COUNTRYSIDE VILLAGE ASSISTED LIVING FACILITY.

“Based on observation, interview, and record review the facility failed to ensure bath facilities were conveniently located so that residents could reach them without passing through another bedroom when Resident #1 was placed ina room with no bath facility immediately available to him/her. The facility census was 18. The facility did not provide a policy regarding the requirements for bath facilities throughout the facility. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 12/23/24; -He/She was sent to the hospital on 12/24/24: -He/She returned to the facility on 12/29/24; -Diagnoses included dementia (a general term for a range of neurological conditions that cause a decline in mental abilities, such as thinking, remembering, and reasoning), Alzheimer's (a brain disorder that causes a gradual decline in memory, thinking skills, and the ability to perform daily tasks), type Il diabetes mellitus (a chronic condition that occurs when the body doesn't produce enough insulin or doesn't use insulin properly), coronary artery disease (a condition Cc 04305M B.WING 12/30/2024 300 WEST FAIRVIEW STREET KING CITY, MO 64463 DEFICIENCY} COUNTRYSIDE VILLAGE ASSISTED LIVING FA A1214 Continued From page 1 that occurs when the coronary arteries narrow or become blocked, restricting blood flow to the heart), and subdural hematoma (a collection of blood that forms between the brain's surface and its protective covering, the dura mater). Observation on 12/30/24 at 12:50 P.M. showed: -Resident #1 was asleep in his/her bed in room; -The resident's room did not have a bath or shower facility within the room; -The facility did not have a bath facility ina common area that Resident #1 could have utilized. During an interview on 12/30/24 at 1:30 P.M. the Administrator said: -He/She knew there had to be a bath or shower facility available to each resident without going through another resident's room, but did not think it would be a problem because Resident #1 was on hospice and received a bed bath; -Resident #1 had been staying in his/her room without a bathing facility available to him/her since 12:00 P.M. on 12/29/24. MO247278”

“Based on observation, interview, and record review, the operator failed to assure the facility remained in compliance with all applicable laws and regulations when the Administrator placed Resident #1 in a roam that was not yet licensed by the Department of Health and Senior Services (DHSS). The facility census was 18. The facility did not have a policy for ensuring only licensed rooms were used to house residents. 1. Review of Resident #1's record showed: -He/She was readmitted to the facility on 12/29/24; -Diagnoses included dementia (a general term for a range of neurological conditions that cause a decline in mental abilities, such as thinking, remembering, and reasoning), Alzheimer’s (a brain disorder that causes a gradual decline in memory, thinking skills, and the ability to perform daily tasks), type Il diabetes mellitus (a chronic condition that occurs when the body doesn't produce enough insulin or doesn't use insulin properly), coronary artery disease (a condition that occurs when the coronary arteries narrow or become blocked, restricting blood flow to the heart), and subdural hematoma {a collection of blood that forms between the brain's surface and its protective covering, the dura mater). Observation on 12/30/24 at 12:50 P.M. showed: -Resident #1 was asleep in his/her bed in his/her room; Cc 04305M B.WING 12/30/2024 300 WEST FAIRVIEW STREET KING CITY, MO 64463 DEFICIENCY} COUNTRYSIDE VILLAGE ASSISTED LIVING FA A4704 Continued From page 3 Review of a bed listing dated 10/09/24 showed the room was in the process of being approved by DHSS, but had not yet been approved as of 12/30/24. During an interview on 12/30/24 at 1:30 P.M. the Administrator said: -He/She placed Resident #1 in the room despite the not being fully approved by DHSS because this was the only room available; -Resident #1 was not expected back to the facility as soon as he/she was brought back, and the plan was to place him/her in another room because the current residents in the planned room were supposed to be vacated on 12/30/24. MO247278 THE PLAN OF CORRECTION WAS REJECTED AND NEVER APPROVED, THEREFORE, NO POC IS INCLUDED WITH THE (2567 FORM)”

“The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as provided in section 660.315, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department ' s website; II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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: A. Within five (5) calendar days of admission; II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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 with the facility; II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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. III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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 trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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; II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Smoking. (B) Ashtrays shall be made of noncombustible material and safe design and shall be provided in all areas where smoking is permitted. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility I or II, and existing prior to November 13, 1980, shall be exempt from this requirement. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility ' s entire plan shall be provided to the local jurisdiction ' s emergency management director. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Sprinkler Systems. (F) All facilities shall have inspections and written certifications of the approved sprinkler system completed by an approved qualified service representative in accordance with NFPA 25, 1998 edition. The inspections shall be in accordance with the provisions of NFPA 25, 1998 edition, with certification at least annually by a qualified service representative. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“If a physician prescribes in writing a modified diet for a resident, the resident may be accepted or remain in the facility if- (C) The modified diet menu is posted in the kitchen and includes portions to be served; III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The operator shall be responsible to assure compliance with all applicable laws and regulations. The administrator shall be fully authorized and empowered to make decisions regarding the operation of the facility and shall be held responsible for the actions of all employees. The administrator ' s responsibilities shall include oversight of residents to assure that they receive care as defined in the individualized service plan. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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: (B) Has twenty-four (24) hour staff appropriate in numbers and with appropriate skills to provide such services; II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as provided in section 660.315, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department ' s website; II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The administrator shall maintain on the premises an individual personnel record on each facility 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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Medication Orders. (F) Influenza and pneumococcal polysaccharide immunizations may be administered per physician-approved facility policy after assessment for contraindications- 1. The facility shall develop a policy that provides recommendations and assessment parameters for the administration of such immunizations. The policy shall be approved by the facility medical director for facilities having a medical director, or by each resident ' s attending physician for facilities that do not have a medical director, and shall include the requirements to: B. Offer the immunization to the resident or obtain permission from the resident ' s designee or legally authorized representative when the immunization is medically indicated unless the resident has already been immunized as recommended by the policy; II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.