement had to be done. *The higher classification merited due te the extent of the violation. 19 CSR 30-86.047(13)(A) Criminal Background Check Requirements Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the person, as provided in section 660.317, RSMo. Each facility shall maintain documents verifying that the background checks were requested, the date of each such request, and the nature of the response received for each such request. Il This regulation is not met as evidenced by: Class fl Based on interview and record review, the facility failed to request a criminal background check (CBC), including documenting the date of request, date received, and nature of the response, for eight staff members of ten staff members reviewed (Director of Nursing (DON), Cook H and G, Level One Medication Aide (LIMA) PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 1. Administrator of Caregivers inn will ensure that all employee files will be In compliance with state laws and regulations by ensuring all employee files have all proper documentation such as OIG, FSCR, EDL, TB prior to employment and annually, Physicals upon employment and license/registry and identification verification to ensure the safety and wellbeing of all residents living in the community. 1a. Administrator will review all employee files prior to new staff start date. 4b. Adminlstrator and or designee will complete monthly audits to ensure that all employee files are in compliance with state regulations. 1c. This action will be completed and in compliance by 05/20/2024. 5/20/2024 2. Administrator at Caregivers Inn wilt ensure that a background check will be completed on all persons employed In the facility prior to direct contact with residents to ensure the safety and wellbeing of our residents and staff. FHFD44 [f continuation sheet 2 of 341 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (44) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 1§342D B, WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST 82 PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG A47111 Continued From page 2 1D, Caregiver C and E, Certified Medication Aide (CMA) B and Certified Nurse Aide (CNA) F). The facility census was 16. 2a, This action will be ongoing per each new hired employee and as required by state reguiation to maintain the safety of our residents and staff. 2b. Administrator and or designee will continue to monitor and reveiw each new hires folder to ensure compliance with the CBC regulations for the safety of all residents and staff. To ensure that no residents are effected by this action. 2c. Administrator and or designee will continue to conduct monthly audits to ensure that all staff files remain in compliance with the regulations for the safety of residents and staff. 2d. All staff files will be in CBC compliance by 04/18/2024 and ongoing. 1, Review of the employee file for the DON on 3/26/24 at 3:00 P.M. showed a hire date of March 48, 2024. Review showed no CBC requested or received. 2, Review of the employee file for Cook H on 3/26/24 at 3:00 P.M. showed a hire date of March 25, 2024. Review showed no CBC requested or received, 3. Review of the employee fila for Cook G on 3/26/24 at 3:00 P.M. showed a hire date of August 24, 2023. Review showed no CBC requested or received. 4, Review of the employee file for LIMA D on 3/26/24 at 3:00 P.M. showed a hire date of May 17, 2023. Review showed no CBC requested or received. 5, Review of the employee file for Caregiver G on 3/26/24 at 3:00 P.M. showed a hire date of February 15, 2024. Review showed no CBC requested or received. 6. Review of the employee file for Caregiver E on 3/26/24 at 3:00 P.M. showed a hire date of October 21, 2023. Review showed showed no CBC requested or received. 7. Review of the employee file for CMAB on 3/26/24 at 3:00 P.M. showed a hire date of March 25, 2024. Review showed no CBC requested or received, 8. Review of the employee file for CNA F on Missourl Department of Health and Sentor Services STATE FORM 6899 FHFD11 {f continuation sheet 3 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 46342D B. WING 03/26/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 NAME OF PROVIDER OR SUPPLIER CAREGIVERS INN (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4711| Continued From page 3 Missour! Department of Health and Senlor Services STATE FORM 3/26/24 at 3:00 P.M. showed a hire date of March 22, 2024. Review showed no CBC requested or received, During an interview on 3/26/24 at 4:15 P.M. the Adrninistrator said a CBC should be done on all employees before hire, 19 CSR 30-86,047(13)(B) EDL Inquiry Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as provided in section 660,315, RSMo, as to whether the person is listed on the EDL, Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department ' s website; I/II This regulation is not met as evidenced by: Class |I* Based on interview and record review, the facility failed to maintain documents to show all employees who had contact with residents in the facility had an Employee Disqualification List (EDL) review completed prior to contact with the residents for eight (the Administrator, Activity Director, Certified Medication Aide (CMA) B, Caregiver C and E, Cook H, Certified Nurse Aide (CNA) F and the Director of Nursing) out of ten PROVIDER'S PLAN OF CORRECTION (X58) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 3. Administrator at Caregivers Inn will ensure that all employees will F be verified through the EDL upon "[/0/2024 hire and annually. 3a. Administrator or designee will continue fo ensure that all staff current and new will bs checked upon the EDL system per state regs to ensure the safety of our residents and staff. 3b. Administrator and/or designee will review all staff files on a monthly basis and keep a record of such audit to ensure compliance with this regualtion for the safety of the community. 3c. this action will be completed by 04/20/2024 on all current employees and will be a continued ongoing. FHFOM If continuation sheet 4 of 44 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUCTION A. BUILDING: (X3} DATE SURVEY GOMPLETED Cc 03/26/2024 B. WING 48342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 CAREGIVERS INN (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATIGN) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} AA714| Continued From page 4 employees reviewed, The census was 16. 1. Review of the employee file for the Administrator on 3/26/24 at 3:00 P.M. showed a hire date of June 9, 2023, Review showed the personnel record did not contain documentation an EDL abtalned and reviewed by the facility. 2, Review of the employee file for the Activity Director on 3/26/24 at 3:00 P.M., showed a hire date of September 19, 2023. Review shawed the personnel record did not contain decurnentation an EDL was obtained and reviewed by the facility. 3. Review of the employee file for CMA B on 3/26/24 at 3:00 P.M., showed a hire date of March 25, 2024. Review showed the personnel record did not contain documentation an EDL was obtained and reviewed by the facility. 4. Review of the employee file for Caregiver C on 3/26/24 at 3:00 P.M., showed a hire date of February 15, 2024, Review showed the personnel record did not contain documentation an EDL was obtained and reviewed by the facility. 5, Raview of the employee file for Caregiver E on 3/26/24 at 3:00 P.M,, showed a hire date of October 21, 2023. Review showed the personnel record did not contain documentation, an EDL was obtained and reviewed by the facility. 6. Review of the employee fils for Cook H on 3/26/24 at 3:00 P.M., showed a hire date of March 25, 2024. Review showed the personnel record did not contain documentation an EDI. was obtained and reviewed by the facility. 7. Review of the employee fila for CNA F on 3/26/24 at 3:00 P.M., showed a hire date of Missourl Deparment of Health and Senior Services STATE FORM ; 09s FHED11 if continuation sheat § of af PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 45342D B, WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG X5) GOMPLETE DATE A4714| Continued From page 5 March 22, 2024, Review showed the personnel record did not contain documentation an EDL was obtained and reviewed by the facility. 8. Review of the employee file for the Director of Nursing on 3/26/24 at 3:00 P.M., showed a hire date of March 18, 2024. Review showed the personnel record did not contain documentation an EDL was obtained or reviewed by the facility, During an interview on 3/26/24 at 4:15 P.M. the Administrator said EDL's should be done on all employees before they have contact with the residents, *The higher classification merited due to the extent of the violation. 19 CSR 30-86.047(19) TB Screen Residents & , Admini i d Staff 4, Administration and qualified nurse manager will ensure that all employees and residents have two step tuberculosis upon hire, admission and an annual assessment. Aa. Clinical Nurse will continue to administer the 2 step TB Skin test to all staff and residents upon hire and or admission, and annually reassess to continue to meet compliance. This task will be completed by 04/30/2024 to ensure that no resident is affected by this action. 