AUTUMN VIEW GARDENS.

PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERYCLIA (X2) MULTIPLE CONSTRUCTION (K3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED 20751C —— 02/40/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 iXay 1D 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) AUTUMN VIEW GARDENS This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB) test was completed prior to hire and a one slep completed annually for four of four sampled staff, The facility also failed to ensure the required two step TB test was completed prior to admission for three of six sampled residents {Residents #6, #5, and #4). The facility also failed te do the annual screening for one of six sampled residents (Resident #6) The census was 81. General requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents and staff for tuberculosis. Each facility shall be responsible for ensuring that ail test results are completed, and that documentation is maintained; -Within one month prior to or one week afler admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -If the resident's initial test is negative, the second test should be given one to three weeks later, The COC (Centers for Disease Centro!) states TB tests should be read 48 to 72 hours after administration; -All tong-term care facility residents shall have a documented annua! evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S ROVIDER/SUPPLIER REPRES, {(X6) DATE ce STATE FORM I conlinuation|shee: 1 of 16 PRINTED: 62/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUSTION (X%3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 207516 B. WING 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE ORIVE ELLISVILLE, MO 63011 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS 44724 Continued From page 1 -Individuats with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease; -Within one month prior to starting employment, all new to long-term care employees are required to have the initial test of a two-step TB test; -All employees and volunteers are required to abtain Mantoux PPD (purified protein derivative) two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mrnj, the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the initial test is negative, tha sacond test should be given as soon as possible within one to three weeks afler employment begins. The CDC states TB tests should be read 48 to 72 hours after administration; -Employees with an initial zero to nine millimeters TB two step test shall have one step tuberculin testing annually and the resuks recorded in a permanent record, 1. Review of Employee E's personnel file, showed the following: -Hire date 2/8/22; -A one-step TB/PPD test administered on 7/10/24, with no documented read date; -No documented two-step TB/PPD test upon hire. 2. Review of Employee |'s personnel file, showed the following: -Hire date 7/5/22: -A two-step TB/PPD test administered on 11/15/22 and read on 11/17/22, with no induration documented; -A second-step TB/PPD test administered on Missouri Department of Health and Senicr Services STATE FORM Bag8 EvIN11 Hf continuation sheet 2 of 16 PRINTED; 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X38) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED 207516 ——————s 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 6) 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) AUTUMN VIEW GARDENS A47z4 Continued From page 2 11/30/24 and read on 12/22/22, with no induration documented; -No documented two-step TB/PPD test administered prior to hire. 3, Review of Employee F's personnel file, showed the following: -Hire date 9/26/24: -A. one-step TB/PPD test administered on 9/11/24 and read on 9/14/24, with an induration of O mm documented: -No documented second step; -No documented two-step TB/PPD test upon hire. 4. Review of Employee J's personnel file, showed the following: Hire date 10/2/23; -A two-step TB/PPD test administered on 10/12/23 and read on 10/14/23, with no induration documented: -A second-step TB/PPD test administered on 10/25/23 and read on 10/27/23, with no induration documented; -No documented two-step administered prior to hire; -No annual one-step TB/PPD test administered in 10/2024, 5, Review of Resident #5's medical record, showed the following: -Admit date 9/17/24: -No documented TB/PPD test upon admission. 6. Review of Resident #4's medical record, showed the following: -Admit date 10/1/24; -No documented TB/PPD test upon admission. 7. Review of Resident #6's medical record, showed the following: Missourt Department of Health and Senior Services STATE FORM s6a2 EJIN14 \F continuation sheet 3 of 16 PRINTED: 02/25/2025 FORM 4PPROVED Missour| Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X7} PROVIGER‘SUPPLIER/CLIA. (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20751C ——————— 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET AODRESS, CITY, STATE, ZIP CODE 16215 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 ex) 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 IDENTIFYINS INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS 44724 Continued From page 3 -Admit date 9/16/21: -A two-step TB/PPD test administered on 8/30/22 and read on 9/1/22, with an induration of 0 mm decumented; -A second-step TB/PPD test administered on 9/20/22 and read on 9/22/22, with an induration of 0 mm documented; -No documented annual screening for 9/2023 or 9/2024. 8. During an interview on 2/10/25 at 2:35 P.M., the Regional Director of Nursing {RDON) said he was aware the two-step test was required for all staff upon hire and a one-step test annually. The RDON said he was also aware a two-step test was required for new residents and a screening done annually. The RDON said he had just taken over on an interim basis until a new Director of Nursing could be hired. The RDON said he had conducted an audit and identified the TB tasting was not being done correctly but has net had the time to get the tests done for all the staff. The RDON said his audit had not yet gotten to all fhe residents, but he had suspected not all the tests were done correctly. The RDON said he has not had an opportunity to review all the resident files, $0 he was not sure which ones were done correctly. 19 CSR 30-86.047{58)(B) Resident Condition/Medication Review The facility shall maintain a record in the facility for each resident, which shall inctude the following: (B) A review monthly or more frequently, if indicated, of the resident 's general condition and needs; a monthly review of medication consumption of any resident controlling his or her Missouri Deparment of Health and Senior Services STATE FORM sae8 EJIN11 If continuation sheet 4 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES 041) PROVIDER/SUPPLIEFYCLIA (2) MULTIPLE CONSTRUCTION {3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATIGN NUMBER: A. BUILDING: COMPLETED 20751C BING 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MC 63011 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION {x5} (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATGRY OR LSC IDENTIFY ING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS 44837 Continued From page 4 own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services fram an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihbod of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident: [II This regulation is nat met as evidenced by: Based on interview and record review, the facility failed to ensure a monthly summary which included the resident's general condition and resident falls was completed each month, for eight of eight sampled residents (Residents #7, #6, #8, #1, #3, #2, #5, and #4}. The census was 81. 1. Review of Resident #7's medical record, showed the following: Admit date 3/18/21; -Diagnoses included dementia with behavioral disturbance, unspecified mental disorder, major depressive disorder and high blood pressure; -A monthly summary dated 7/6/24; -No documented monthly summaries for 8/2024, 9/2024, 10/2024, 11/2024, 12/2024 or 1/2025. 2. Review of Resident #6's medical record, showed the following: -Admit date 9/16/21; -Diagnoses included high blood pressure, history of breast cancer and pelvic fracture; -No documented monthly summaries. Missouri Department of Health and Senior Services STATE FORM esan EJIN41 if continuation sheet 5 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIERICLIA (X2}) MULTIPLE CONSTRUCTION (X3}) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20751C 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 82011 (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) AUTUMN VIEW GARDENS AABA? | Continued From page 5 During an interview on 2/10/25 at 1:42 P.M., the resident said he/she had fall on 1/1/25 and a staff member helped him/her off the floor. The resident said he/she did not have any injuries from this fall. During an interview on 2/10/25 at 2:58 P.M., Certified Medication Aide (CMA) L said the resident had a fall on 1/1/25, but did not go out to the hospital, The CMA said he/she fargot to write the fall incident in the resident's medical record. Review of the resident's medical record, showed no documentation regarding the resident's fall on 4/1/25. 3. Review of Resident #8's medical record, showed the following: -Admit date 1/28/22: -Diagnoses included Alzheimer’s disease, anxiety and depression: -No documented monthly summaries. 4, Review of Resident #1's medical record, showed the following: -Admit date 9/29/23: ~Diagnoses included Alzheimer's disease, chronic kidney disease and history of falls; -A monthly summary dated 7/6/24: -No documented monthly summaries for 8/2024, 9/2024, 10/2024, 11/2024, 12/2024 or 1/2025. 5. Review of Resident #3's medical record, showed the following: -Admit date 4/15/24; -Diagnoses included dementia, chronic kidney disease, and arthroscierosis of aorta (hardening of the aorta); -No documented monthly summaries. Missouri Department of Health and Senior Services STATE FORM begs EJIN14 lf continuation shest $ of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES 01) PROVIDER/SUPPLIEA/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IGENTIFICATION NUMBER: A BUILDING: COMPLETED 207516 a 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, Z|P CODE 16219 AUTUMN VIEW TERRACE BGRIVE ELLISVILLE, MO 63071 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) {EACH DEFICIENCY MUST BE PRECECED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCES TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS 44837 Continued From page 6 6. Review of Resident #2’s medical record, showed the following: Admit date 8/8/24; -Diagnoses included schizoaffective disorder, bipolar, type II diabetes and slaep disorder; -No documented monthly summaries. 