TIMBERS ASSISTED LIVING, THE.

PRINTED: 06/20/2024 ; . FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLUIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30384 B.WING 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 239 KAREN DRIVE HOLTS SUMMIT, MO 65043 (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) TIMBERS, THE 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. I/II This regulation is not met as evidenced by: Class II Based on observation, interview, and record review, facility failed to document an accurate code status for one resident's (Resident #1) when they listed the resident as a Full Code status instead of a Do Not Resuscitate (DNR) on his/her Electronic Medical Record (EMR) which resulted with facility staff providing the wrong code status to the Emergency Medical Technician's (EMT's) when they arrived to transport the resident to the hospital. EMT staff administered Cardiopulmonary Resuscitation (CPR) and intubated the resident against his/her directive as a result of the inaccurate information. The facility census 25. 1. Review of the Facility's Advanced Directives Policy, revised 10/2017, showed advanced directives will be respected in accordance with state law and facility policy. Prior to admission the facility will inquire of the resident, his/her family members, and/or his/her legal representative about existence of written advanced directives. Advanced Directives instructions will be included in the electronic health record. The resident's Advanced Directives must be easily accessible to staff in order for staff to make appropriate clinical decisions during emergencies. A resident will not be treated against his/her wishes. Emergency medical personal will be advised of a resident's advanced directives related to treatment options and will be provided with a copy of such directives when transfers from the facility via ambulance or Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE rex Jaanbrtee , LUN We oo l2i | 2.07244 L27K11 If continuation sheet 1 of 5 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER TIMBERS AATT? Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 30384 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 239 KAREN DRIVE , THE HOLTS SUMMIT, MO 65043 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 other means are made. 2. Review of Resident #1's medical record showed the resident admitted to the facility on 04/15/24. The medical record did not contain a signed Advanced Directives/Code Status Form, and the resident was listed as a full code. Review of the resident's face sheet, dated 04/15/24, showed staff documented the resident as a DNR. Review of the resident's Individual Service Plan, dated 04/15/24, showed staff documented the resident as a DNR. Review of the resident's Physician's Order Sheets, dated 04/29/24, showed a code status of DNR. Review of the resident’s nurses notes, dated 06/08/24, showed Level One Medication Aid (LIMA) A documented the resident used his/her call light at 7:00 A.M. Resident complained of pain in his/her upper back between shoulder blades that radiated to his/her chest and stated pain at a nine out of 10. Staff documented the residents vital signs, blood pressure 170/86, pulse 96 and irregular, respirations 22. Resident reported he/she was short of breath. Staff called 911 and the resident agreed at 7:20 A.M. Ambulance arrived at 7:29 A.M. while EMT's assessed the resident, the resident reported he/she was going to pass out and he/she became unresponsive. EMT's began CPR. At 7:45 A.M. resident taken to the ambulance while EMT's continued CPR. Review of the EMS report, dated 6/08/24, showed EMS arrived at the facility for the resident with Missouri Department of Health and Senior Services STATE FORM CROSS-REFERENCED TO THE APPROPRIATE LZ7K11 PRINTED: 06/20/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 06/10/2024 STREET ADDRESS, CITY, STATE, ZiP CODE PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} if continuation sheet 2 of 5 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER TIMBERS AATT? Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 30384 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 239 KAREN DRIVE , THE HOLTS SUMMIT, MO 65043 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 complaints of chest pain. Review showed documented the resident alert and talking but became unresponsive. EMS documented the resident was intubated, and transported to the local hospital. During an interview on 6/10/24 at 1:20 P.M., the administrator said the resident had a signed DNR form in the facility, but they have not been able fo locate it. During an interview on 6/10/24 at 1:22 P.M., the Director of Nursing (DON) said the process for admission advanced directives is the marketing director completes the admission paperwork with the family then it is given to him/her or the Assistant Director of Nursing (ADON) and they will enter the code status into the computer. He/She said this one was his/her mistake because there was conflicting information in the chart. During an interview on 6/10/24 at 1:30 P_M_, the Marketing Director said he/she does the admission and then hands the information to DON or ADON. He/She said the information is entered into the computer by the DON or ADON. During an interview on 06/10/24 at 1:40 P.M_, LIMA B said if a resident needs to be transferred to the hospital, he/she is responsible to call the ambulance, DON, and family to notify them. LIMA B said he/she is responsible to print a face sheet, POS, and copy the signed advance directive to send with the EMS personal upon transfer. LIMA B said floor staff are directed to look ata resident's doorway to see what the resident's code status is. LIMAB said if a resident has a red dot on their door, they are a DNR, but if the resident has a green dot on their door, they are a Missouri Department of Health and Senior Services STATE FORM CROSS-REFERENCED TO THE APPROPRIATE LZ7K11 PRINTED: 06/20/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 