4b. Administration will continue review staff and resident's files to ensure continued compliance for the safety of our residents and staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Class Hl Based on interview and record review, the facility faited to ensure a two step tuberculosis (TB - a communicable diseasé that affects the lungs characterized by fever, cough, and difficulty in breathing) test was completed as required upon hire for five of 10 sampled employees (Director of Nursing (DON), Caregiver C and E, the Activity Director (AD) and the Administrator), and failed to ensure three of four sampled residents (Resident #1, #2, and #4) were screened for TB as Missouri Department of Health and Senior Services STATE FORM 5999 FHFD11 If contInvation sheet 6 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/GLIA AND PLAN OF CORRECTION IDENTIFICATIGN NUMBER: (X2} MULTIPLE CONSTRUCTION A. BUILDING: — (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B, WING 45342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD CAREGIVERS INN DARDENNE PRAIRIE, MO 63368 (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 LSG IDENTIFYING INFORMATION) CROSS-REFERENGCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 6 required. The facility census was 16. The facility did not provide a policy for TB testing for employees or residents. 4. Review of the DON's employee file showed a hire date of 3/18/24. There was no documentation of any TB tests administered/completed. 2. Review of Caregiver C's employee file showed a hire date of 2/15/24. There was no documentation of any TB tests administered/campleted, 3. Review of Caregiver E's employee file showed a hire date of 10/21/23. There was no documentation of any TB tests administered/completed, 4, Review of GNA F's employee file showed there was no hire data documented in the employee file. There was no decumentation of any TB tests administered/completed. 5, Review of the AD's employee file shawed a hire date of 9/19/23. There was no documentation of any TB tests administered/completed. 6. Review of the Administrator's employee file showed a hire date of 6/10/23, There was no documentation of any TB tests administered/completed. 7. Review of Resident #1's medical record showed: -The resident admitted to the facility on 12/18/23; -No documentation of any TB tests administered/resident screened for TB. 8. Review of Resident #2's medical record Missoun Department of Health and Sentor Services STATE FORM eae FHFD11 if cantinuation sheet 7 of 34 PRINTED: 04/08/2024 FORM APPROVED - Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: {X3) DATE SURVEY COMPLETED Cc 03/26/2024 B. WING 15342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE GROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (BACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) 1D PREFIX TAG (x5) COMPLETE DATE A4724\ Continued From page 7 showed: -Admitted to the facility on 1/17/18; -No documentation of any TB tests administered/resident screened for TB. 9. Review of Resident #4's medical record showed: -Admitted fo the facility on 5/2/23; -No documentation of any TB tests administered/resident screened for TB. During an interview on 3/26/24 at 3:10 P.M. the DON said the following: -She could not find any record of any staff members’ TB tests, so she administered all of them last week; -There has not been another nurse in the facility to complete a TB test for her testing; -The first TB test should be given before a new amployee starts work, then a second TB test 2-3 weeks after the first one; -She had not had the time to check on the residents’ testing status to see if they needed to have TB screens or if any TH tests had been administered. During an interview on 4/5/24 at 2:30 P.M. the Administrator said: -Staff should have a TB test done prior to hire and a second test done 2-3 weeks after the first one then annually there after; -Residents should have a 2 step TB test done upon admission then a TB screen done annually thereafter. 19 CSR 30-86,047(20)(E) Personnel Record - exp/training/license/ed. The administrator shall maintain on the premises Missouri Dapartment of Health and Senfor Services STATE FORM ease FHFD11 : if continuation sheet 6 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B, WING 15342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (ZACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG (x5) COMPLETE DATE 44729! Continued From page 8 an individual personnel record on each facility employee, which shall include the following: (E) Documentation of experience and education including for positions requiring licensure or certification, documentation evidencing competency for the position held, which includes copies of current licenses, transcripts when applicable, or for thase individuals requiring certification, such as certified medication technicians, level | medication aides and insulin administration aides; printing the Web Registry search results page available at www.dhss.ma.govicnaregistry shall meet the requirements of the employer's check regarding valid certification; Il 5. Administrator of Caregivers Inn will ensure all personnel files will have documentation of experience and education per position held. - Certifications and Licensure will be reviewed and updated per agency regulation. 4/20/2024 5a. Administration and/or designee will continue to ensure that ail staff's certifications and or license is verified through the state registry to ensure that all staff meet the qualifications of the position they are hired to do this will be completed on all current staff members by 04/20/2024, and will continue to be conducted upon hirlng and at feast annually unless otherwise needed. Sb. This search will be conducted to ensure that all staff working with our residents meet this qualification and state compliance so that no resident is effected by these actions. This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to maintain documentation of experience and education for employees requiring licensure or certification and dacumentation supporting competency for the position held for four of ten sampled amployees (the Director of Nursing (DON), Level One Medication Aide (LIMA) D, Certified Medication Aide (CMA) B and Certified Nurse Aide (CNA) F. The facility census was 16. 4. Review of the DON's employee file on 3/26/24 at 3:00 P.M. showed - Ahire date of 3/18/24; . No documentation verifying an active nursing license. 2. Review of LIMA D's employee file on 3/26/24 at 3:00 P.M. showed: -A hire date of 6/17/23; -No documentation of active medication Missouri Department of Heallh and Senior Services STATE FORM 6099 FHFD11 if continuation shaet 9 of 34 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CAREGIVERS INN (x4) ID PREFIX TAG (44) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 15342D (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 04/08/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED C 03/26/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A47298; Continued From page 9 Missourl Department of Health and Sentor Services STATE FORM administration certification. 3. Review of CMAB employee file on 3/26/24 at 3:00 P.M.: -A hire date of 3/25/24. -No documentation of an active medication administration certification, 4, Review of CNAF employee file on 3/26/24 at 3:00 P.M. showed: -A hire date of 3/22/24: -No documentation of an active Certified Nurse Aide certification. During an interview on 3/26/24 at 4:15 P.M. the Administrator said a copy of an employee's license or certification should be in the employee file. 49 CSR 30-86.047(20)(I) Personne! Record-physician statement, employ The administrator shal! maintain on the premises an individual personnel record on each facility employee, which shall include the following: (1) Written statement signed by a licensed physician or physician 's designee indicating the person can work in a long-term care facility and indicating any limitations; ttl This regulation is not met as evidenced by: Class tH Based on interview and record review, the facility failed to ensure ten of ten sampled staff members (the Administrator, the Director of Nursing (DON), Certified Medication Aide (CMA) G, Caregiver C and E, Level One Medication Aide (LIMA) D, $899 FHFD14 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6, Administrator of Caregivers Inn will ensure that ali personnel will have physician or physician designee written statement indicating the person can work in a long-term care facility and Identify any limitations. 6a. Administrator and/ or designee will ensure that all staff have a written statement from a physician or physician designee before start date to ensure they meet the physical requirement for the LTC work enviornment. 6b. Ali current staff members will reach full compliance by 05/20/2024. 6c.Administrator and / or designee will review all new staff files to ensure all proper physical documentation and staff meet physical requiremnets to perform the job in which they were hired, If continuation sheat 10 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 8, WING 15342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION {EAGH CORRECTIVE ACTION SHOULD @E CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL (X6) COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) DATE Continued From page 10 Certified Nurse Aide (CNA) F, Cook G and H) had a written and signed statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any {imitations. The facility census was 16. 