MEYER CARE CENTER.

PRINTED: 12/40/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C —_—-_-_-—__——. 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (X4} ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) 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) MEYER CARE CENTER A2216) 19 CSR 30-86.022(5)(C) Plan Accessible/Evacuation Diagram Posted Fire Drills and Emergency Preparedness. (C) The written plan shall be accessible at all times and an evacuation diagram shall be posted on each floor in a conspicuous place so that employees and residents can become familiar with the plan and routes to safety. I/II This regulation is not met as evidenced by: Class Ill Based on observation, interview, and record review, the facility failed to adequately space and display evacuation route maps located along all egress paths that sufficiently addressed all the requirements, in accordance with State of Missouri rules and regulations. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. This facility had a census of 23 residents at the time of the survey. 1. Observation on 10/30/24 between 12:19 P.M. and 12:49 P.M. during the initia! facility walk-through inspection showed the following: -There was no evacuation route map on the 400 Hall from the double smoke doors at the entrance by the Activities Room, past a nurses’ station, and down to the Main Dining Room approximately (app.) 100 feet (ft.} away. -There was an evacuation route map on the 500 Hall at its beginning just inside the double smoke doors by resident room #502, but none down the app. 64 ft. hallway to the exit door by resident room #516. Review of the facility's policy entitled “Evacuation,” copyrighted 2024 and provided by the Administrator, showed under the heading Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE LNHA STATE FORM sane GC5D11 if continuation sheet 1 of 4 PRINTED: 12/10/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER 19 CSR 30-86.022(5)(C) Plan Accessible/Evacuation Diagram Posted Fire Drills and Emergency Preparedness. (C) The written plan shall be accessible at all times and an evacuation diagram shall be posted on each floor in a conspicuous place so that employees and residents can become familiar with the plan and routes to safety. II/III This regulation is not met as evidenced by: Class III Based on observation, interview, and record review, the facility failed to adequately space and display evacuation route maps located along all egress paths that sufficiently addressed all the requirements, in accordance with State of Missouri rules and regulations. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. This facility had a census of 23 residents at the time of the survey. 1. Observation on 10/30/24 between 12:19 P.M. and 12:49 P.M. during the initial facility walk-through inspection showed the following: -There was no evacuation route map on the 400 Hall from the double smoke doors at the entrance by the Activities Room, past a nurses' station, and down to the Main Dining Room approximately (app.) 100 feet (ft.) away. -There was an evacuation route map on the 500 Hall at its beginning just inside the double smoke doors by resident room #502, but none down the app. 64 ft. hallway to the exit door by resident room #516. Review of the facility's policy entitled "Evacuation," copyrighted 2024 and provided by the Administrator, showed under the heading Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 GC5D11 If continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 05326C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 MEYER CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 "Definitions" it read that evacuation "is the process of moving residents, visitors, and staff either totally or partially out of the facility when a safe environment of care cannot be maintained." During an interview on 10/30/24 at 12:57 P.M. the Director of Maintenance said that he/she would expect evacuation route maps to be located at the ends of hallways and in their middles. During an interview on 10/30/24 at 1:47 P.M. the Administrator said the following: -An evacuation route map should be found in their disaster manual. -Evacuation route maps should also be located at the entrances to their respective care units. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. 1/Il This regulation is not met as evidenced by: Class II Based on observation, interview, and record review, the facility failed to provide thorough and complete documentation of monthly fire drills that included concurrent verifications of a successful monthly transmission of the fire alarm signal to their alarm monitoring company, in accordance with State of Missouri rules and regulations. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 23 residents at the time of the survey. Missouri Department of Health and Senior Services STATE FORM 6899 GC5D11 PRINTED: 12/10/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/30/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 4 PRINTED: 12/10/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER Continued From page 2 1. Observation on 10/30/24 between 12:13 P.M. and 12:37 P.M. during the initial facility walk-through inspection showed the following: -There were at least 2 pull stations located throughout the 400 and 500 Halls that could be used for activation of the fire alarm. -Those halls were equipped with a full fire sprinkler system with numerous ceiling and/or sidewall sprinkler heads which activated the fire alarm system when they reached a predetermined temperature. -There were five sets of double smoke doors that had magnetic holding devices on them to keep them open until the alarm system was activated. Review of the facility's fire drill