7. Review of Resident #5’s medical record, showed the following: -Admit date 9/17/24; -Diagnoses included high biood pressure, type II diabetes, and hardening of the aorta; -No documented monthly summaries. &. Review of Resident #4's medical record, showed the following: -Admit date 10/1/24; -Diagnoses included chronic kidney disease, high blood depression chronic back pain, and diabetes; -No documented monthly summaries. 9. During an interview on 2/10/25 at 2:35 P.M., the Regional Director of Nursing {RDON) said he was aware each resident required a monthly summary to be done but thought the previous Director of Nursing had been completing the summaries. The RDON said he was unsure where the monthly summaries were located in the electronic system. The RDON said he has not yet had the opportunity te review all of the resident medical records to ensure all required information had been included. 18 CSR 30-86.047(61){A) Staffing Ration, Resident Care & Fire Safety Staffing Requirements. Missoun Department of Heallh and Senior Services STATE FORM sane EJIN14 If continuation sheet 7 sf 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES. (84) PROVIDER/SUPPLIER/CLIA (42) MULTIPLE CONSTRUCTION (&3) DATE SURVEY AND PLAN OF CORRECTION IOENTIFICATION NUMBER: A. BUILDING: COMPLETED 20751¢ B.WING 02/10/2025 NAME OF PROVIDER OR SUPFLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS 44841 Continued From page 7 (A) Fhe-facility shai! have an adequate number and type of parsennel forthe proper care of residents, the residents ‘social well being, _ protective oversight of residents and uckeep of the facity. Ata minimum. the staffing pattem for fire safety and care of residents shall be one (1) staff person for évery fifteen (15} residents Or major fraction of fifteen (15) during the day shifi, one (1) person for every twenty (20} residents or major fraction of twenty (20) during the evening shifl and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. I/Ik | Time Personael Residents | 7 a.m. to 3 p.m. (Day}* 1 315 ‘3 p.th. to 9 p.m. fEvening}® 1 320 ¢ p.m. to 7 am, dight}* 1 225 *lf the shifl hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than six (6) hours. Ill This regulation is not met as evidenced by: Class II , Based on interview and record review, the facility care staff faited to notify a nurse for an assessment after resident falls. The staff lifled | the resident off the floor without an assessment by 2 qualified person for ona of eight sampled residents (Resident #6). The cerisus was 81. Review of Resident #6's medical record, showed the facility admitted the resident on 9/16/21, with diagnoses which included high blood pressure, Missouri Department of Health and Senior Services STATE FORM cea EJIN11 lf continuation sheet 8 of 16 PRINTED; 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT GF DEFICIENGIES (%1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (<3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, RUILDING: COMPLETED 20751¢ ) 8. WING 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (rap 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION m5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EAGH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS 44841 Continued From page 8 history of breast cancer and pelvic fracture. Review of the resident's progress notes, showed the following: -On 11/6/24 at 7:11 P.M_, Gertified Medication Aide (CMA) K went into the resident's room and saw the resident on the floor on his/her knees. The resident said he/she was trying to open the door to talk to the CMA about medications. The resident did not hit his/her haad. The resident had a skin tear on his/her left thumb. CMA K put antibiotic créam and a bandage on the thumb and notified the Director of Nursing (DON) and the resident's family member; -On 11/8/24 at 7:24 P.M., CMAK went into the resident's room because the resident called for CMA K stating he/she was on the floor. The resident was on the floor, on his/her back, by his/her dresser, by the bed. The resident said he/she bent down to get his/her shirt out of the drawer and his/her arm got caught in the drawer. The resident had a skin tear on his/her right arm. CMA K cleaned the wound and notified the DON and the resident's family member. During an interview on 2/10/25 at 1:42 P.M., the resident said he/she had two fails back in November, probably on 11/7/24 and then the very next day he/she fell again. The resident said CMA K helped him/her off the floor. The resident said the employee no longer worked at the facility, he/she was going to Nursing school but was nota Nurse yet. The resident said no Nurse came in to assess him/her after the fall. The resident said the facility had not had their own Nurse for a while and could not remember if the Nurse had still been employed, at the facility, at the time of his/her falls. The resident said ever since the falls, he/she has been weak. The resident said hefshe had another fall on 1/1/25 and CMAL Missouri Department of Health and Serlor Services STATE FORM BBS EJIN11 If continuation sheet 9 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (%2} MULTIPLE CONSTRUCTION (%3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 4. BUILDING: COMPLETED 20751¢ BEING 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS A4841 Continued From page 9 helped him/her off the floor. The resident said CMA L assessed him/her. The resident said he/she did not have any injuries from this fall. During an interview on 2/10/25 at 3:04 P.M., CMA K said the resident had two falls in November and he/she helped the resident of the floor for both of the falls. CMA K said when eniering the resident's room for both falls, he/she tock the resident's vitals and did a neuro-check and the resident had na "signs ar symptoms of anything going on with his/her brain". After the assessment, CMA K called for a second person to come in and help him/her lift the resident off the floor. CMA K said the Director of Nursing {DON) was employed when ihe two falls in November happened and he/she notified the DON after assisting the resident off the floor. The DON assessed the resident the next day when he/she was in the facility. CMA K said he/she had never been told only a Nurse was qualified to assess a resident after a fall and only afler the assessment could the resident be lifted off the floor. CMA K said he/she was told he/she was responsible to assess a resident affer a fail and there was no Nurse in the building during the two falls in November. During an interview on 2/10/25 at 2:58 P.M., CMA L said the resident had a fall on 1/1/25, but did not go out to the hospital. CMA L said there was a second staff member in the room with him/her when assessing the resident, but he/she dic not ramember who the second staff member was. CMA L said the staff did not usually call the Nurse after a resident falls. When the prior DON (two DONs back) worked at the facility, the staff were required to call her any time a resident fell no matter the time of day, but with the most recent DON, the staff were not required to call her and if Missouri Department of Health and Senior Services STATE FORM saga EJIN44 If cantinvation shast 10 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA 0X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20751C B. WING 02/40/2025 NAME OF PROVIDER OR SUPPLIER STREET ACDRESS, CITY, STATE, ZIP CODE aint EW GA NRDEN. , 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 4x4} ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDEO BY FULL (EAGH CORRECTIVE ACTION SHOULO BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATICN) CROSS-REFERENCED TO THE APPROPRIATE DATE a DEFICIENCY) 44845, Continued From page 10. _ they did, she would not answer. CMA.L said the most recent DON was less available than other DONs and the staff had to take care of things on their own. CMA L said there was no Nurse in the building on 1/1/25, when the resident fell so he/she did not call a Nurse and did not know who to call. CMA L said there was a iist of questions he/she would ask the resident while thay were still on the floor, like if they hit their head and if they were in pain. CMA L said no one told him/her only a Nurse could assess a resident after a fall and only after the assessment could a resident be lifted off the floor. CMA L said he/she must have forgotten to write his/her progress note for this fall. During an interview on 2/10/25 at 3:21 P.M., the Regional Director of Nursing said accarding to his internal report the resident had two falls, ane on 1/1/25 and the other on 11/6/24. He did not know of the third fall on 11/8/24. He said the resident returned fram the hospital on 11/6/24 and was very weak. He said he was not aware a resident who had fallen required a Nurse's assessment prior to being lifted off the floor, but he was aware the facility's policy said a Nurse would direct the assessment of a resident. 19 CSR 30-87 .030(65) Nonfood Contact Sunaces,Cleaned as Needed Nonfood-contact surfaces of equipment shall be claaned as oflen as is necessary io keep the equipment free of accumulation of dust, dirl, food particles and other debris. Ill This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure all non-food contact surfaces Missouri Department cf Health and Senior Services STATE FORM Sea EJINd1 If conlinuation sheet 71 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20751C ———_ 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (<4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAS REGULATORY ORLSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} AUTUMN VIEW GARDENS A?7067 Continued From page 11 were kept clean when multiple non-food contact surfaces were covered in focd grime and grease, for one of one day of observation. This had the potential to affect all residents. The census was 81. Observation on 2/10/25 between 7:40 A.M. and 3:20 P.M., of the kitchen, showed the following: -A flat top surface approximately 3 feet (fi) by 3 ft, with accumulated black, brown, and yellow grease buildup along the sides and comers, -A stove approximately 3 ft by 3 ft, with accumulated yellow and white grease deposits along the sides; -A steam table with three dred food stains, orange in color, running down the front near the temperature knobs. The protective glass was covered in a clear grease film which had random food particles stuck to the grease, across the entire surface. During an interview on 2/10/25 at 3:20 P.M., the Culinary Director (CD) said she knows the gnill, stove and steam table should be cleaned better. The CD said the grill was last cleaned three weeks ago but needs fo be done more often. The CD said the steam table gets dirty fast because of heavy use, and staff have struggled to keep it clean. 