4. Review of the employee file for the Administrator on 3/26/24 at 3:00 P.M., showed a hire date of June 9, 2023. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 2. Review of the employee file for the Activity Director on 3/26/24 at 3:00 P.M., showed a hire date of September 19, 2023. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 3. Review of the employee file for CMAB an 3/26/24 at 3:00 P.M., showed a hire date of March 25, 2024, Review showed the personnel racord did nat contain a statement by a licensed physician or physician's designee indicating the persan could work in a long-term care facility and indicating any limitations. 4. Review of the employee file for Caregiver C on 3/26/24 at 3:00 P.M., showed a hire date of February 15, 2024. Review showed the personnel record did not contain a statement bya licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 5. Review of the employee file for Caregiver E on Missouri Department of Health and Sentor Services STATE FORM sees FHFD114 : {f continuation sheet 41 of 31 PRINTED; 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X4) PROVIDER/SUPPLIBRICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B, WING 18342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 CAREGIVERS INN (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X65) 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) A4733| Continued From page 11 3/26/24 at 3:00 P.M., showed a hire date of October 21, 2023. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 6, Review of the employee file for Cook H on 3/26/24 at 3:00 P.M., showed a hire date of March 25, 204. Review showed the personnel record did not contaln a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 7, Review of the employee file for CNA F on 3/26/24 at 3:00 P.M, showed a hire date of March 22, 2024. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 8, Review of the employee file for the DON on 3/26/24 at 3:00 P.M., showed a hire date of March 18, 2024. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 9. Review of the employee file for LIMAD on 3/26/24 at 3:00 P.M., showed a hire date of May 17, 2023. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 10, Review of the employee file for Cook G on Missoun Department of Health and Senior Services STATE FORM 6a39 FHED14 if continuation sheet 12 of 31 PRINTED; 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES O41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (<3) DATE SURVEY COMPLETED G 03/26/2024 B. WING 16342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X5} COMPLETE DATE A4733{ Continued From page 12 3/26/24 at 3:00 P.M., showed a hire date of August 24, 2023. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the parson could work in a long-term care facility and indicating any limitations. During an interview on 3/26/24 at 4:15 P.M. the Administrator said ha was not aware that a physical from a physician had to be done before hire. 7. Administrator of Caregivers Inn will ensure all employees personne! records have documentation. of hire date and Tuberculin screening status. 7a. Administrator and Licensed nurse will ensure that all staff members before hire date has completed the 2 step TB skin test and will ensure that all employees have repeated testing upon annual review. 7b. Administrator and or licensed nurse will ensure that all current staff members have completed the 2 step TB skin test and that all annual test are conducted and in compliance with state regulation to prevent any effects to the residents by 04/18/2024. 7c, Administration will continue to conduct regular revelws to ensure that all current and new staff members are in compliance with this requirement. 49 CSR 30-86,047(20)(J) Personnel Record - TB screening status 04/18/2024 The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (J) Documentation of the employee ' s tuberculin screening status; Ill This regulation is not met as evidenced by: Class Ill Based on record review and interview, the facility failed to maintain an individual personnel record of documentation of the employee's tuberculin screening status which affected six of 10 sampled employees (Director of Nursing (DON), Caregiver C and E, Certified Nurse Aide (CNA) F, the Activity Director (AD) and the Administrator. The facility cansus was 16. The facility did not provide a policy for TB records for the employee file. 4. Review of the Director of Nursing employee filed showed a hire date of 3/18/24 with no Missouri Department of Health and Santor Services STATE FORM gag FHFD14 If contInuaiton sheet 13 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X14} PROVIDER/SUPPLIER/CUA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B, WING 15342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) 1D PREFIX TAG (X8) COMPLETE DATE A4734) Continued From page 13 documentation of administration of TB screening status, 2. Review of Caregiver C's employee file showed; -No hire date was documented in the employee file; -No documentation of administration of TB screening status. 3. Review of Caregiver E’s employee file showed: -No hire date was documented in the employee file; -No documentation of administration of TB screening status. 4. Review of CNA F's employee fila showed: «No hire date was documented in the employee file; -No dacumentation of administration of TB screening status. 5. Review of the AD's employee file showed: -Hire date of 9/19/23; -No documentation of administration of TB screening status. 6. Review of the Administrator's employee file showed: -Hire date of 6/10/23; -No documentation of administration of TB screening status. During an interview on 3/26/24 at 3:10 P.M. the DON said the following: -She could not find any record of any staff members’ TB tests, so she administered all of them last week; -There had not been another nurse in the facility Missouri Deparment of Health and Senior Services STATE FORM 4699 FHFD14 {f continuation sheet 14 of 31 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Heaith and Senior Services STATEMENT OF DEFICIENCIES (¥1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B. WING 16342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD CAREGIVERS INN DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENGED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) 1D PREFIX TAG (x5) COMPLETE DATE 447341 Continued From page 14 to administer one to her; -The first TB test should be given before a new employee starts work, then a second TB test 2-3 weeks after the first one. During an interview on 4/5/24 at 2:30 P.M. the Administrator said employees should have a TB test before hire then a second TB test 2-3 weeks there after and annually. 19 CSR 30-86.047(26) Admission Physical 8. Administration will ensure all admitting residents have History and Physical upon entering the facility and annually to meet all state regulations. 8a. Administrator and/or designee will ensure that a history and physical is completed on all residents before admission to the community. 8b. Administrator and / or designee will ensure that all current residents have a completed history and physical signed by a physician on file by 04/18/2024. 8c. Administrator and/or designee will ensure that all residents initial H&P and annual H&P will be maintained of the resident's file at ali times. The facility shall ensure that each resident being admitted or readmitted to the facility receives an admission physical examination by a licensed physician. The facility shall request documentation of the physical examination prior to admission but must have documentation of the physical examination on file no later than ten (10) days after admission. The physical examination shall contain documentation regarding the individual 's current medical status and any spacial orders or procedures to be followed, If the resident Is admitted directly from an acute care or another long-term care facility and is accompanied on admission by a report that raflects his or her current medical status, an admission physical shall not be required. fll This regulation is not met as evidenced by: Class tt Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident #2 and #3), had an admission physical examination completed by a licensed physician. The facility census was 16. The facility did not provide a policy for admission Missouri Department of Heallh and Senior Services STATE FORM 6089 FHFD11 If continuation sheet 15 of 31 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED Cc 15342D B.WING 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TA CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CAREGIVERS INN A4742} Continued From page 15 physicals for residents. 1. Review of Resident #2's medical record showed: -Admittad to the facility on 12/48/23; -No admission physical was found in the medical record, 2. Review of Resident #2's medical racord showed: -Admitted to the facility on 1/7/18; -No admission physical was found in the medical 1 record. . During an interview on 3/26/24 at 4:15 P.M. the Administrator said aach resident should have a physical by a physician prior to admission or soon after admission. 