ORILLA'S WAY.

es Se PRINTED: 06/21/2024 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 08591C EWING See ae 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1209 SOUTH HIGH ST GRANT CITY, MO 64456 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ORILLA'S WAY 19 CSR 30-86.047(13)(A) Criminal Background Check Requirements Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the person, as provided in section 660.317, RSMo. Each facility shall maintain documents verifying that the background checks were requested, the date of each such request, and the nature of the response received for each such request. II This regulation is not met as evidenced by: Class Il Based on interview and record review, facility Staff failed to request a criminal background check (CBC) and document with the date of request, date received, and nature of the response for three of three newly hired staff members. The facility census was 9. 1. Record review of Certified Nurse Assistant (CNA) A's personnel record showed: -A hire date of 5/1/24: -The only CBC completed was on 6/4/24. 2. Record review of Licensed Practical Nurse (LPN) A's personnel record showed: -A hire date of 5/2/24; -There was no CBC on file. 3. Record review of the Administrator's personnel record showed: -A hire date of 4/2/24; Missouri Department of Health and Senior Services LABORATO (X6) DATE STATE FORM en UN9E11 \{ continuation sheet 1 of 5 PRINTED: 06/21/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 08591C — 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1209 SOUTH HIGH ST GRANT CITY, MO 64456 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ORILLA'S WAY A4711_ 19 CSR 30-86.047(13)(A) Criminal Background Check Requirements Prior to allowing any person who has been hired in a fulltime, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted frorn an employment agency, the employment agency shail, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the person, as provided in section 660.317, RSMo. Each facility shall maintain documents verifying that the background checks were requested, the date of each such request, and the nature of the response received for each such request. Il This regulation is not met as evidenced by: Class Hl Based on interview and record review, facility staff failed to request a criminal background check (CBC) and document with the date of request, date received, and nature of the response for three of three newly hired staff members. The facility census was 9. 1. Record review of Certified Nurse Assistant (CNA) A's personnel record showed: -Ahire date of 5/1/24: -The only CBC completed was on 6/4/24. 2. Record review of Licensed Practical Nurse (LPN) A's personnel record showed: -Ahire date of 5/2/24: -There was no CBC on file. 3. Record review of the Administrator's personnel record showed: -A hire date of 4/2/24; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 UNSE11 lf continuation sheet 1 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 08591C NAME OF PROVIDER OR SUPPLIER ORILLA'S WAY (X2) MULTIPLE CONSTRUCTION A. BUILDING: GRANT CITY, MO 64456 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4711 Continued From page 1 -The only CBC completed was on 6/4/24. During an interview on 6/17/24, at 2:05 P_M., the Owner said: -CBC's should be completed for ail employees prior to their start date; -She was not aware CBC's had not been done for all newly hired employees. 19 CSR 30-86.047(26) Admission Physical The facility shall ensure that each resident being admitted or readmitted to the facility receives an admission physical examination by a licensed physician. The facility shall request documentation of the physical examination prior to admission but must have documentation of the physical examination on file no later than ten (10) days after admission. The physical examination shall contain documentation regarding the individual's current medical status and any special orders or procedures to be followed. If the resident is admitted directly from an acute care or another long-term care facility and is accompanied on admission by a report that reflects his or her current medical status, an admission physical shall not be required. Ill This regulation is not met as evidenced by: Class tl Based on record review and interview, the facility failed to ensure admission physicals were conducted for two of three sampled residents (Resident #1 and #2). The facility census was 9. 1. Record review on 06/17/24 of Resident #1's files showed: -Admit date 04/22/23- Missouri Department of Health and Senior Services STATE FORM 899 UN9E11 PRINTED: 06/21/2024 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/17/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1209 SOUTH HIGH ST PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 08591C NAME OF PROVIDER OR SUPPLIER ORILLA'S WAY (X2) MULTIPLE CONSTRUCTION A. BUILDING: GRANT CITY, MO 64456 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4742 Continued From page 2 -No admission physical was found for the resident. 2. Record review on 06/17/24 of Resident #2’s files showed: -Admit date 11/30/23: -No admission physical was found for the resident. During an interview on 06/17/24 at 2:05 P.M., the Owner said: -She knew all residents should have physicals prior to admission; -She did not know these residents were missing physicals in their records. 