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, Missoun Department of Health and Senior Services STATE FORM in EJIN11 If continuation shest 12 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {41} PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20751C oo 02/10/2025 NAME GF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (x4) 1D SUMMARY STATEMENT DF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X8) PREFIX {EACH DEFICIENCY MUST BE PREGEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS 48004 Continued From page 12 legally authorized representative or designee, either in a group session or individually. Il/Il| 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, annually, for four of eight sampled residents, (Residents #8, #7, #6 and #1}. The census was 81. 1, Review of Resident #8's medical record, showed the following: -Admit date 1/28/22: -Diagnoses included Alzheimer's disease, anxiety and depression; -A review of resident rights dated 1/25/22; -No documented annual review of resident rights for 1/2023, 1/2024 or 1/2025, 2. Review of Resident #7's medical record, showed the following: Admit date 3/18/21; -Diagnoses included dementia with behavioral disturbance, unspecified mental disorder, major depressive disorder and high blood pressure; -A review of resident rights dated 2/24/23; -No documented review of resident rights for 2/2024. 3, Review of Resident 46's medical record, showed the following: -Admit date 9/16/21; «Diagnoses included high blood pressure, history of breast cancer and pelvic fracture; -4 review of resident rights dated 2/25/23: -No documented annual review of resident rights for 2/2024, Missouri Department of Health and Senior Services STATE FORM ean EJIN11 If continuation sheet 13 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2} MULTIPLE CONSTRUCTION 043) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETES 20751C Be MVING se 02/10/2025 NAME GF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, Z!F CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 630114 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH GORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR. LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS A8004 Continued From page 13 4, Review of Resident #1's medical record, showed the following: Admit date 9/29/23; “Diagnoses included Alzheimer's disease, chronic kidney disease and history of falls: -A review of resident rights dated 9/27/23; -No documented annual review of resident rights for 9/2024. 5. During an interview on 2/10/25 3:42 P.M., the Regional Director of Nursing said he was aware the residents required an annual review of their resident rights and when reviewing the resident's charts, he noticed there was an inconsistency. “The higher the classification merited due to the extent of the violation. ABGTG19 CSR 30-88.010(10) Advance Directive Requirements Prior to or upon admission and at least annually afler that, each resident or his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding provision of ermengency and life-sustaining care, of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handied either on a group or on an individual basis. Residents‘ next of kin, fegally authorized representatives or designees shall be informed, upon request, regarding state laws related to advance directives for health-care decision making a$ Well as the facility's policies regarding the provision of emergency or life-sustaining medical care or treatment, If a resident has a written advance health-care directive, a copy Missouri Department of Health and Senior Services STATE FORM bana EJIN11 If continuation sheet 14 of 16 PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {41} PROVIDERASUPPLIERVCLIA (X2) MULTIPLE CONSTRUCTION (GQ) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: GOMPLETED 20751C — 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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 L&C IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN VIEW GARDENS A8010 Continued From page 14 shall be placed in the resident's medical record and reviewed annually with the resident unless, in the interval, he or she has been determined incapacitated, in accordance with section 475.075 or 404.825, RSMo. Residents’ next of kin, legally authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. HA This regulation is not met as evidenced by: Class Ill Based on interview and record review, the facility failed to review advanced directives with residents or their representative, upon admission and annually for three of eight sampled residents (Residents #8, #6 and #7). The census was 81 1. Review of Resident #8's medical record, showed the following: -Admit date 1/28/22- -Diagnoses included Alzheimer's disease, anxiety and depression; -A review of the resident's advanced directives dated 1/26/22: -No documented annual review for 1/2023, 1/2024 or 1/2025, 2. Review of Resident #6’s medical record, showed the following: -Admit date 9/16/21: -Diagnoses included high blood pressure, histary of breast cancer and pelvic fracture: -A review of the resident's advanced directives dated 9/2/21; -No decumented annual review for 9/2023 or 9/2024, Missour Department of Health and Senior Services STATE FORM bes EJIN41 IF continuation sheet 15 of 16 Missouri Department of Heatth and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER 20751C (X2) MULTIPLE CONSTRUCTION A. BUILDING: STREET ADDRESS, CITY, STATE, ZIP CODE 162179 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS (x4) ID PREFIX TAG A8010 ELLISVILLE, MO 63011 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 3. Review of Resident #7's medical record, showed the following: Admit date 3/18/21; -Diagnoses included dementia with behavioral disturbance, unspecifiad menial disorder, major depressive disorder and high blood pressure; -A review of the resident's advancod directives dated 3/1 8/21; -No documented annual review for 3/2023 or 3/2024, 4, During an interview on 2/10/25 at 3:45 P.M., the Regional Director of Nursing said he was not aware the residents required an annual review of their advanced directives. Missouri Department of Health and Senior Services STATE FORM B99 EJIN4+1 PROVIDER'S PLAN OF CORRECTION PRINTED: 02/25/2025 FORM APPROVED (X3) OATE SURVEY COMPLETED 02/10/2025 {x5} (EACH CORRECTIVE ACTION SHOULD BE GOMPLETE CROSS-REFERENCEO TO THE APPROPRIATE DATE DEFICIENCY) lf continuation sheet 16 of 16 PLAN OF CORRECTION Provider/Supplier Name: Autumn View Gardens Ellisville Street Address, City, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE This Plan of Correction (“POC”) is submitted as required under State Law. The submission of this POC does not constitute an admission on the part of Autumn View Gardens (the “Facility”, “Community”} as to the accuracy of the surveyors’ findings written in the Summary Statement of Deficiencies, nor the conclusions drawn therefrom. This POC is Intended to constitute the Community's credible letter alleging compliance. Compliance has been and willbe achieved no later than the last completion date identified in the POC. Compliance will be maintained as provided in the Plan of Corrections on 4.7.2025 ns All residents & Staff have the potential to be affected by this deficient practice. 16219 Autumn View Terrace Drive Ellisville, 63011 HSD or Designee to audit and curate a spreadsheet with all TBs Added TB test check to monthly audit/checklist far new residents and staff members. Health Services Director or designee will do a monthly audit of “sa eS new residents and staff members to ensure they have completed the TB testing and that the induration of millimeters is indicated on the results. AABS7 19 CSR 30-86.047(58\(B) Resident Candition/Medicafion Review All residents have the potential to be affected by this deficient practice. HSD or Designee to create a monthly summary schedule staff willbe educated on this. HSD or Designee will be auditing menthly summary schedule by the end of month to ensure Dyvecdkd- SISA 4.7.2025 19 CSR 30-86.047 (61) {A} Staffing Ratio, Resident Care & Fire Safet All residents have the potential to be affected by this deficient practice, Staff to be reeducated that HSD or Designee to ba notified of each fall. Staff will be trained by HSD or Designee on our fall protocol/procedure upon hire, annually and as needed. ee | 18 CSR 30-87.020(65) Nonfoed Contact surfaces, cleaned as needed All residents have the potential to be affected by this deficient practice. Surface areas that were noted were cleaned by CSD on 2,12,26, Moving forward CSD or Designee will be checking daily that cleaning check lists are being completed by dining staff. a AB004 19 CSR 30-88.010 (4) Residents Rights Annual Review _ All residents have the potential to be affected by this deficient these are signed each month with new residents. a practice. A8010 19 CSR 30-8.101 (10) Advance Directive Requirements Alf residents have the potential to be affected by this deficient practice. 4.7.2025 100% of residents and/or representatives will be presented with resident rights and re-sign them. HSD or Designee will ensure these are done annually. HSD or Designee will include checking 100% Resident or representative to be presented with advance directive dacuments to be re-signed to ensure we are all caught up and in compliance. 4,7,2025 HSD or designee will ensure all advance directives are re- igned annuall The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 04/22/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: 20751C B.WING_ 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS A4506) 19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include the following components: A. The responsibilities of specific staff positions in an emergency specific to the individual; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to provide an individualized evacuation plan (IEP, the planning document prepared by an assisted living facility which outlines a resident's evacuation plan) with responsibilities of specific staff positions, in an emergency, specific to that resident with cognitive or other impairment, that cannot evacuate on their own, for two of eight sampled residents (Residents #1, and #2). The census was 83. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 6/30/20, with diagnoses which included dementia, anxiety and chronic heart failure. Review of the resident's IEP dated 3/28/24, showed the resident received hospice care and was unable to self-transfer or self-propel a wheelchair, open an exit door and was not able to go down stairs. Staff were instructed that in the event of an evacuation staff would need to use a gait belt to transfer the resident to a wheelchair and transport the resident to the exit. The IEP did not include which specific staff position was Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE tc 9 ; is STATE FORM /2024 If continuation sheet 1 of 33 se O90R11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 responsible for the resident's evacuation, during an emergency. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 1/24/24, with diagnoses which included anxiety, high blood pressure and chronic obstructive pulmonary disease, (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's IEP dated 3/6/24, showed the resident required a wheelchair. The resident was able to self-propel his/her wheelchair. The resident was not able to open the exit door. The resident was not able to go down the stairs. The resident required three verbal prompts and two physical interventions to complete an evacuation. The IEP did not include which specific staff position was responsible for the resident's evacuation, during an emergency. 3. During an interview on 4/8/24 at 3:02 P.M., the Director of Nursing said she was responsible for creating the resident IEP's and she was not aware the specific staff position responsible for the resident needed to be included in the IEP. 4. During an interview on 4/8/24 at 5:00 P.M., the Administrator said she was not aware the specific staff position responsible for the resident needed to be included in the IEP. 19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include the following components: C. The plan shall evaluate the resident for his or her location within the facility and the proximity to exits and areas of refuge. The plan shall evaluate the resident, as applicable, for his or her risk of resistance, mobility, the need for additional staff support, consciousness, response to instructions, response to alarms, and fire drills; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents who required more than minimal assistance to safely evacuate the facility had an individual evacuation plan (IEP, the planning documented prepared by an assisted living facility which outlines the plan to safely evacuate the resident out of the facility in the event of an emergency) with the resident's location within the facility and the proximity to the nearest exit or area of refuge (AOR), for two of eight sampled residents (Residents #1 and #2). The census was 83. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 6/30/20, with diagnoses which included dementia, anxiety and chronic heart failure. Review of the resident's IEP dated 3/28/24, showed the resident received hospice care and was unable to self-transfer or self-propel a wheelchair, open an exit door and was not able to go down stairs. Staff were instructed that in the event of an evacuation staff would need to use a gait belt to transfer the resident to a wheelchair Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 and transport the resident to the exit. The IEP failed to include the distance or direction from the resident's room to the nearest exit or AOR. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 1/24/24, with diagnoses which included anxiety, high blood pressure and chronic obstructive pulmonary disease, (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's IEP dated 3/6/24, showed the resident required a wheelchair. The resident was able to self-propel his/her wheelchair. The resident was not able to open the exit door. The resident was not able to go down the stairs. The resident required three verbal prompts and two physical interventions to complete an evacuation. The IEP did not indicate the distance or direction from the resident's room to the nearest exit or AOR. 3. During an interview on 4/8/24 at 3:02 P.M., the Director of Nursing said she was responsible for creating the resident IEP's and she was not aware the resident's location and distance to the nearest exit or AOR should be included in the IEP. 4. During an interview on 4/8/24 at 5:00 P.M., the Administrator said she was not aware the distance and direction to the nearest exit or AOR was required to be put into the IEP. 19 CSR 30-86.022(7)(A) Exits-2 per Floor-Remote/Unobstructed Exits, Stairways, and Fire Escapes. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. Il This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to ensure the doors leading to the exits were unobstructed by placing a mural of a bookcase on a memory care, designated fire exit door, for one of one day of observation. The census was 83. Observation on 4/8/24 between 7:22 A.M. and 5:00 P.M., of the south memory care fire exit door, showed a bookcase mural covering the door, which obstructed the clear view of the exit door. During an interview on 4/8/24 at 5:00 P.M., the Director of Nursing (DON) said the mural was installed prior to her arrival. The DON said both she and the Administrator did not think the mural was allowed but were told by corporate the mural was fine and would remain. During an interview on 4/8/24 at 5:00 P.M., the Administrator said she had several conversations with the corporate office about the mural but was told she was not allowed to remove it. The Administrator said she was aware the mural could be viewed as an obstruction by a confused person in the event of an emergency. 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB) test was completed prior to hire, for three of six sampled employees and failed to ensure residents’ two step TB tests indicated the induration of millimeters (mm) on the test for five of eight sampled residents (Residents #4, #8, #3, #2 and #7). The census was 83. General requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents and staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -lf the resident's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease; -Within one month prior to starting employment, Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 all new to long-term care employees are required to have the initial test of a two-step TB test; -All employees and volunteers are required to obtain Mantoux PPD (purified protein derivative) two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the initial test is negative, the second test should be given as soon as possible within one to three weeks after employment begins. The CDC states TB tests should be read 48 to 72 hours after administration; -Employees with an initial Zero to nine millimeters TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record. 1. Review of Employee B's personnel file, showed the following: -Hire date 1/25/24; -A first step TB/PPD test administered on 1/24/24, and read on 1/27/24, with 0 mm of induration documented; -No documented second step TB/PPD test administered one to three weeks after the first step TB/PPD test. 2. Review of Employee C's personnel file, showed the following: -Hire date 9/11/23: -A first step TB/PPD test administered on unknown date and read on unknown date, with no induration of mm documented; -A second step TB/PPD test administered on unknown date and read on unknown date, with no induration of mm documented. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 7 3. Review of Employee E's personnel file, showed the following: -Hire date 1/25/24: -A first step TB/PPD test administered on 1/25/24, and read on 1/27/24, with no induration of mm documented; -A second step TB/PPD test administered on 2/5/24, and read on 2/8/24, with no induration of mm documented. 4. Review of Employee D's personnel file, showed the following: -Hire date 11/16/24: -A first step TB/PPD test administered on unknown date and read on unknown date, with no induration of mm documented; -A second step TB/PPD test administered on unknown date and read on unknown date, with no induration of mm documented. 5. Review of Resident #4's medical record, showed the following: -Admit date 3/21/24; -No documented first step TB/PPD test; -No documented second step TB/PPD test. 6. Review of Resident #8's medical record, showed the following: -Admit date 8/23/21; -A first step TB/PPD test administered on 8/30/22, and read on 9/1/22, with no induration of mm documented; -A second step TB/PPD test administered on 9/19/22, and read on 9/22/22, with no induration of mm documented; -An annual screening dated 10/16/23, one month late. 7. Review of Resident #3's medical record, Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 8 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 8 showed the following: -Admit date 2/14/24: -A first step TB/PPD test administered on 2/14/24, and read on 2/16/24, with no induration of mm documented; -A second step TB/PPD test administered on 2/28/24, and read on 3/1/24, with no induration of mm documented. 8. Review of Resident #2's medical record, showed the following: -Admit date 1/24/24: -A first step TB/PPD test administered on 1/24/24, and read on 1/26/24, with no induration of mm documented; -A second step TB/PPD test administered on 2/6/24, with no documented read on date. 9. Review of Resident #7's medical record, showed the following: -Admit date 2/9/24: -A first step TB/PPD test administered on 2/1/24, and read on 2/3/24, with no induration of mm documented; -No documented second step TB/PPD test. 10. During an interview on 4/8/24 at 5:23 P.M., the Administrator said the Charge Nurse was responsible for the TB/PPD tests. The Administrator said she was not aware the TB/PPD tests were missing the induration of mm and she was aware the induration of mm was required to be documented. 