9, Administrator and or nurse will 19 CSR 30-86,047(28)(D) Complete a obtain and maintain proper Premove-in Screening cartification to complete CBA process per state requirements. 04/20/2024 The facility may admit or retain an individual for 9a, CBA Certifled Administrator residency in an assisted living facility only if the and/or Licensed Nurse will ensure individual does not require hospitalization or that all current residents have a skilled nursing placement as defined in this rule, completed initial, semi-annual, and only if the facility: annual, or a significant change (D) Completes a premove-in screening Assessment by 04/20/2024 to conducted as required by section 198.073.4 (4), meet pre-move in and continuing RSMo (CCS HCS SCS SB 616, 93rd General of care requirements to ensure no Assembly, Second Regular Session (2006)). 1 residents are at risk of effects from this action. This regulation is not met as evidenced by: 9b. Administrator and/or designee Class ll will ensure that all pre-move In . . - screenings Is completed. Based on record review and interview, the facility failed to complete a premove-in screening prior to the admission of two residents (Resident #3 and #5) out of four sampled residents. Missouri Department of Health and Senlor Services STATE FORM se90 FHFD11 if continuation sheet 16 of 31 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (x3) DATE SURVEY COMPLETED Cc 03/26/2024 B, WING 15342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES {EAGH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG 9c. Administrator of designee will continue to ensure that no resident Is effected hy this action by continuing {o schedule intlal, seml-annual, annual, or significant change updates fo the GBA and review wilh resident of respansible party at appropreate times. AA747| Continued From page 16 The facility did nat provide a policy for completion of premove-in screenings. 1. Review of Resident #3's medical record showed: -Adrnitted to the facility on 1/7/18; -No premove-in screening in the medical record, 2. Review of Resident #5's medical record showed: -The resident admitted to the facility on 5/2/23, -No pramove-in scraening in the medical record. During an interview on 3/26/24 at 4:15 P.M. the Administrator said: -He assumed the role of the Administrator in June of 2023; -lf the pramove-in screening was not in the medical record, he did not know where to find one. 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually 40, Administrator or nurse will complete required Community Based Assessment Semi Annually or upon significant change. 10a. Administrator will ensure that a CBA certified staff member is on staff at all times to ensure that community meets state requirement of a completed CBA within five days of moving into the community, to ensure that all admissions are safe and appropriate to ensure no residents are affected by this action. The facility may admit or retain an individual for rasidency in an assisted living facitity only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 4. Time frame requiraments for assessment shail be: B. At least semiannually; II This regulation is not met as evidenced by: Missouri Department of Healih and Senior Services STATE FORM anee FHFD11 if continuation sheet 17 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 45342D B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63168 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (4) ID PREFIX TAG (x5) COMPLETE DATE A4750| Continued From page 17 Class II 10b. Administrator or designee will ensure the completion of all outstanding CBA assessments by 05/17/2024 to meet all state requirements. Based on interview and record review, the facility failed to ensure community based assessments (CBAs) were completed at least semi-annually for three residents (Resident #3, and #4) out of four residents sampled. The facility census was 16. 10c. Administrator or designee will review all current resident files to ensure CBA assessment ls complete and current to ensure no residents are affected by the deficient practice. The facility did not provide a policy for CBAs. 40d. Administrator and or designee will continue to review and schedule regular reviews of residents file to eliminate any potential affect of deficient practice to any other residents. 4. Review of Resident #3's medical record showed: -Admitted to the facility on 1/7/18; -5 day CBA completed on 1/4/24 CBA completed on 1/26/22, and 7/25/23; -No semi-annual CBA completed in 2022 or 2023. 2. Review of Resident #4's medical record showed: -Admitted to the facility 11/16/2020; -CBA completed on 1/6/20, 8/9/22 and 8/1/2023; -A CBA was not done semi-annually since the resident's admission date. During an interview on 3/26/24 at 4:15 P.M. the Administrator said CBA’s should be completed semi-annually based on a resident's admission date. 49 CSR 30-86.047(28)(G) Individual Service Plan | A4754 - Develop 41. Administrator will ensure that licensed nurse will complete the 0. ISP for each new resident within 30 days of admission, semi annually and significant change to ensure no residents are affected by the deficient practice. 5/20/2024 The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by Missour! Department of Health and Sentor Services STATE FORM Seas FHFD11 ff continuation sheet 18 of 31 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING; (X3) DATE SURVEY COMPLETED C B, WING 03/26/2024 15342D NAME GF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN (X4) {D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) «X5) COMPLETE DATE A4754; Continued From page 18 an assisted living facility which outlines a resident gs needs and preferences, services to he provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; tl This regulation is not met as evidenced by: Based on interview and record review, the facility dia. Administrator and or designee will ensure the completion of all outstanding ISP assessments found to be deficient at time of survey by 05/20/2024. 11b. Administrator and or designee will maintain a schedule for regular review of all residents per initial 30 days, semi- failed to develop individualized service plans (ISP, the planning documented prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's lagal representative in partnership with the facility) which included resident needs, preferences, services to be provided by staff and goals expected by the resident or the resident's legal representative for three of four sampled residents (Residents #2, #3 and #4). The census was 16. annually and on significant change to continue to ensure no resident is affected by deficient practice. 11c. Administrator and licensed nurse will meet with Director of Clinical Services weekly to continue to monitor the ISP's and clinical risk for all residents to prevent any affect by dificient practice, The facility did not provide a policy for ISP's, 1. Review of Resident #2's medical record showed: -Admitted to the facility on 12/18/23; -No {SP completed. 2. Review of Resident #3's medical racord showed: -Admitted to the facility on 11/16/20; -No admission ISP found in the medical record. 3, Review of Resident #4's medical record showed: -Admitted to the facility on 1/7/2018; -No admission ISP found in the record, During an interview on 3/26/24 at 4:15 P.M. the Administrator said: Missourl Department of Health and Senior Services STATE FORM . 6899 FHFD14 ff continuation sheet 19 af 31 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 15342D B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (Xd) 1D PREFIX TAG {X5) COMPLETE DATE A4754| Continued From page 19 -He could not locate all of the resident medical records and could not find the records back to admission; -The Administrator should monitor for the completion of the required documents; -The ISP should be completed upon admission. 49 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements 42. Administration will ensure that Caregivers Inn policy will meet all state regulations by ensuring that individual Service Plans are completed within 30 days of admission, annually and upon significant change. The facility may admit or retain an individual for residency in an assisted living facility only if the individual doas not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident ' g condition which may require a change in services; Il 12a. Administrator and or designee will ensure the all ISP's are completed within timely manner and reviewed by community careplan team and resident or responsible party within 30 days. This regulation is not met as evidenced by: Based on interview and record review, the facllity failed to ensure all individualized service plans (ISP, the planning documented prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) were reviewed annually with the resident and/or resident's representative for two of four sampled residents (Residents #3 and #). The census was 16. 12b. Administrator and or designee will ensure a schedule for the review of all residents [SP's per review date. This will be completed by 4/22/2024. 