records, conducted between August and October of 2024 and provided by the Director of Maintenance (DOM), showed there were three 2-page documented drill forms dated 8/26/24, 10/21/24, and 10/25/24 that all had a "Time Received Signal" for their alarm monitoring company's receipt of the alarms’ activation signal marked as 15:30, 19:02, and 13:23, respectively. Review of the "Individual Account History," dated 10/1/24 to 10/25/24 and provided by the Administrator, showed on the two October dates and times indicated on the fire drills provided, no concurrent activation signal had been received by the alarm monitoring company. During an interview on 10/30/24 at 12:57 P.M. the DOM said the following: -If they conducted a fire drill between 9:00 P.M. and 6:00 A.M. it would be done silently without activating the fire alarm. -They usually did more than one drill a month. -He/She did know it was required that the alarm Missouri Department of Health and Senior Services STATE FORM 6899 GC5D11 If continuation sheet 3 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 05326C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET MEYER CARE CENTER HIGGINSVILLE, MO 64037 PRINTED: 12/10/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/30/2024 (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 Continued From page 3 be activated monthly. -They would only get an activity report from their alarm monitoring company when needed. -It would help confirm their receipt of the alarm signal if they got one on every drill. During an interview on 10/30/24 at 1:47 P.M. the Administrator said they would expect confirmation of the alarm monitoring company's receipt of the fire alarm activation signal during a drill. Missouri Department of Health and Senior Services STATE FORM oeee GC5D11 DEFICIENCY) If continuation sheet 4 of 4 PLAN OF CORRECTION Provider Name: John Knox Village East & Meyer Care Center Street Address, th i i r City, Zip: 1201 W. 19" Street, Higginsville MO, 64037 Date of Survey: 10/30/2024 Provider number: | 265667 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} COMPLETION DATE 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? A2216 E . . . vacuation route maps will be placed in the center of the 400 hallway, in the center of the 500 hallway, and the end of the 500 hallway. January 1%, 2025 2. How you will identify other residents found to have been affected by the deficient practice? All residents have the potential to be affected by the deficient practice. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Maintenance director and/or designee will audit the evacuation route maps remain in place, at the locations specified in this plan of correction, monthly x 3 months, quarterly x 3 months, then annually thereafter. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Audit results will be reviewed by the quality assurance committee until such time consistent substantial compliance has been achieved as determined by the committee. 1. What corrective action will be accomplished for those residents found to have been affected by the deficient A2291 practice? January 1%, 2025 Tech electronics will send a transmission report to the director of maintenance, and the administrator after each fire drill, indicating a successful transmission of the fire alarm signal. 2. How you will identify other residents found to have been affected by the deficient practice? All residents have the ability to be affected by the same deficient practice. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Education will be provided to the director of maintenance by the administrator, related to the deficient findings as listed in the 2567 by January 1%, 2025. Maintenance director and/or designee has provided education to the maintenance staff responsible for fire drills related to the deficient findings as listed in the 2567 by January 15, 2025. Maintenance director and/or designee will review the fire drill log, and transmission log from tech electronics monthly ongoing to ensure fire drills are held according to guidelines. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Audit results will be reviewed by the quality assurance committee until such time consistent substantial compliance has been achieved as determined by the committee. 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: 04/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (x2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 04/16/2024 05326C B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 MEYER CARE CENTER (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} 19 CSR 30-86.047(47)(G) Medication Administration, Documented Medication Orders. (G) The administration of medication shall be recorded on a medication sheet or directly in the resident‘ s record and, if recorded ona medication sheet, shall be made part of the resident’ s record. The administration shall be recorded by the same individual who prepares the medication and administers it. I/II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure facility staff administered and documented the 5:00 A.M. medication pass for four sampled residents (Residents #1, #2, #3, and #4) on 3/25/24, 3/26/24, 3/30/24, 4/5/24, 4/8/24 and 4/11/24 out of four sampled residents. The facility census was 25 residents. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Irritable Bowel Syndrome (IBS-an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation). -Gastro-Esophageal Reflux Disease (GERD- a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the resident's Individual Service Plan dated 2/15/24 showed: -The resident would probably be able to make limited decisions that require simple understanding related to his/her health care decision making capacity. -The resident needed to have medications administered by someone else. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE THLE (X6) DATE UNHa STATE 8888 68J111 If continuation sheet 1 of 7 PRINTED: 04/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER Continued From page 1 -The resident had administration of oral and topical medications as part of his/her medication management. Review of the resident's Physician Order Sheet (POS) dated March 2024 showed: -An order for Linzess (a medication used to treat IBS) Oral Capsule 145 micrograms (mcg), give one capsule by mouth one time a day ordered on 12/14/23. -An order for Protonix (Pantoprazole- a medication used to treat GERD) Oral Tablet Delayed Release 40 milligrams (mg), give 40 mg by mouth two times a day ordered on 8/8/23. Review of the resident's Medication Administration Record (MAR) dated March 2024 showed: -The resident was to receive his/her Linzess and Protonix at 5:00 A.M. -The resident's Linzess was not documented as given on 3/25/24, 3/26/24, and 3/30/24. -The resident's Protonix was not documented as given on 3/25/24, 3/26/24, and 3/30/24. Review of the resident's POS dated April 2024 showed: -An order for Linzess Oral Capsule 145 mcg, give one capsule by mouth one time a day. -An order for Protonix Oral Tablet Delayed Release 40 mg, give 40 mg by mouth two times a day. Review of the resident's MAR dated 4/1/24 through 4/16/24 showed: -The resident was to receive his/her Linzess and Protonix at 5:00 A.M. -The resident's Linzess was not documented as given on 4/5/24, 4/8/24, and 4/11/24. -The resident's Protonix was not documented as Missouri Department of Health and Senior Services STATE FORM 6899 68J1I11 If continuation sheet 2 of 7 PRINTED: 04/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER Continued From page 2 given on 4/5/24, 4/8/24, and 4/11/24. During an interview on 4/16/24 at 12:15 P.M. the resident said: -His/her medications were frequently given late. -His/her 5:00 A.M. medications were not consistently given to him/her. 2. Review of Resident #2's Face Sheet showed he/she admitted to the facility with the diagnosis of Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Review of the resident's Individual Service Pan dated 1/30/24 showed: -The resident would probably be able to make higher level decisions (undergo or withdraw life sustaining treatments) related to his/her healthcare decision making capacity. -The resident needed to have his/her medications administered by someone else. -The resident had administration of pain medications and monitoring of blood sugar as part of his/her medication management. Review of the resident's POS dated March 2024 showed an order for Levothyroxine Sodium Tablet (a medication used to treat Hypothyroidism) 100 mcg, give one tablet by mouth one time a day ordered on 1/29/24. Review of the resident's MAR dated March 2024 showed: -The resident was to receive his/her Levothyroxine at 5:00 A.M. -The resident's Levothyroxine was not documented as given on 3/25/24, 3/26/24, and 3/30/24. Missouri Department of Health and Senior Services STATE FORM 6899 68J1I11 If continuation sheet 3 of 7 PRINTED: 04/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER Continued From page 3 Review of the resident's POS dated April 2024 showed an order for Levothyroxine Sodium 100 mcg, give one tablet by mouth one time a day. Review of the resident's MAR dated 4/1/24-4/16/24 showed: -The resident was to receive his/her Levothyroxine at 5:00 A.M. -The resident's Levothyroxine was not documented as given on 4/5/24, 4/8/24, and 4/11/24. During an interview on 4/16/24 at 1:09 P.M. the resident said: -The 5:00 A.M. medications were administered later than 5:00 A.M. -He/she thought the time given was usually when residents were getting up for the day but could not give an exact time. 3. Review of Resident #3's Face Sheet showed he/she admitted to the facility with the following diagnoses: -GERD. -Hypothyroidism. Review of the resident's Individual Service Plan dated 2/1/24 showed: -The resident would not effectively participate in any kind of health care decision making. -The resident needed to have medications administered by someone else. -The resident had administration of oral and topical medications as part of his/her medication management. Review of the resident's POS dated March 2024 showed: -An order for Levothyroxine Sodium Oral Tablet 100 mcg, give one tablet by mouth one time a day Missouri Department of Health and Senior Services STATE FORM 6899 68J1I11 If continuation sheet 4 of 7 PRINTED: 04/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER Continued From page 4 ordered on 3/27/23. -An order for Pantoprazole Sodium Oral Tablet Delayed Release 40 mg, give one tablet by mouth one time a day ordered on 9/23/22. Review of the resident's MAR dated March 2024 showed: -The resident was to receive his/her Levothyroxine and Pantoprazole at 5:00 A.M. -The resident's Levothyroxine was not documented as given on 3/25/24, 3/26/24, and 3/30/24. -The resident's Pantoprazole was not documented as given on 3/25/24, 3/26/24, and 3/30/24. Review of the resident's POS dated April 2024 showed: -An order for Levothyroxine Sodium Oral Tablet 100 mcg, give one tablet by mouth one time a day. -An order for Pantoprazole Sodium Oral Tablet Delayed Release 40 mg, give one tablet by mouth one time a day. Review of the resident's MAR dated 4/1/24-4/16/24 showed: -The resident was to receive his/her Levothyroxine and Pantoprazole at 5:00 A.M. -The resident's Levothyroxine was not documented as given on 4/5/24, 4/8/24, and 4/11/24. -The resident's Pantoprazole was not documented as given on 4/5/24, 4/8/24, and 4/11/24. 