06/10/2024 STREET ADDRESS, CITY, STATE, ZiP CODE PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} if continuation sheet 3 of 5 Missouri Department of Health and Senior Services PRINTED: 06/20/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA {X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30384 B.WING 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE TIMBERS AATT? 239 KAREN DRIVE HOLTS SUMMIT, MO 65043 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} , THE Continued From page 3 full code. LIMA B said the ADON or DON are responsible to update the resident's dots on their door. Observation on 06/10/24 at 1:50 P.M., showed the resident's doorway was marked with his/her name and did not contain a red or green dot to indicate code status. During an interview on 06/10/24 at 2:12 P.M_, L1MAA said he/she was there the day the resident had to be sent to the hospital. He/She said residents are supposed to have dots on their doors by their name to alert staff of the resident's code status. He/She said red means DNR and green means full code. L1MAA said the resident did not have any dots on the door and when he/she printed the documents for EMS the code status was conflicting. He/She said the resident's face sheet and ISP showed DNR. L1MA said the residents electronic EMR said to do CPR. He/She said he/she went to get the hard chart fo check the DNR status but the resident's chart was missing. He/She said the administrator was called who confirmed he/she did not have it. The LIMA said the chart was found at the sister facility next door but by the time he/she got back EMS had started CPR since they were not sure of the code status. LIMAA said when he/she found the chart there was no signed DNR form in Resident #1's hard chart either. During an interview on 6/10/24 at 2:40 P_M., the family member said the resident was a DNR. During an interview on 6/13/24 at 2:30 P.M., the administrator said he/she does not have the signed DNR form and has not been able to locate it. Missouri Department of Health and Senior Services STATE FORM 5ee9 LZ7K11 if continuation sheet 4 of 5 PRINTED: 06/20/2024 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 30384 B.WING 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 239 KAREN DRIVE HOLTS SUMMIT, MO 65043 (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} TIMBERS, THE A4777 Continued From page 4 During an interview on 6/13/24 at 4:35 P.M., the EMS manager said he/she arrived on scene for the call and the resident was initially alert and able to communicate. He/She said the facility had conflicting resuscitation information on multiple documents. He/She said no one ever provided them the signed legal DNR form they said they had. The EMS manager said the resident became unresponsive minutes after they arrived and without the DNR form they began CPR and intubated the resident. He/She said their protocol is if they don't have a signed legal DNR form they start CPR and intubate. He/She said if they would have been given the legal signed DNR form they would have called their medical director for further guidance. MOQ00237360 Missouri Department of Health and Senior Services STATE FORM 5899 L27K114 if continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier The Timbers Assisted Living Name: Street Address, . : 239 Karen Drive Holts Summit, MO 65043 City, Zip: Date of Survey: 06/10/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Prior to admission the Marketing Director or designee will request a copy of the Outside The Hospital Do-Not Resuscitate (OHDNR) Order from the resident or his/legal representative if a OHDNR is available. Requesting a copy of the Outside The 07/01/2024 Hospital Do-Not-Resuscitate Order, if available, will be included in the pre-admission form to be completed by the Marketing Director or designee. The Administrator or designee will review all admission paperwork to ensure effectiveness. In-service with Marketing Director to assure that the Outside The Hospital Do-Not-Resuscitate Order form, if available, is received 07/05/2024 from the resident or his/her legal representative prior to admission. A4777 Director of Nursing or designee will speak with each resident or his/her legal representative to assure that the wishes of the resident or his/her legal representative are met regarding the code status of the resident. Once the code status is obtained, the Director of Nursing or designee will send the form to the residents’ physician for his/her signature. After receiving the code status form with signature of the residents’ physician, the Director of Nursing or designee will assure that the code status is correct in both EMR locations, room name plate, and the 07/19/2024 emergency binder to assure that the code status wishes of the resident or his/her legal representative are easily accessible to staff during emergencies to allow staff to make the appropriate clinical decisions. A spreadsheet will be created to assure that current residents or his/her legal representatives’ wishes are completed in the appropriate locations. This spreadsheet will be kept current with all new residents until September 30, 2024 to develop a pattern. This spreadsheet will be monitored by the Administrator or designee to ensure effectiveness. In-service with DON, ADON, and designee(s) as to where the code status of each resident will be input upon admission and . : : 07/05/2024 kept updated as resident or his/her legal representative make changes. 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. PLAN OF CORRECTION Provider/Supplier The Timbers Assisted Living Name: Street Address, . : 239 Karen Drive Holts Summit, MO 65043 City, Zip: Date of Survey: 06/10/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE In-service will be done with all nursing staff at The Timbers Assisted Living to assure that they know where to find the code 07/12/2024 status of each resident. 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.