42c. Administrator and or licensed nurse will have a weekly risk call with Director of Clinical Services to verify the accuracy and completion of ISP's per community schedule. The facility did not provide a policy for ISP's, 1. Review of Resident #3's medical record showed: -Admitted to the facility on 11/16/2020, Missourl Department of Health and Senior Services STATE FORM 6898 FHFD14 i continuation sheel 20 of 34 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xt) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (Xa) DATE SURVEY COMPLETED Cc 03/26/2024 15342D 8, WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD CAREGIVERS INN DARDENNE PRAIRIE, MO 63368 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X68) PREFIX (EACH DEFICIENCY MUST SE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AA765/ Continued From page 20 -No admission ISP found in the medical record; -No documentation in the medical record to show an ISP was reviewed with the resident or the resident representative. 2, Review of Resident #4's medical record showed: -Admitted to the facility on 1/7/2018; -No admission ISP found in the record. -No documentation in the medical record to show an JSP was reviewed with the resident or the resident representative. During an interview on 3/26/24 at 4:15 P.M. the Administrator said he should monitor for required documentation and completion of the ISPs. 19 CSR 30-86.047(28)(1) individual Service Plan - Signatures 43. Administration and or nurse will ensure that the Individual Service Plan Is reviewed upon 05/18/2024 admission, annually and upon significant changes. ISP will be reviewed and signed by resident and or responsible party. 13a, Administrator and or designee will invite each resident and or responsible party to attend ISP meeting to ensure the residents needs are addressed and verify information Is current and signatures are received per state regulation. 13b, Administrator and or designee will report to Senior Executive Director a quarterly audit to ensure signatures are in place. The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or 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 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: Based on interview and record review, the facility staff failed to obtain signatures from four of four sampled residents (Residents #2, #3, #4.and #5) or the resident's legal representative on the individualized service plan (ISP) to acknowledge Missaun Depariment of Health and Senlor Services STATE FORM e899 FHFO1 if continuation shaet 21 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 18342D B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD CAREGIVERS INN DARDENNE PRAIRIE, MO 63368 SUMMARY STATEMENT OF DEFICIENCIES (K4) ID PROVIDER'S PLAN OF CORRECTION (X85) 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 21 the plan had been reviewed and understood by the resident or representative. The facility census was 16. The facility did not provide a policy for ISP's. 1. Review of Resident #2's medical record showed: -Admitted to the facility on 12/18/23; -No ISP completed; -No resident or resident legal representative signatures found, 2. Review of Resident #3’s medical record showed: -Admitted to the facility on 11/16/2020; -[SP completed on 7/25/23 with no resident or resident legal representative signature. 3, Review of Resident #4's medical record showed: -Admitted to the facility on 1/7/2018; -ISP completed on 7/24/23 with no resident or resident legal reprasentative signature. 4, Review of Resident #5's medical record showed: -Admitted to the facility on 5/2/23; -ISP completed on 5/1/23 and 7/26/23 with no resident or resident legal representative signature. During an interview on 4/5/24 at 2:30 P.M. the Administrator said the ISP should be reviewed with the resident and the legal representative upon admission and with any change of condition and include required signatures. Missouri Department of Health and Senlor Services STATE FORM 6893 FHFD14 Jf continuation sheet 22 of 34 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA {IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B, WING 16342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} (x4) 1D PREFIX (x5) COMPLETE TAG DATE A4805| Continued From page 22 A4805| 19 CSR 30-86.047(47)(F)(1)(C) influenza/Pneumococcal - Palicy/Refuse 44, Administration will ensure a policy to reflect Influenza and pneumococcal polysaccharide immunization consent or refusal per resident cholce to meet state regulations. A record wiil be kept in accordance with the consent/refusal. 14a. Community representatives will ensure all residents are offered influenza and pneumococcal polysaccharide immunizations when available. 14b. The community will continue to provide consent/refusal forms for residents or responsible parties fo sign. 44c¢, The community shail maintain record in resident file for proof of consent or refusal of such vaccinations. 14d. The consents/refusals shall be completed and signed by resident or responsible party by 05/18/2024, 14e. The community ISP team will ensure all consents/refusals are maintalned upon scheduled reviews to prevent affects to Medication Orders. (F) Influenza and pneumococcal polysaccharide immunizations may be administered per physician-approved facility policy after assessment for contraindications- 4. The facility shall develop a policy that provides recommendations and assessment parameters for the administration of such immunizations. The policy shall be approved by the facility medical director for facilities having a medical director, or by each resident's attending physician for facilities that do not have a medical director, and shall include the requirements to: C. Provide the opportunity to refuse the immunization; and [/IH 05/18/2024 This regulation is not met as evidenced by: Class Il* Based on record review and interview, the facility falled to document when residents or their representatives refused the flu vaccine. This affected all 16 residents who currently resided in the facility. The census was 16. The facility did not provide a policy for the administration or refusal of the flu vaccine. During an interview on 3/26/24 at 4:30 P.M. the Administrator said; -He does not have any documentation for residents who received or who have refused to take the flu vaccine; -Saveral family members took residents to their own physician or pharmacy and received the flu vaccine, he does not know who those residents are; Missourl Department of Health and Senior Services STATE FORM 6ea9 FHFD11 If continuation shael 23 of 34 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: {X3) DATE SURVEY COMPLETED Cc 03/26/2024 153420 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD 8E GROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST 8& PRECEDED BY FULL REGULATORY OR LSG IDENTIFYING INFORMATION) (x4) ID PREFIX TAG (x5) COMPLETE DATE A4805 | Continued From page 23 -Sevaral residents refused the flu vaccine, he did not keep a record of those residents that refused. *The higher classification merited due to the extent of the violation. 15. Facllity will maintain record of Schedule I! medications upon receipt and disposition. An inventory of controlled substances will be reconciled each shift. Two staff members will sign off on reconciliation at time of medication count. 49 CSR 30-86.047(51)(A)(1) Scheduie If Meds-Reconcile Each Shift, Record Records shall be maintained upon receipt and disposition of all controlled substances and shall be maintained separately from ather records, for two (2) years. (A) Inventories of controfled substances shall be reconciled as follows: 4, Controlled Substance Schedule li medications shall be reconciled each shift; Il 45a. Licensed nurse will educate staff on maintaining proper documentation of controlled substance inventory and reconciliation/disposition. 45 b, Licensed Nurse will continue to provide education monthly and audit medication counts and logs to ensure no residents are affected by deficlent practices. 15 c. Licansed Nurse will ensure that all controlled medication records are current and up to date with signatures from reconciliation from each shift by 04/18/2024. This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to ensure inventories of Schedule Il controlled substances (medications which have a high potential for abuse) were reconciled each shift. The facility census was 16. Review of the undated facility policy for Medication Administration showed all controlled medications will be counted between the oncoming Certified Medication Aide (CMA) and the off going CMA on every shift. 