4. Review of Resident #4's Face Sheet showed he/she admitted to the facility with the diagnosis of Unspecified Osteoarthritis (a type of arthritis (swelling and tenderness in one or more joints, Missouri Department of Health and Senior Services STATE FORM 6899 68J1I11 If continuation sheet 5 of 7 PRINTED: 04/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER Continued From page 5 causing joint pain or stiffness that often gets worse with age) that occurs when flexible tissue at the ends of bones wears down). Review of the resident's Individual Service Plan dated 1/1/24 showed: -The resident would probably be able to make limited decisions that require simple understanding related to his/her health care decision making capacity. -The resident needed to have medications administered by someone else. -The resident had oral and topical medications as part of his/her medication management. Review of the resident's POS dated March 2024 showed an order for Tylenol (Acetaminophen- used to treat pain) eight-hour Arthritis Pain Oral Tablet Extended Release 650 mg, give two tablets by mouth one time a day ordered on 3/18/23. Review of the Resident's MAR dated March 2024 showed: -The resident was to receive his/her Tylenol at 5:00 A.M. -The resident's Tylenol was not documented as given on 3/26/24 and 3/30/24. Review of the resident's POS dated 4/1/24-4/16/24 showed: -The resident was to receive his/her Tylenol at 5:00 A.M. -The resident's Tylenol was not documented as given on 4/5/24, 4/8/24, and 4/11/24. 5. During an interview on 4/16/24 at 12:11 P.M. Licensed Practical Nurse (LPN) A said: -Someone on night shift is responsible for the 5:00 A.M. medication pass. Missouri Department of Health and Senior Services STATE FORM 6899 68J1I11 If continuation sheet 6 of 7 PRINTED: 04/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 05326C — 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1201 WEST 19TH STREET HIGGINSVILLE, MO 64037 (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) MEYER CARE CENTER Continued From page 6 -He/she had received complaints from residents related to the 5:00 A.M. medication pass. -The residents complained about receiving the medication late or not at all. -He/she had informed the Director of Nursing (DON) of the resident's complaints. During an interview on 4/16/24 at 12:26 P.M. the DON said: -He/she was unsure why there was no documentation of the 5:00 A.M. medication pass on 3/25/24, 3/26/24, 3/30/24, 4/5/24, 4/8/24, and 4/11/24. -He/she expected the staff responsible for the medication pass to chart all administered medication. -Nurses were able to float to the Assisted Living portion of the facility to administer the 5:00 A.M. medications when a Level 1 Medication Aide (L1MA) was not available. -There would be a chance that the 5:00 A.M. medications were given and not documented on, but there would not be a way to prove the administration without the documentation. During an interview on 4/16/24 at 1:20 P.M. the Assistant Director of Nursing (ADON) said: -If the 5:00 A.M. medication was not assigned on the Daily Staffing Roster then he/she would be unsure of who would have been responsible for the medication pass. -When a L1MA called in, he/she might have only replaced with only a Certified Nurses Aide (CNA) forgetting about the 5:00 A.M. medication pass and forgot to tell a nurse the medications needed passed. M000233769 Missouri Department of Health and Senior Services STATE FORM 6899 68J1I11 If continuation sheet 7 of 7 PLAN OF CORRECTION Provider Name: John Knox Village East & Meyer Care Center Street Address, th Lo. City, Zip: 1201 W. 19" Street, Higginsville, MO 64037 Date of Survey: 4/16/2024 Provider number: | 265420 ID PREFIX TAG A48039 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? No residents or staff were adversely affected by this deficient practice. A medication audit review was performed for resident #1, resident #2, resident #3 and resident #4 to ensure all medications are available, the correct dosages, and appropriate staff are available, and scheduled to administer medications as ordered by prescriber, by May 10°. 2. How you willidentify other residents having the potential to be affected by the same deficient practice All residents with daily routine medication orders scheduled for 0500 have the potential to be affected by this practice. The medication administration record will be reviewed on 5/10 to determine other residents effected by this practice. 3. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur An in-service will be provided to all licensed staff by May 25th to provide education to facility staff regarding policies related to medication administration. The ADON will be provided with 1:1 education related to ensuring appropriate staff are scheduled for the 0500 medication pass administration time by director of nursing services or designee by May 10". The staffing coordinator will be provided with 1:1 education related to ensuring appropriate staff are scheduled for the 0500 medication pass administration time by the director of nursing services or designee by May 10°. The daily staffing roster will be edited by May 10° to indicate staff member responsible for 0500 medication pass. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness; and Director of nursing services or designee will audit daily staffing roster three times weekly x 4 weeks, monthly x 3 months, then quarterly thereafter to ensure appropriate staff are available for 0500 medication pass. Audit results will be reviewed by the quality assurance committee until such time consistent substantial compliance has been achieved as determined by the committee. Findings of this audit will be discussed with the resident council, May 18%, 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.