19 CSR 30-86.047(28)(F}(1})(B) Community Based Assessment - Semi-Annually 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: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; tI This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to review and complete a community based assessment (CBA) semiannually for three of three sampled residents (Resident #1, #2, and Missouri Department of Health and Senior Services STATE FORM 899 UN9E11 PRINTED: 06/21/2024 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/17/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1209 SOUTH HIGH ST PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 3 of 5 PRINTED: 06/21/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 08591C — 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1209 SOUTH HIGH ST GRANT CITY, MO 64456 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ORILLA'S WAY A4750 Continued From page 3 #3). The facility census was 9. 1. Review of Resident #1's record on 06/17/24 showed: -He/She was admitted to the facility on 04/22/23; -The only CBA found in the resident's record was dated 04/21/23. 2. Review of Resident #2’s record on 06/17/24 showed: -He/She was admiited to the facility on 11/30/23; -The only CBA found in the resident's record was dated 11/30/23. 3. Review of Resident #3's record on 06/17/24 showed: -He/She was admitted to the facility on 03/24/23; -The only CBA found in the resident's record was dated 08/24/23. During an interview on 06/17/24 at 2:05 P.M. the Owner said: -He/She did not know CBA's should be reviewed semi-annually in addition to prior to admission. 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 the resident ' s legal representative in partnership Missouri Department of Health and Senior Services STATE FORM 6838 UN9E11 If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 08591C NAME OF PROVIDER OR SUPPLIER ORILLA'S WAY (X2) MULTIPLE CONSTRUCTION A. BUILDING: GRANT CITY, MO 64456 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4754 Continued From page 4 with the facility; This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to develop an individualized service plan (SP, the planning document 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 inclucled resiclent needs, preferences, services to be provided by staff and goals expected by the resident or the resident's legal representative for one of three sampled residents (Resident #2). The facility census was 9. 1. Review of Resident #2's face sheet showed: -Admit date was 11/30/23; -Diagnoses included: Type {I diabetes, incontinence, muscle weakness, and falls; -The only ISP on file was dated 4/11/24. During an interview on 06/17/24 at 2:05 P.M. the Owner said: -She knew an ISP should be developed for each resident upon admission. Missouri Department of Health and Senior Services STATE FORM 899 UN9E11 PRINTED: 06/21/2024 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/17/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1209 SOUTH HIGH ST PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet §& of 5 PLAN OF CORRECTION Provider/Supplier | Orilla’s Way Name: Street Address, . City, Zip: 1209 South High Street, Grant City MO 64456 Date of Survey: June 17, 2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 08591C This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the provider as to the Correction serves as the allegation of substantial compliance PROVIDER'S PLAN OF ID PREFIX TAG CORRECTION: (EACH CORRECTIVE COMPLETION ACTION SHOULD BE CROSS-REFERENCED DATE accuracy of the surveyor's findings or the conclusion drawn there TO THE APPROPRIATE DEFICIENCY from. The Plan of Correction does not constitute a deficiency or that 19CSR 30-86.047(13)(A) Criminal Background Check Requirements Corrective actions that will be accomplished A4711 for those residents found to be affected by July 1, 2024 the alleged deficient practices and the measures that will be put in place/systematic changes made to ensure that the alleged deficient practice will not recur are as follows: the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in Rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. This Plan of A4742 An application will be completed with the Family Care Safety Registry to utilize and streamline the background check process. The New Hire Checklist will be updated to include the request and response of a criminal background check for all potential employees PRIOR to first workday at the facility and prior to any contact with residents. The facility will maintain in the Employee File the document verifying that the background check was requested, the date of each request, and the response of each request. The Administrator will monitor the corrective actions to ensure that the deficient practice will not recur as follows: Administrator or Designee will complete the background check and receive results prior to the hiring of any employee. The Administrator or Designee will review all new hire files at each episode of new hire to ensure all current employees/new hires are compliant with the Criminal Background Check Requirement. The Administrator or Designee shall ensure all current employees/new hires are educated on the systems, policies and procedures developed and implemented by this directed Plan of Correction. 