4. Review of the Memory Care Unit Narcotic Book Controlled Substance Shift change Count Sheet showed the following: Missourl Department of Health and Senlor Services STATE FORM agga FHFD11 If cantinuation sheet 24 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B. WING 15342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1297 FEISE ROAD CAREGIVERS INN DARDENNE PRAIRIE, MO 63368 (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) A4817| Continued From page 24 -For February 2024 there was no staff signature for the narcotic shift count for 2/12/24, 2/43/24, 2/26/24, 2/28/24 and 2/29/24 for the 7:00 A.M. or the 7:00 P.M. shift; -For March 2024 there was no staff signature for the narcotic shift count for 3/6/24, 3/7/24, 3/28/24, 3/11/24, 3/12/24, 3/17/24, for the 7:00 A.M. or the 7:00 P.M. shifts, 3/9/24 for the 7:00 A.M. shift, or 3/22/24 and 3/23/24 for the 7:00 P.M. shift. Raview of the Memory Care Unit Narcotic Book showed the medication cart contained lorazapam (antianxiety medication) 0.25 milligrams (mg) prescribed for for Resident #9, hydrocodone (a narcotic medication used to treat pain) § mg/325 mg prescribed for Resident #4, hydrocodone 5 mg/325 mg and Tramadol (a strong medication used to treat pain) 25 mg prescribed for Resident #10. During an interview on 3/26/24 at 10:45 A.M. Licensed Medication Aide (LIMA) A said narcotics should be counted by the off going and an coming LIMA and CMA, 2, Review of the Assisted Living Narcotic Book Controtled Substance Shift change Count Sheet showed for March 2024 there was no staff signature for the narcotic shift count for 3/19/24 7:00 P.M. shift; 3/23/24, 3/24/24 and 3/25/24 7:00 A.M. and 7:00 P.M. shifts. Review of the Assisted Living Narcotic Book showed the medication cart contained Tramadol 50 mg for Resident #11 and atropine (a medication used to decrease the amount of saliva produced) 0.25 mg, lorazepam 1 mg for Resident #5, alprazolam (a medication used to treat anxiety and panic disorders) 0.25 mg and Tramadol 50 mg for Resident #8. Missoun Department of Health and Senior Services STATE FORM ass FHFD14 ff continuation sheet 25 of 34 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 03/26/2024 16342D B, WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD CAREGIVERS INN DARDENNE PRAIRIE, MO 63368 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION XB 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) A4817) Continued From page 25 During an interview on 3/26/24 at 2:00 P.M. the Director of Nursing said narcotics should be counted by the on coming LIMA or CMA and the off going CMA. 19 CSR 30-86.047(56){E)(1 - 2) Medications-Return to RX / Destroy, Records 16, Facility will maintain all necessary records to prove the return of medications to pharmacy or destruction per regulation. 04/48/2024 Medications that are not in current use shall be disposed of as follows: (E) Medications may be returned to the pharmacy that dispensed the medications pursuant to 20 CSR 2220-3.040 or returned pursuant to the Prescription Drug Repository Program, 19 CSR 20-50,020, All other medications, including all controlled substances and all expired or otherwise unusable medications, shall be destroyed within thirty (30) days as follows: 1. Medications shall be destroyed within the facility by a pharmacist and a licensed nurse or by two (2) licensed nurses or when two (2) licensed nurses are not available on staff by two (2) individuals who have authority to administer medications, ane (1) of whom shall be a licensed nurse or a pharmacist; and 2. Arecord of medication destroyed shail be maintained and shall include the resident's name, date, medication name and strength, quantity, prescription number, and signatures of the individuals destroying the medications; [l/l 16a.Licensed Nurse will keep records of medication destruction and medications that were returned to pharmacy. 16b. Licensed Nurse will conduct frequent audits of medications and dispose of any medications said to be discontinued or expired per regulation to ensure that no residents are affected by deficient practices. 16c, Licensed Nurse will destroy medications found to be noncompliant with regulation by 04/18/2024.with another qualified personnel. This regulation is not met as evidenced by: Class Il] Basad on observation and interview, the facility failed to dispose of expired medications within Missourl Depariment of Health and Senior Services STATE FORM 8a8 FHFD11 if contnuatlon sheet 26 af 34 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED B. WING Cc 16342D 03/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF GORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSG IDENTIFYING INFORMATION) (X4) 1D PREFIX TAG (X5) COMPLETE DATE A4833| Continued From page 26 thirty 30 days for one resident (Resident #7). The facility census was 16. The facility provided no policy for medication destruction. 4. Review of Resident #7's medical record showed: -Admitted on 1/16/24 and discharged on 2/1/24; -Diagnoses of heart failure, hypertension, and diabetes: -Order for marphine sulfate (a narcotic used for pain) 0.25 mg ordered on 1/27/24 and discontinued on 1/30/24; -Lorazepam (a medication used to treat anxiety) oral concentrate 2 mg per 100 milliters (ml), give 0.5 ml ordered on 1/27/24 and discontinued on 4/30/24, Observation on 3/26/24 at 12:15 P.M. of the medication cart in the Assisted Living showed lorazapem 2 mg in the locked compartment of the cart with no narcotic count sheet available for Resident #7. Observation on 3/26/24 at 12:15 P.M. of the refrigerator in the Assisted Living Medication/Nurse room showed an unopened bottle of morphine suifate in the locked compartment of the refrigerator for Resident #7 with no narcotic count sheet available. During an interview on 3/26/24 at 12:15 P.M. Certified Medication Aide (CMT) B said: -He/She did not know the morphine sulfate was in the refrigerator as he/she did not count this medication with the off going shift; -He/she did not know who Resident #7 was. During an interview on 3/26/24 at 12:45 P.M. the Missaurl Department of Health and Senlor Services STATE FORM age FHFD11 if continuatian sheet 27 of 34 PRINTED: 04/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1} PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: _—_————— (X3) DATE SURVEY COMPLETED Cc 03/26/2024 15342D B. WING NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 CAREGIVERS INN (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X85) PREFIX (GAGH 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) A4833) Continued From page 27 Director of Nursing said: -The resident was discharged from the facility on 2/1/24; -The medication should have been removed and destroyed or returned to the pharmacy, -She does not know why the medication was not destroyed or returned, she hads only been at the facility for a few days; -Medication that has been discontinued or the resident has been discharged should be destroyed immediately. 49 CSR 30-88.010(4) Resident 17, Facility will continue to review Rights-Admission/Annual Review Residents Rights upon admission and annually and maintain signed record from resident and or responsible party. 17a. Residents Rights review will be conducted on ail current residents during ISP meetings to ensure compliance with state regulations and to secure signature of resident or responsible party by 05/18/2024. 17b, Administrator or designee will ensure that resident rights review is added to ISP team schedule for review. 47c. Administrator or designee will ensure that Resident Rights reviews are up to date and current per state regulation fo ensure no resident is affected by deficient practice. 5/18/2024 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/AU This regulation is not met as evidenced by: Class Ii* Based on interview and record review, the facility failed to review resident rights with residents or their representative upon admission and annually for four of four sampled sampled residents. (Residents #2, #3. #4, and #5). The census was 46. The facility did not provide a policy for resident rights. 4. Review of Resident #2's medical record showad: Missourl Department of Health and Senlor Services STATE FORM ae99 FHFD11 If continuation sheet 28 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: _—_——__. (X3) DATE SURVEY COMPLETED Cc 03/26/2024 B. WING 15342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 PROVIDER'S PLAN OF CORRECTION (GACH CORRECTIVE ACTION SHOULD BE GROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CAREGIVERS INN SUMMARY STATEMENT OF DEFICIENCIES (EAGH DEFICIENCY MUST 8E PRECEDED BY FULL (x5) COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) DATE A8004| Continued From page 28 -Admitted to the facility on 12/18/23; «No documentation of resident rights reviewed with the resident and/or legal representative upon admission. 2, Review of Resident #3's medical record showed: -Admitted to the facility on 1/7/18; -No documentation of resident rights reviewed with the resident and/or legal representative upon admission and annually thereafter. 3, Review of Resident #4's medical record showed: -Admitted to the facility on 14/16/20; -Resident rights completed upon admission and 41/6/2022, but no review done in 2023. -No documentation of resident rights reviewed annually with the resident and/or legal represeniative. 4. Review of Resident #5's medical record showed: — -Admitted to the facility on 5/2/23; -No documentation of resident rights reviewed with the resident and/or legal representative upon admission and annually thereafter. During an interview on 4/5/23 at 2:30 P.M. the Administrator said resident rights should be reviewed upon admission and annually thereafter. *The higher classification merited due to the extent of the violation. 