19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ The administrator shall maintain on the premises an individual personnel record on each facility Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 9 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 employee, which shall include the following: (I) 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; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure employees had a written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility and indicated any limitations, for six of six sampled employees. The census was 83. 1. Review of Hostess E's personnel file, showed the following: -Hire date 9/11/23; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 2. Review of Hostess C's personnel file, showed the following: -Hire date 10/2/23; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 3. Review of Culinary Services Director's personnel file, showed the following: -Hire date 11/27/23: -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 4. Review of Certified Medication Aide (CMA) A's personnel file, showed the following: -Hire date 12/14/23; Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 5. Review of Care Partner B's personnel file, showed the following: -Hire date 1/25/24; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 6. Review of CMA E's personnel file, showed the following: -Hire date 1/25/24: -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 7. During an interview on 4/8/24 at 5:45 P.M., the Administrator said she was not aware the employee's files did not have a physician statement in them which indicated the person could work in long-term care and she was not aware a physician statement was needed for all employees. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop 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 an assisted living facility which outlines a resident "s needs and preferences, services to be provided, and goals expected by the resident or Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 the resident ' s legal representative in partnership with the facility; II This regulation is not met as evidenced by: Based on interview and record review, the facility 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 legal representative in partnership with the facility) which included resident needs, services to be provided by staff and goals expected by the resident or the resident's legal representative when a resident required his/her leg to be wrapped each morning and it was not indicated on the resident's ISP and when a resident had bed rails which were not indicated on the resident's ISP, for two of eight sampled residents (Residents #8 and #3). The census was 83. 1. Review of Resident #8's medical record, showed the facility admitted the resident on 8/23/21, with diagnoses which included high blood pressure and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's ISP dated 1/1/24, showed the resident had no skin issues with his/her leg. During an interview and observation on 4/8/24 at 2:00 P.M., the resident had his/her right leg wrapped and both feet were gray in color, with flaky skin. The resident said the staff come in each morning and wrap his/her leg for him/her and he/she unwrapped the leg at night. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 12 Review of the resident's ISP dated 1/1/24, showed the ISP did not indicate the staff were required to wrap the resident's right leg. 2. Review of Resident #3's medical record, showed the facility admitted the resident on 2/14/24, with diagnoses which included Parkinson's disease, dementia, high blood pressure and history of falls. Review of the resident's ISP dated 1/1/24, showed the resident had a need of fall intervention. The resident's goal was to remain free from falls. The staff were required to implement appropriate fall interventions to help the resident prevent falls. Observation on 4/8/24 between 7:47 A.M. and 10:00 A.M., showed the resident lay in his/her hospital bed on his/her back with both bed siderails raised on each side of the bed. Review of the resident's ISP dated 1/1/24, showed the ISP did not address the resident's use of bed siderails. The ISP did not specify what the staff were required to do to prevent the resident from falling. 3. During an interview on 4/8/24 at 5:50 P.M., the Director of Nursing (DON) said all needs should be listed on each resident's ISP. The DON said her and the Charge Nurse were responsible for creating and updating the ISPs. The DON said the bed siderails for Resident #3 should be listed on the ISP. The DON said information on Resident #8's leg and feet and the condition they were in, should be listed on the ISP. 4. During an interview on 4/8/24 at 5:55 P.M., the Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 13 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 13 Administrator said all resident needs should be listed on the individual resident ISPs. The Administrator said she was not aware Resident #8's ISP did not specify instructions on wrapping the resident's leg in the morning and address the resident's feet. The Administrator said Resident #3's ISP should list the use of bed siderails if the resident used them. 19 CSR 30-86.047(29)(B) Not Admit/Care For-Physical Restraints The facility shall not admit or continue to care for a resident who: (B) Requires physical restraint as defined in this rule; II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure residents did not require the use of physical restraints when a resident had a hospital bed with bed siderails on each side of the bed, pulled up, which prevented the resident from transferring out of his/her bed, for one of eight sampled residents (Resident #3). The census was 83. Review of Resident #3's medical record, showed the facility admitted the resident on 2/14/24, with diagnoses which included Parkinson's disease, dementia, high blood pressure and history of falls. Observation on 4/8/24 between 7:47 A.M. and 10:00 A.M., showed the resident lay in his/her hospital bed on his/her back with both bed siderails raised on each side of the bed. During an interview on 4/8/24 at 4:30 P.M., Certified Medication Aide (CMA) E said the Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 14 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 14 resident had a fall history and would get up in the middle of the night sometimes. CMA E said he/she thought the bed rails were on the bed to keep the resident from getting up during the night. During an interview on 4/8/24 at 4:39 P.M., CMA F said he/she checked on the resident three days ago and the resident had the bed siderails up at that time. CMA F said the resident had a fall history and the siderails are put up at night to prevent the resident from transferring by him/herself and falling out of bed. CMAF said he/she was unsure if the staff were required to put the bed rails back down in the morning. During an interview on 4/8/24 at 5:39 P.M., the Director of Nursing said she was aware the resident had bed rails but she was not aware staff were raising the bed rails at night to prevent the resident from transferring out of bed on his/her own. She said the resident was never assessed for the use of siderails and the siderails should have been taken off the hospital bed. During an interview on 4/8/24 at 5:40 P.M., the Administrator said she was not aware the resident had siderails and the resident should not have them because they can be used as a restraint. 19 CSR 30-86.047(40) Self-Control of Medication Requirements Self-control of prescription medication by a resident may be allowed only if approved in writing by the resident's physician and included in the resident ' s individualized service plan. A resident may be permitted to control the storage and use of nonprescription medication unless Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 15 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 there is a physician 's written order or facility policy to the contrary. Written approval for self-control of prescription medication shall be rewritten as needed but at least annually and after any period of hospitalization. II/III This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to obtain a physician's order to self-administer medications and outline the resident's self-administration in the resident's individualized service plan (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) for two of two reviewed residents during the medication pass (Residents #8 and #9) and one sampled resident (Resident #6). The census was 83. 1. Review of Resident #8's medical record, showed the facility admitted the resident on 8/23/21, with diagnoses which included high blood pressure and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's self-assessment dated 3/2024, showed the resident verbalized knowledge of medications and proper self-administration. The resident was able to take the medications at the proper times with the proper dose. The resident's medications were stored in a locked drawer/box or had the room locked when the resident was out of the room. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 16 The refill dates coincide with proper administration of medications. The medications agree with the physician's order sheet. Review of the resident's ISP dated 1/1/24, showed the resident self-administered and completed his/her own medications. Notes: The physician must approve self-administration of medications. Review of the resident's physician's orders sheet (POS) dated 4/8/24, showed the following: -Amlodipine (used to treat high blood pressure), 10 milligrams (mg). Give one tablet by mouth one time daily; -Losartan (used to treat high blood pressure), 50 mg. Give one tablet by mouth one time daily; -Furosemide (used to treat fluid build up in the body), 20 mg. Give one tablet by mouth one time daily; -No order for the resident to self-administer his/her own medications; -No order for the resident to keep the medication in his/her room. Observation on 4/8/24 between 7:47 A.M. and 1:40 P.M., of the resident's room, showed the following: -A bottle of amlodipine with approximately 19 pills, on the desk by the resident's bed; -A bottle of losartan with approximately 23 pills, on the desk by the resident's bed. During an interview on 4/8/24 at 1:45 P.M., the resident said he/she took his/her medication him/herself. The resident said he/she has kept his/her medication in his/her room since he/she moved into the facility. The resident then pulled out a bottle of furosemide with approximately 30 pills, from his/her purse. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 17 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 2. Review of Resident #6's medical record, showed the following: -Admit date 5/30/23; -Diagnoses included diabetes, major depressive disorder and high blood pressure; -No documented self-administration assessment. Review of the resident's ISP dated 1/21/24, showed the resident required medication administration assistance. Staff were required to administer the resident's inhaler. Review of the resident's POS dated 4/8/24, showed the following: -Flutic/salme (inhaler, used to treat asthma), annualized exacerbation rate (aer) of 500/50. Inhale one puff two times daily. Rinse mouth after use; -Spiriva (inhaler, used to treat asthma), aer 1.25 micrograms (mcg). Inhale two puffs one time daily; -The POS did not indicate the resident could self-administer his/her own medications; -The POS did not indicate the resident could keep the medication in his/her room. Observation on 4/8/24 at 2:00 P.M., of the resident's room, showed the following: -Flutic/salme inhaler on the kitchen counter; -Spiriva inhaler on the kitchen counter. During an interview on 4/8/24 at 2:05 P.M., the resident said he/she preferred to keep his/her inhalers in his/her room so he/she could take them as he/she pleased. The resident said the inhaler had been in his/her room since he/she could remember. 3. Review of Resident #9's medical record, Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 18 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 showed the following: -Admit date 6/28/23; -Diagnoses included arthritis, high blood pressure, fatigue, acid reflux and insomnia; -No documented self-administration assessment. Review of the resident's POS dated 4/8/24, showed the following: -Fluticasone Propionate (used to treat allergies), 50 mcg. Instill one spray into each nostril once daily as needed for allergy symptoms; -No order for the resident to self-administer his/her own medications; -No order for the resident to keep the medication in his/her room. Review of the resident's ISP dated 1/1/24, showed the resident had a need of medication assistance. The goal of the resident was to be in compliance with all of their physician's medication orders. The staff were required to assist the resident in taking their medications as per their physician's orders. The ISP did not indicate the resident had medication in their room and self-administered the medication. Observation on 4/8/24 at 1:55 P.M., of the resident's room, showed a full bottle of Fluticasone Propionate, 50 mcg., on the counter near the microwave. During an interview on 4/8/24 at 2:00 P.M., the resident said he/she administers his/her nasal spray him/herself “all the time." The resident said his/her family member brings the nasal spray to him/her. The resident said he/she has kept the nasal spray in his/her room since he/she was admitted. 4. During an interview on 4/8/24 at 5:15 P.M., the Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 19 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 19 Director of Nursing (DON) said she was not aware some residents had prescription medications in their room. The DON said no resident should have prescription medications in their room without a physician's order indicating it was okay. 5. During an interview on 4/8/24 at 5:18 P.M., the Administrator said she was not aware some residents had prescription medications in their room. The Administrator said no resident should have prescription medications in their room without a physician's order indicating it was okay. 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 20 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Wl This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to ensure a safe and effective medication system for three of four residents observed during the medication pass. The facility staff failed to administer eye-drops properly, watch residents consume their medication, left medications with residents, and failed to use acceptable infection control practices for one of one observed medication pass (Residents #10, #2 and #12). The census was 83. 1. Observation on 4/8/24 at 7:35 A.M., of the medication pass, showed Certified Medication Aide (CMA) E prepared Resident #10's medication at the medication cart and put it ina medication cup while the resident sat on a nearby bench. CMA E gave the resident his/her medication and then opened the resident's eye drop medication while the resident consumed his/her medication. When the resident was done with his/her pills, CMA E asked the resident to tilt his/her head back a little so he/she could administer the eye drops. The resident put his/her head back just a little and CMA E dropped the resident's eye drop medication in the corner of the resident's eye, touching the corner of the resident's eye with the tip of the bottle. CMAE did not hold the resident's inner canthus. The resident blinked several times while a tear rolled down his/her cheek and the resident wiped it away with his/her hand. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 21 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 21 2. During observation on 4/8/24 at 8:08 A.M., CMA E prepared Resident #2's medication, the resident sat in his/her recliner and CMA E handed the resident a medication cup and the resident took 16 of the 19 pills. The resident did not take his/her potassium pill and he/she did not take his/her two Bumetanide pills. CMA E asked the resident if he/she would take the medication and the resident said he/she would later. The three pills remained in his/her medication cup on the table in front of his/her recliner. CMA E left the medications with the resident and left the room. Review of the resident's physician's orders dated 4/2024, showed no order to self administer or leave medications in the resident's room. 3. Observation on 4/8/24 at 7:19 A.M., showed CMA E prepared Resident #12's medication. CMA E handed the resident his/her medication, turned around and shut the door without watching the resident take his/her medication. 4. During an interview on 4/8/24 at 8:33 A.M., CMA E said he/she did not always watch the residents take their medications. CMAE said if he/she did not watch the resident take their medications, he/she would go back in about 20 to 30 minutes to make sure the resident took the medications. CMA E said it was "common practice" to not watch the resident take their medication and it was how he/she was trained. 5. During an interview on 4/8/24 at 5:15 P.M., the Director of Nursing (DON) said she expected CMA E to watch all residents take all their medications and she was not aware CMA E did not hold the inner canthus after administering a resident's eye drops. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 22 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 22 6. During an interview on 4/8/24 at 5:20 P.M., the Administrator said she expected all Medication Technicians (MT) to watch all residents take all of their medications. The Administrator said she was not aware CMA E did not watch the residents take medications. The Administrator said she was not aware CMA E did not hold the inner canthus of a resident's eye after administering eye drops but she said he/she should have held the inner canthus. 19 CSR 30-87.020(5) Toxic Material Storage Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents when chemicals were found in unlocked areas accessible to residents and in individual resident rooms. This had the potential to affect all residents. The census was 83. 1. Observation on 4/8/24 between 7:35 A.M. and 5:00 P.M., of the unlocked housekeeping/electrical storage room across from room 224, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 23 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 23 -Fifteen full, one quart bottles of Foul Odor Digester. The precautionary statement read, "Danger keep out of reach of children. Causes severe burns and eye damage. May be corrosive to metals. Do not breath dusts or mists.; -Nine full 32 ounce (oz) bottles of Creme Clean. The precautionary statement read, "DANGER: Harmful if swallowed. Causes skin irritation. Causes serious eye damage."; -Two full one quart bottles of Bowl and Porcelain cleaner. The precautionary statement read. "DANGER Keep out of the reach of children. Causes severe burns and eye damage." 2. Observation on 4/8/24 between 8:08 A.M. and 6:00 P.M., of resident room 216, showed the following: -A full 19 oz can of Lysol by the resident's recliner. The precautionary statement read, "Hazardous to humans and domestic animals. Causes mild eye irritation. Do not spray in eyes, on skin, or on clothing. Wash hands thoroughly after use and before eating. Keep out of reach of children."; -A full container of Clorox wipes on the left side of the recliner, underneath the rolling table. The precautionary statement read, "Hazards to humans and domestic animals. Caution: may cause eye irritation. Avoid contact with eyes or clothing. Keep out of reach of children.” 3. During an interview on 4/8/24 at 5:00 P.M., the Administrator said she was not aware the housekeeping storage room door was open and unlocked, it should not have been. The Administrator said it was important for the safety of the residents that all chemicals are kept locked up and not left where residents can have access to them. The Administrator said residents should not have chemical cleaners in their rooms. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 24 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. II/III This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to ensure staff washed their hands and/or changed gloves between tasks while preparing and serving resident meals for one of one observed prepared and served meal. This had the potential to affect all residents. The census was 83. Observation on 4/8/24 between 7:15 A.M. and 7:40 A.M., showed the following: -The Culinary Service Director (CSD) donned a pair of gloves and walked to the preparation area. With her right hand, she took a slice of bread out of the toaster and placed it on a plate. She picked up tongs with her right hand and plated some bacon and sausage; -She walked to the stove and with her right hand, grabbed a spatula and flipped eggs that were cooking on the stove; -She walked back to toaster and with same gloved right hand, took a slice of toast out of the toaster and put it on a plate. She walked back to the stove and with her right had picked up the spatula and flipped the eggs; -She picked up a plate with her left hand. She scooped the eggs and some ham onto the plate, Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 25 of 33 PRINTED: 04/22/2024 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 20751C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE ELLISVILLE, MO 63011 (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) AUTUMN VIEW GARDENS Continued From page 25 while she had her gloved thumb resting on the top of the plate surface. With the same gloved left hand, she picked up a tomato and put it on the plate; -At 7:38 A.M., she put on a new pair of gloves and with her right hand removed a piece of toast from the toaster and placed it on a plate. She picked up a plate cover and placed it on top of the plate with he right hand and placed the plate up to the window to be picked up by the server. With the same gloved right hand she placed four fingers on top of a clean plate and placed the plate onto the service line. She picked up another piece of toast out of the toaster with her right hand and placed a piece of toast onto the plate; -She changed her gloves, did not wash her hands, and put on new pair of gloves. With her left hand, she picked up a plate and placed it on the line. With her right hand she picked up a scoop and scooped eggs onto the plate, then picked up tongs to plate the bacon and sausage. She used her gloved right hand to pick up a piece of toast out of the toaster and place it on the plate. During an interview on 4/8/24 at 4:58 P.M., the Administrator said the CSD should have changed gloves throughout the meal preparation and plating process. She said she would expect her to use tongs to place the toast on the plate and to not grab a plate by putting four fingers on the plate surface. 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints The outer clothing of all employees shall be clean and employees shall use effective hair restraints Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 If continuation sheet 26 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 26 to prevent the contamination of food or food-contact surfaces. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure the proper use of hairnets when two employees without hairnets cooked and served food, for one of one observed meal preparation and service. The census was 83. 1. Observation on 4/8/24 at 7:18 A.M., showed the Culinary Service Director (CSD) made eggs to order and prepared breakfast plates of eggs, bacon, and toast without wearing a hairnet. The CSD's hair was approximately 12 inches long. 2. Observation on 4/8/24 at 7:26 A.M., showed Hostess C entered the kitchen, walked into the kitchen to the serving line to get the prepared breakfast plates and carry them out to the dining room, without wearing a hair net. Hostess C's hair was approximately 12 inches long. 3. Observation on 4/8/24 at 1:18 P.M., showed Hostess C served lunch plates, from the kitchen, to residents, without wearing a hairnet. 4. During an interview on 4/8/24 at 4:58 P.M., the Administrator said she expected everyone to wear a hairnet when in the preparation area of the kitchen when there was food out. She said she was unaware the employees were not wearing their hair nets. She said she would expect the workers to wear a hairnet during preparation or when serving the food. 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 27 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 27 At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to ensure stored food was maintained free from potential contamination and that foods requiring refrigeration were refrigerated between meals. For one of one days of observation. The census was 83. 1. Observation on 4/8/24 between 7:18 A.M. and 3:52 P.M., of the walk-in freezer in the kitchen, showed one case of diced potatoes, three cases of lemon meringue pies, and one case of pastry dough stored directly on the floor, of the freezer. 2. Observation on 4/8/24 between 7:16 A.M. and Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 28 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 28 3:52 P.M., of the dining room, showed approximately 12 tables, with opened bottles of French's mustard in small caddies at the center of the table. The bottles read, "refrigerate after opening." 3. Observation on 4/8/24 between 8:00 A.M. and 3:52 P.M., of the the refrigerator in the Memory Care kitchen, showed four plates with individual slices of chocolate cream pie. The plates were not covered and not dated. 4. During an interview on 4/8/24 at 3:52 P.M., the Administrator said items should not be directly on the floor in the freezer and she was not aware the items were on the floor. She said she expected food requiring refrigeration would be kept in the refrigerators between uses. She said she expected food in the refrigerators to be covered and labeled and she was not aware that mustard required refrigeration or there was food in Memory Care that was not covered or dated. 19 CSR 30-88.010(23) Develop/Implement A/N A8023 Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 29 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 29 Class II* Based on interview and record review, the facility failed to follow their abuse and neglect policy when the facility failed to report an incident where a resident was given five times the ordered dosage of medication for one of eight sampled residents (Resident #1). The census was 83. Review of the facility's medication administration error policy dated 11/1/06, and revised 2/21/23, showed the following: -It is the policy of the facility that if a medication administration error is made, the charge staff/supervisor will be notified immediately, the error will be documented, the resident's physician will be notified; -Definition: A medication error shall include a drug was not dispensed in the right amount, in the right strength, at the right time ( more than 60 minutes from the ordered administration time), by the correct route or method of administration, to the correct resident, omission of a drug for which the reason and justification was not documented, the drug was expired or improperly stored, transcription error or dispensed improperly by the pharmacy; -Procedure: in the event of a medication error immediate action is taken, as necessary to protect the resident's safety and welfare. Call 911, if the resident is in severe medical distress. The licensed nurse, charge staff or supervisor will be notified promptly of the error. The attending physician is notified promptly of the error. The physician's orders are implemented. The following information is documented in the resident's medical record: -Factual description of the error; -Name of the physician and time notified; -Resident's condition for 24- hours or as directed. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 30 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 30 An unusual occurrence report and medication error report form are completed. Family or legal representative will be notified. Take appropriate follow up to medication errors to promote resident safety and welfare. Review of the facility's abuse and neglect and misappropriation of property policy dated 1/1/09 and revised on 10/17/19, showed the following: -Policy: The facility prohibits neglect, mental or physical abuse, including involuntary seclusion a, and the misappropriation of the property of residents; -The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to the state and federal regulations; -Management of the abuse, neglect, and misappropriation of property policy will be under the leadership of the Executive Director (ED) and /or the Health Services Director (HSD); -Training:- All new and current employees will receive training and reinforcement that will identify all aspects of abuse prohibition; at the time of employment with their initial employee orientation, annually, and through on-going in-service programs. The training will include identification of potential victims of abuse or neglect, interventions and reporting as well as staff indicators, i.e. , stress that may lead to the potential for abuse; -Each new employee will be informed of his or her responsibility to immediately report any violations or alleged violations. Failure to do so will result in disciplinary action, up to and including termination. Training may include, but is not limited to: Stressful working environment, employees at risk, training and education, intentional and unintentional harm, definitions and Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 31 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 31 examples of abuse mistreatment, and neglect, laws and regulations, and the agencies that enforce them, predicting abusive behavior, understanding stress and abusive behavior and understanding the resident's perspective. Review of Resident #1's medical record, showed the following: -Admitted 6/30/20; -Diagnosis included dementia, anxiety and chronic heart failure. Review of the resident's progress notes dated 4/7/24, no time noted, showed the Director of Nursing (DON) noted a medication error which occurred on 4/6/24. Review of the facility investigation dated 4/6/24, showed Level One Medication Aide (LIMA) G was unable to locate the syringe used to measure the resident's medication and instead used a medication cup. LIMA G misread the medication cup and mistakenly administered 2.5 milliliters (mls) of morphine (medication used to treat moderate to severe pain) instead of .5 mls. The physician and family were notified of the incident and per the physician's instructions, the resident was monitored for three hours checking vitals every 15 minutes to watch for any adverse reaction. The resident did not show any adverse reaction during the monitoring time and was cleared by the physician to remain in the facility. Staff was in-serviced on the proper way to administer liquid morphine and LIMA G was issued a written reprimand. During an interview on 4/8/24 at 2:58 P.M., the DON said she talked with the Administrator about the medication error and they decided not to report the incident. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 32 of 33 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20751C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 16219 AUTUMN VIEW TERRACE DRIVE AUTUMN VIEW GARDENS ELLISVILLE, MO 63011 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 32 During an interview on 4/8/24 at 3:02 P.M., the Administrator said all incidents which involve abuse or neglect should be reported to the Department of Health and Senior Services (DHSS). The Administrator said she could see how the incident could be viewed as neglect but was uncertain if this matter qualified because the resident displayed no adverse reaction during the hours of observation. The Administrator said when she spoke with the DON about the issue they both questioned if the matter should be reported or not. The Administrator said she was still uncertain after talking with the DON, so she reached out to several peers who all recommended not to report the issue because the resident did not have an adverse reaction. The Administrator said she should have contacted DHSS instead of calling peers and then she would have known for sure if the matter should be reported or not. *The higher the classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 O90R11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 33 of 33 PLAN OF CORRECTION Provider/Supplier Name: Autumn View Gardens Ellisville Street Address, City, Zip: 16219 Autumn View Terrace Drive Ellisville, 63011 Date of Survey: 4.8.24 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} This Plan of Correction (“POC”) is submitted as required under State Law. The submission of this POC does not constitute an admission on the part of Autumn View Gardens (the “Facility”, “Community”) as to the accuracy of the surveyors’ findings written in the Summary Statement of Deficiencies, nor the conclusions drawn therefrom. This POC is intended to constitute the Community's credible letter alleging compliance. Compliance has been and will be achieved no later than the last completion date identified in the POC. Compliance will be maintained as provided in the Plan of Corrections on 5/30/2024. COMPLETION DATE A4506 19 CSR 30-86.045(3)(A)(6}(A) individual Evacuation Plan-Staff Requirements All residents have the potential to be affected by this deficient practice. Care staff will continue to complete a pathway to safety assessment for all residents monthly. HSD, MCC and HSC will identify IEPs needed, ensure they are in place monthly, and ensure they identify the specific staff position responsible to help the resident evacuate. HSD or designee will audit EPs monthly to ensure all residents with an IEP have the specific staff position responsible to help the resident evacuate in their plan. 5.30.24 A4508 19 CSR 30-86.045(3)(A}(6)(C) Individual Evacuation Plan - Evaluate All residents have the potential to be affected by this deficient practice. Care staff will continue to complete a pathway to safety assessment for all residents monthly. HSD, MCC and HSC will identify IEPs needed, ensure they are in place monthly, and that they include the direction for exit/AOR and distance to exi/AOR. HSD or designee will audit all IEPs monthly to ensure all residents with an IEP have the direction for exit/AOR and distance to exit/AOR in their plan. 5.30.24 A2222 19 CSR 30-86.022(7)(a) Exits-2 per floor- remote/unobstructed All residents have the potential to be affected by this deficient practice. The mural on the memory care doors was removed on 4/10/2024 so the exit is no longer considered obstructed. The Maintenance Director or designee will monitor all emergency exits to ensure they are not hidden or obstructed. 4.10.24 A4724 19 CSR 20-20.100 TB as required for LTC All residents have the potential to be affected by this deficient practice. Education to Health Services Coordinator (LPN), Health Services Director (RN), Executive Director and Business Office Manager to outline the expectation that millimeters are to be documented on all TB reads moving forward. Added TB test check to monthly audit/checklist for new residents and staff members. All resident TBs have been corrected and are up to date. All staff TB audit to be completed by the HSD and HSC. Health Services Director or designee will do a monthly audit of new residents and staff members to ensure they have completed the TB testing and that the induration of millimeters is indicated on the results. 5.30.24 A4733 19 CSR 30-86.047(20)(1) Personnel Record Physician Statement, employ All residents have the potential to be affected by this deficient practice. Community will get a statement from a physician or physician’s designee for all new employees stating they can work in a long- term care facility with any applicable limitations listed. All Current staff will be audited by the Executive Director and Business office manager to ensure compliance. Business Office Manager or designee will audit new employee files monthly to ensure they have a statement signed by a physician or physician’s designee stating they can work ina long-term care facility with any applicable limitations listed. 5.30.24 A4754 19 CSR 30-86.047(28}(G) Individual service plan develop All residents have the potential to be affected by this deficient practice. Resident #8 and Resident #3 have been corrected by the HSD. 5.30.24 Education done with HSD, MCC & HSC to ensure they are personalizing all ISPs and ensuring all resident needs are reflected. HSD or designee will review all residents’ ISPs upon move-in, every six months, and on change of condition to ensure all resident needs are reflected in the ISPs. A4760 19 CSR 30-86 .047(29)(B) Not Admit/Care for Physical Restraints All residents have the potential to be affected by this deficient practice. All resident rooms were inspected to ensure no bed rails or other restraints are in place. Resident #3’s bed rails were removed on 4/8/24. ED notified Hospice company and supply company that we cannot have rails or any restraints in our community. All staff were in-serviced on 4/11/24 to inform HSD or ED if they see any rails or restraints in resident rooms so they can be removed immediately. Staff are trained to report any findings to the HSD/Designee. A monthly review and audit will be completed by the HSD or designee to ensure no bed rails or other restraints are in place. 4.11.24 A4781 CSR _30-86.047(40) Self-control of Medication Requirements All residents have the potential to be affected by this deficient practice. Due to company policy a letter was sent to residents and families regarding prescription medications and OTCs and the need for the community to have an order for them to have them in the resident's apartment. Leadership team did a room-to-room overlook to identify any prescription and OTC medications out in the apartments that did not have an order. Resident in 306 who had the medications in their apartment were addressed by the HSD. Residents to be inserviced at resident council about our company policy on OTCs. Residents to be inserviced at council about prescription medications and that they can not be in their apartments. Staff are trained to report any findings of prescription/OTCs in apartments to the HSD/Designee. HSD or designee will round resident apartments monthly to ensure no Prescription or OTC medications are present unless that resident has an order to self-administer those specific prescription and OTC medications. 4.19.24 A4797 19 CSR 30-86.047(46) Safe and Effective Medication System All residents have the potential to be affected by this deficient practice. 9.30.24 Medication Aides will be in-serviced on properly administering medications and witnessing residents taking their medication. HSD is doing additional medication pass competencies for all Medication Aides. L1MA that was identified in survey was inserviced on not leaving medications in residents’ apartments completed by HSD. HSD or designee will conduct medication pass competencies for all staff at least twice per year. A6005 19 CSR 30-87 .020(5) Toxic Material Storage All residents have the potential to be affected by this deficient practice. Housekeeping will be in-serviced on importance of keeping supply closets closed and locked when not in use. Sign posted on doors to closets that contain chemicals that the door is to be closed and locked at all times. All resident rooms will be checked to ensure no chemicals are present. Chemicals were removed from resident apartments 224 and 216 by HSD. Maintenance Director or designee will round weekly to ensure ali supply closets are closed and locked and no chemicals are present in resident apartments. 5.30.24 A7?002 19 CSR 30-87 .030(2) Wash hands/Arms& Clean Fingernails All residents have the potential to be affected by this deficient practice. Dining staff will be in-serviced on handwashing and use of gloves. Culinary Services Director or designee will ensure proper handwashing and glove use practices are maintained. 4.11.24 A?003 19 CSR 30-87.030(3) Clean, clothing & hair restraints All residents have the potential to be affected by this deficient practice. Dining staff will be in-serviced on proper use of hairnets. Staff have been educated on reporting any findings to the Culinary Director or Designee. Culinary Services Director or designee will ensure proper hairnet practices are maintained. 4.11.24 A7015 19 CSR 30-87.030 (13) Food Protected., Temp All residents have the potential to be affected by this deficient practice. Dining staff will be in-service on items not being stored on the floor in the freezer. Mustard bottles were immediately removed 4.11.24 from tables and disposed of since they were not refrigerated. Community now ordering mustard that does not need to be refrigerated. Staff have been educated to report any findings to the Culinary Services Director or designee. Culinary Services Director or designee will round monthly to ensure items are properly stored in the freezer, and that items that need to be refrigerated put back in the refrigerator. A8023 19CSR 30-88.010(23) Develop/Implement A/N Policies All residents have the potential to be affected by this deficient practice. All staff were in-serviced on community’s Abuse and Neglect Policy (Policy A-21). Education included reporting applicable occurrences to the state in a timely manner according to state regulations. All staff who administer medications were inserviced on proper medication administration and using the right method to administer. 4.11.24 L1MA who reported her error was in-service on medication rights including the right method to administer medications by the HSD. Executive Director or designee will ensure the state is notified in a timely manner when deemed necessary by state regulation. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.