19 CSR 30-86.047(26) Admission Physical Corrective actions that will be accomplished for those residents found to be affected by the alleged deficient practices: A system will be put into place to flag any missing components of the resident admission The Facility will identify other residents having a potential to be affected by the same alleged deficient practice as follows: All residents, including Resident #1, Resident #2, and Resident #3 have the potential of being affected by the alleged deficiency. The measures that will be put in place or systematic changes made to ensure that the alleged deficient practice will not recur are as follows: The Admission Packet will be updated to include a checklist of the required components of resident admission. This has been completed and implemented. The Checklist will include Admission Physical completed prior to admission or re-admission to the facility. A Master Calendar will be implemented to note the due date to have on file the physical examination no later than ten (10) days after admission. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: Checking due dates will be the responsibility of the facility manager at each episode with oversite provided by the Administrator monthly. The Administrator or Designee will review all files monthly to ensure all residents have documentation regarding the resident’s current medical status and any special orders or procedures to be followed. This will take place at admit/re-admit. The Administrator or Designee will ensure all current employees/new hires are educated on the systems, policies and procedures developed and implemented by this directed Plan of Correction. 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment — Semi-Annually Corrective actions that will be accomplished for those residents found to be affected by the alleged deficient practices: A system will be put into place to flag any missing components of the resident admission process. The Facility will identify other residents having a potential to be affected by the same alleged deficient practice as follows: All residents, including Resident #1, Resident #2, and Resident #3 have the potential of being affected by the alleged deficiency. The measures that will be put in place or systematic changes made to ensure that the alleged deficient practice will not recur are as follows: July 1, 2024 The New Admission Packet Checklist will include Community Based Assessments to be completed at admission. A Master Calendar will be implemented to note the due date to have on file the Community Based Assessment. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: The Administrator or Designee will review admissions paperwork at each episode and monthly to ensure all residents have completed Community Based Assessments at admit and semi-annually. These updates will coincide with the semi-annual Care Plan to further facilitate compliance. Checking due dates will be the responsibility of the facility manager at each episode with oversite provided by the Administrator monthly. The Administrator or Designee shall ensure all current employees/new hires are educated on the systems, policies and procedures developed and implemented by this directed Plan of Correction. 19 CSR 30-86.047(28)(G) Individual Service Plan — Develop Corrective actions that will be accomplished for those residents found to be affected by the alleged deficient practices: A system will be put into place to flag any missing components of the resident chart. A Care Plan meeting will be conducted with the resident/family upon admission and semi- annually thereafter. The Individual Service Plan will be updated quarterly and with each significant change to accurately reflect the current snapshot of the resident. The Master Calendar will be utilized to AATSA track compliance dates. July 1, 2024 At the annual care plan, an Annual Care Plan checklist will be developed and implemented and will include the review of Resident’s Rights, confirmation of DNR status and review of the Individual Service Plan. This will be completed by the Registered Nurse with oversite provided by the Facility Manager and/or Administrator. The Facility will identify other residents having a potential to be affected by the same alleged deficient practice as follows: All residents, including Resident #1, Resident #2, and Resident #3 have the potential of being affected by the alleged deficiency. The measures that will be put in place or systematic changes made to ensure that the alleged deficient practice will not recur are as follows: The Administrator or Designee will review admissions paperwork to ensure all residents have complete Individualized Service Plan at admit, semi-annually, and with all significant changes. These updates will coincide with the semi-annual Care Plan to further facilitate compliance. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: Checking due dates will be the responsibility of the facility manager with oversite provided by the Administrator monthly. The Administrator or Designee shall ensure all current employees/new hires are educated on the systems, policies and procedures developed and implemented by this directed Plan of Correction. Robin A. Davidson, LNHA Administrator Elaina Welch, RN 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.