419 CSR 30-88.020(12) Provide Account of Funds to Fiduciary Upon the death of a resident who has not been a Missouri Deparment of Health and Senior Services STATE FORM o406 FHFD11 tf continuation sheat 29 of 34 PRINTED: 04/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt), PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION {1DENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED C B. WING 03/26/2024 45342D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP GODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 CAREGIVERS INN (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) A90171 Continued From page 29 recipient of aid, assistance, care, services, or who has not had moneys expended on the resident's behalf by DSS or DSS has not made claim on the funds, the operator shall provide the fiduciary or resident ' s estate, at the fiduciary's request, a complete account of all the resident's personal funds and possessions and deliver ta the fiduciary all possessions of the resident and the balance of the resident's funds, II/IH 18. Facility has returned the refund to the responsible party and will continue to submit refunds upon request within the 45-day threshold per state requirements, 18 a. Administrator or designee will ensure that all refunds are issued in a timely manner to ensure that no residents are affected by deficient practices. This regulation is not met as evidenced by: Class if* Based on interview and record review, the facility failed to provide one resident's (Resident #1's) rasponsible party the remainder of the resident's personal funds upon the resident's death in a timely manner, The facility census was 16. The facility did not provide a policy for resident funds following request. 4, Review of Resident #1's medical recard showed: -Admitted to the facility on 9/2/22 and expired at the facility on 12/18/23; -The resident was not a recipient of Medicaid funds. During an interview on 4/2/24 at 9:00 A.M. Resident #1's Responsible Party said: -The resident passed away in December 2023; -The Administrator told him/her that he/she would receive the remainder of the resident's funds; -He/She has not received the refund and has not been told why the money has not been refunded. During an interview on 3/26/24 at 9:30 A.M. the Administrator said: -The resident passed away on 12/18/23 and was Missourl Department of Health and Senior Services STATE FORM 803 FHFD14 If cantInuation sheet 30 of 34 PRINTED: 08/25/2024 . FORM APPROVED Missouri Department of Health and Senlor Services STATEMENT OF DEFICIENCIES (X1) PROVIDERJSUPPLIERICLIA AND PLAN OF CORRECTION fOENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUCTION A. BUILDING: (X83) OATE SURVEY COMPLETED R-C 483420 B. WING 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ISE RO. CAREGIVERS INN 1207 FEISE ROAD DARDENNE PRAIRIE, MO 63368 (x4) 1D SUMMARY STATEMENT OF DEFICIENGIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR L&C IDENTIFYING INFORMATION} {A4733]] 19 CSR 30-86.047(20)(!) Personnel Racord-physiclan statement, employ The administrator shall maintain on the premises an individual personnel recard on each facility employee, which shall include the following: (I) Written statement signed by a licensed physician or physiclan ’s designee indicating the person can work In a long-term care facillty and indicating any limitations; III This regulation is nat met as evidenced by: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficlencles dated 3/26/24. Based on Interview and record review, the facility failed fo ensure sight of eight sampled staff members (Director of Nursing (DON), Distary Manager, Level One Medication Aide (LIMA) A, Cook B, Caregiver C, Caregiver D, Caregiver E, and the Maintenance Director) had a written statement by a licensed physician or physician's designee Indicating the person could work in a tong-term care facility and Indicating any limitatlons. The facility cansus was 20. 1, Review of the employee file for Caregiver C on 3/26/24 at 3:00 P.M., showed a hire date of February 15, 2024, Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a fong-term care facllity and indicating any limitations. 2. Review of the employee file for Caregiver E on 3/26/24 at 3:00 P.M., showed a hire date of October 21, 2023. Review showed the personnel racord did not contain a statement by a licensed physician or physician's designee indicating the ID PREFIX TAG {A4733) PROVIDER'S PLAN OF CORRECTION {BAGH CORRECTIVE ACTION SHOULD BE CROS8-REFERENGED TO THE APPROPRIATE DEFIGIENCY) The following Is the Plan of Correction for Caregivers Inn regarding the statements of deficiencies dated 06/11/2024 This Plan of correction is nat to be construed as an admission of or agreement with the findings and conclusions In the statement of deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforis to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to the delivery of quality health care services and will continue to make changes and Improvement to satisfy that abjective. The following corrective actions have been Implemented to ensure our continued commitment to the quality of care to our residents. Missourl Department of Health and Santor Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE THLE _ 066) DATE STATE FORM ; ss00 FHFD12 _ If continuation sheat, 1 of 7 AS , S32 mes \\S\OH PRINTED: 06/25/2024 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 R-C 18342D B. WING 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x6) (EACH DEFICIENCY MUST BE PREGEDED BY FULL PREFIX {GACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENGED TO THE APPROPRIATE DATE DEFICIENCY) CAREGIVERS INN (A4733} |} C: d {4739} Continued From page 1 (4733) {44733} 19 CSR 30-86.047(20)(I) person could work in a long-term care facility and Personnel Record-physiclan indicating any iimitatlons. statement, employ 3. Review of the employee file for the DON on 1. Administrator or designee of 3/26/24 at 3:00 P.M., showed a hire date of Caregivers Inn will ensure that all recard did not contain a statement by a ficensed compieted physical before official physician or physician's designee indicating the start date. This to be implemented person could work In a long-term care faclilly and effective by 8/3/2024, Indicating any limitations. 2. Administrator will complete contract with physician or physician’s designee to ensure this requirement is met by 8/3/2024. 4, Review of the employee file for LIMAA showed, a hire date of May 29, 2024. Review showed the personne! record did not contain a statement by a licensed physician or physician's designee Indicating the person could work in a long-term care facility and indicating any limitations. 3. Administrator or designee will review employee files quarterly to ensure compliance with current §. Review of the employee file for the Dietary regulations. Manager showed, a hire date of April 1, 2024, Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 6. Review of the employee file for Cook B showed a hire date of May 16, 2024. Review showed the personnel record did not contain a statement by a ficensed physician or physician's designee indicating the person could work jn a long-term care faclilly and Indicating any” limitations, 7. Review of the employee file for Caregiver D showed a hire date of March 21, 2024. Review showed the personnel record did not contain a statement by a licensed physician or physician's designee indicating the persan could work in a Missoun Department of Health and Senlor Services j . STATE FORM ese FHFD12 | Ifcaniinuation shaat 2 of 7 Fsrorg Woes LP xo, SP | | AVS SOM Missouri Depariment of Health and Senior Sarvices STATEMENT OF DEFICIENCIES AND PLAN OF GORRECTION NAME OF PROVIDER OR BUPPLIER (X1) PROVIDER/QSUPPLIER/CLIA IDENTIFICATION NUMBER: 45342D 8. WING 1297 FEISE ROAD CAREGIVERS INN (X4) ID PREFIX TAG {A4733} {A4805} (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 06/25/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 06/11/2024 STREET ADDRESS, CITY, STATE, ZIP CODE DARDENNE PRAIRIE, MO 63368 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR L&C IDENTIFYING INFORMATION) Continued From page 2 {A4733} long-term care facllity and indicating any limitations. 8. Review of the employee file for the Maintenance Director, showed a hire date of April 20, 2024, Review showed. the personnel record did not contaln a statement by a licensed physician or physician's designee Indicating the person could wark In @ long-term care facility and Indicating any imitations, During an Interview on 6/11/24 at 3:00 P.M. the DON sald the faclilty was having a hard time finding a physician who will complete a statement for the employee files, They have not had a physician statement written for any employaes including those that was listed on the previous statement of deficlenctes, 18 CSR 30-86.047(47)(F)(1)(C) Influenza/Pneumococcal.- Policy/Refuse {A4805} Medication Orders. (F) influenza and pneumococcal polysaccharide immunizations may be administered per physician-approved facility policy after assessment for contraindications- 1. The facitlty shalt develop a palicy that provides recommendations and assessment parameters for the administration of such immunizations, The policy shall be approved by the facility medical director for faciiitles having a medical director, or by each resident's attending physician for facllitles that do not have a medical director, and shall include the requirements to: C, Provide the opportunity to refuse the immunization; and I/Hll | This regulation is not met as evidenced by: PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD 8E CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} {A4805} 19 CSR 30-86.047(47)(F) (1)(C) influenza/Pneumococcal - Policy/Refuse 1. Administration of Caregivers Inn has implemented a policy to ensure that the flu and pneumococcal vaccinations are offered to the residents and a consent or refusal to receive such vaccinations as prescribed by licensed professional facility of choice. ie. Pharmacy or physician's office 2. Administrator or designee will ensure fhat all residents and or responsible party will receive a copy of the policy and consent upon admission and upon care plan review, 3, Administrator and or designee willl ensure that vaccination consent forms are uploaded to electronic resident files and audited annually or significant change. Missourl Department of Health and Santor Services STATE FORM ifeontInuation sheat 3 of 7 FHFD12 Missourl Department of Health and Ssnior Services PRINTED: 06/25/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (Xf) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: 45342D B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAREGIVERS INN (X4) 1D PREFIX TAG {A4805} STATE FORM 1297 FEISE ROAD DARDENNE PRAIRIE, MO 633668 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EAGH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (A4805} A4817 Bane FHFD12 : Vra0ar Waa, LPR. US W\VES\VOU Continued From page 3 This deficlency is uncorrected. For previous examples, sée the Statement of Deficlencles dated 3/26/24, Class ti* Based on record review and Interview, the facility falled to document when residents or their representatives refused the Influenza vaccine, This affected all 16 residents who currently resided In the facility. The census was 20. The facility did not provide a poltcy for the administration or refusal of the influenza vaccine. During an interview on 6/11/24 at 2:30 the Administrator/Director of Nursing said the following: -The facility had not obtained any consents or refusals for the influenza vaccinations for residents; -The facility has signed a contract with a new pharmacy and were waiting until this pharmacy began operations In the facility to have consent forms signed; . -The new pharmacy was to begin In a couple of weeks; -The facillty did not complete any consents for the residents who were reviewed during the licensure on 3/26/24, *The higher classificatlon merited due to the extent of the violation. 18 CSR 30-86.047(51}(A){1) Schedule II Meds-Reconclle Each Shift, Record Records shall be maintained upon receipt and disposition of alf controiled substances and shall Missouri Department of Health and Senior Services COMPLETED R-C - 06/11/2024 If continuation shast 4of7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/QUPPLIBRICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 15342) NAME OF PROVIDER OR SUPPLIER CAREGIVERS INN PRINTED: 06/25/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED R-C 06/11/2024 STREET ADDRESS, GITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 62368 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A4817) Continued From page 4 be maintained separately from other records, for two (2) years. - (A) inventories of controlled substances shall be reconciled as follows: 1. Controllad Substance Schedule |! medications shall be reconcllad each shift; tl This regulation !s not met as evidenced by: This deficlancy is uncorrected, For previous examples, refer to the Statement of Deficiencies dated 3/26/24, Based on observation, Interview and record review, the facility failed to ensure inventories of Schedule Il controlled substances (medications which have a high potential for abuse) were reconciled when staff failed to document when the narcotic was administered resulting in a discrepancy In the narcotic count for two of four sampled residents (Resident #2 and Resident #4). The facllity census was 20. The facility did not provide a policy for documentation of narcotics. 1. Review of Resident #2's face sheet showed the resident admitted to the facility on 2/26/18 with diagnoses of asteoporosis (when the bones become brittle and fragile fromm loss of tissue), dementia and anxiety. Review of the Physician Order Sheat (POS) dated June 2024 showed an order far Tramadol (an oplold madication used to treat moderate pain) 50 milligrams (mg), one half tablet for 25 mg two (BID) times a day for discomfort and pain. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A4817 19 CSR 30-86.047(51)(A) (1) Schedule It Meds-Reconcile Each Shift, Record 1. Administrator and or designee has reviewed current company policy of controlled medication reconciliation and distribution with all current level one medication aides. 2. Administrator or designee will continue to reeducate all level one medication aides on the © counting and adminisiration of controlled substances. 3. Administrator or designee will continue to complete controlled medication audits three times a week for the next 80 days to ensure that medications ara correctly reconciled to meet company policy and state regulation. Missour Department of Health and Senior Services , . STATE FORM cacy FHFD12 Jf continuation sheet 6 of 7 okra, LPR SD >WAIDY PRINTED: 08/25/2024 FORM APPROVED Missourl Depariment of Health and Sentor Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 45342D B. WING 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 (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) CAREGIVERS INN A4817| Continued From page 5 Review of the resident's Medication Administration Record (MAR) dated June 2024 showed Tramadol 50 mg, one half tablet (25 mg) {o be given at 8:00 A.M. and 5:00 P.M. for pain. Documentation showed staff administered the medication June 1, 2024 through June 10, 2024 at 8:00 A.M, and 5:00 P.M. Review of the residant’'s narcotic count sheet for Tramadol 50 mg, one half tablet (25 mg) showed: the following: -A card of Tramadol! 26 mg received on 5/29/24 with 30 tablets In the card; -Tramadol 25 mg one tablet administered dally at 8:00 A.M. and another at 5:00 P.M. with a count of four tablets remaining on 6/10/24. Review of the resident's card for Tramadof 50 mg, one half tablet BID showed a total of three tablets remaining in the card. 2. Review of Resident #4's face sheet showed the resident admitted to the facility an 41/9/23 with dlagnoses of Alzheimer's disease and chronic atrial fibrillation (an irregular and often very rapid heart rhythm), Review of the resident's POS for June 2024 showed an order for Tramadol 50 mg BID for pain. Review of the resident's MAR for June 2024 showed staff documented administration of Tramadol 50 mg 6/4/24 through 6/11/24 at 8:00 A.M. and 6/1/24 through 6/10/24 at 5:00 P.M. Review of the resident's narcotic count sheet for Tramadol 50 mg, take one tablet BID showed the following: ; ~14 tablets recelved on 5/28/24; Missourl Department of Health and Santor Services STATE FORM aad FHFD12 . Ifcontinuatian sheel 6 of 7 PRINTED: 06/25/2024 FORM APPROVED Missourl Department of Health and Senior Services ‘ STATEMENT OF DEFICIENCIES (X4} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY , AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 45342D B.WING 06/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1297 FEISE ROAD DARDENNE PRAIRIE, MO 63368 0X4} |O 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) CAREGIVERS INN 44817) Continued From page 6 -One tablet documented as given on 6/6/24 at 7:00 P.M. with a total of 13 remaining; -On 6/7/24 at 7:00 P.M., one tablet documented as given for 12 tabiets remaining; -On 6/8/24 at 5:00 P.M., one tablet documented as given with 11 tablets remaining; -On 6/9/24 at 8:00 A.M., one tablet documented as given with 16 tablets remaining; -On 6/9/24 at 6:00 P.M., ons fablet documented as given with 9 tablets remaining; -On 6/40/24 at 8:00 A.M., one tablet documented as given with 8 tablets remaining; -On 6/10/24 at 5:00 P.M., one tablet documented as given with 7 tablets remaining; -On 6/11/24 at 7:00 A.M., one tablet documented as given with 6 tablets remaining. Review of the resident's medication card for Tramado! 50 mg, give one tablet BID showed 7 fablets remained in the card. During an interview on 6/10/24 at 2:00 P.M. Level One Medication Alde F said the following: -He/She counted the narcotics at the beginning of his/her shift and the narcotic count was correct; -He/She possibly did not sign out the medication on the narcotic count sheet when he/she gave the medication on the morning medication pass; -He/she should sign off the medication on the narcotic count sheet when he/she administers the medication. During an Interview on 6/10/24 at 3:00 P.M. the Administrator/Director of Nursing said she expected staff to document on the MAR and the narcotic count sheet at the time of narcotic administration. Missour Deparment of Heallh and Sentor Services STATE FORM ; anne FHFO12 ff continualion sheet 7 of 7 L Pas, CID Ys 0Iu) Osis \e\ ay