OUR LADY OF MERCY COUNTRY HOME.

PRINTED: 05/29/2024 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. BUILOING: COMPLETED Cc 06153D Ee 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 (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} OUR LADY OF MERCY COUNTRY HOME A4259 19 CSR 30-86.042(28) Negotiate Path to Safety - A4259 5 minutes All residents shall be physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five (5) minutes of being alerted of the need to evacuate the facility as defined in subsection (1)(C} of this rule. I/II This regulation is not met as evidenced by: Class {| Based on observation, record review, and interview, the facility failed to ensure two of three sampled residents (Resident #1 and #2) were physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five minutes of being alerted af the need to evacuate the facility. The facility census was 42. Review of the facility's Pathway to Safety policy dated 5/22/24 showed all residents should be physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five (5) minutes of being alerted of the need to evacuate the community. 1.Review of Resident #1's medical record showed: -Admit date was 4/15/22: -Diagnoses included: chronic atrial fibrillation (a type of heart arrhythmia that causes the top chambers of your heart, the atria, to quiver and beat irregularly), heart failure, and a history of falls. Review of the April 2024 monthly summary showed the resident uses a wheelchair for Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OF PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE ' Con : ADpeT CEO /Adminstectv (3/2 699 STATE FORM T72F11 (fcontinualion sheet 1 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06153D NAME OF PROVIDER OR SUPPLIER OUR LADY OF MERCY COUNTRY HOME (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 ambulation. During an interview on 5/22/24 at 12:20 A.M., Resident #1 said: -He/she needed staff assistance for transfers; -He/she was never able to stand on his/her own. During an observation on 5/22/24 at 2:38 P.M., of staff doing a path to safety drill: -Resident #1 required staff assistance to transfer from his/her bed to the wheelchair; -Staff assisted the resident verbally several times by telling her "keep going” "is this how fast you would move if there were a fire", and "keep going, go, go, go"; -The resident said "It would help if someone would push me"; -The resident made it to the area of refuge in 3 minutes and 38 seconds with physical and verbal assistance. 2. Review of Resident #2's medical record showed: -Admit date was 5/8/21; -Alzheimer's disease (a disease that affects the memory and thought process); Dementia; depression; and anxiety. Review of the April 2024 monthly summary showed the resident uses a walker for ambulation. During an interview on 5/22/24 at 1:06 P.M., Resident #2 said she could stand on her own sometimes and other times it was too difficult, and he/she needed staff assistance. During an observation on 5/22/24 at 2:38 P.M., of staff doing a path to safety drill: -Resident #1 said she didn't know if she could Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 T72F11 PRINTED: 09/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 05/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 PRINTED: 09/20/2024 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 06153D — 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 (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) OUR LADY OF MERCY COUNTRY HOME Continued From page 2 transfer herself; -He/she put her shoes on; -Resident then transferred himself/herself to the wheelchair; -Staff instructed the resident to take the brakes off of the wheelchair; -Resident propelled her wheelchair with her feet; -The resident arrived at the area of refuge in 4 minutes and 15 seconds with verbal assistance. During an interview on 5/21/24 at 3:30 P.M., the Administrator said she did not know residents needed to be able to make path to safety within 5 minutes without any assistance. MO236187 Missouri Department of Health and Senior Services STATE FORM 6899 T72F11 If continuation sheet 3 of 3 PRINTED: 08/01/2024 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 R-C 06153D — 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 (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) OUR LADY OF MERCY COUNTRY HOME {44259} | Continued From page 1 {A4259} During an interview on 07/17/24 at 9:52 A.M., Resident #1 said: -He/She doubted he/she would make it outside by himself/herself within five minutes if there were a fire; -He/She could walk a little but used the his/her wheelchair mostly. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 08/20/15; -Diagnoses included dementia (disease characterized by impairment of at least two brain functions, memory loss and judgment) and depression. Review of monthly resident pathway to safety reviews for May, June, and July 2024, showed the resident could make path to safety, but needed verbal cues. Observation on 07/17/24 at 10:15 A.M. showed: -Resident #2 laying in his/her bed, hollering, and speaking to himself/herself incoherently; -Resident #2 was not interviewable; -A wheelchair was pulled up to the side of Resident #2's bed. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 07/13/23; -He/She was on hospice; -Diagnoses included Type II diabetes mellitus (condition where body has difficulties regulating blood sugars), and chronic kidney disease with heart failure. Review of monthly resident pathway to safety reviews for May, June, and July 2024, showed the resident was bed bound. Missouri Department of Health and Senior Services STATE FORM 6899 T72F12 If continuation sheet 2 of 3 PRINTED: 08/01/2024 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 R-C 06153D — 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 (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) OUR LADY OF MERCY COUNTRY HOME {44259} Continued From page 2 {A4259} During an interview on 07/17/24 at 9:31 A.M. Resident #3 said: -He/She got out of bed occasionally, but not often; -He/She thought he/she could get out of bed by himself/herself, but the staff tell him/her not to. 4. During an interview on 07/17/24 at 11:00 A.M., the Director of Nursing (DON) said: -He/She completed the monthly pathway reviews; -During the reviews, he/she had the residents run the drill to see if they could make it to the nearest area of refuge (AOR), not to an exit to the outside; -On the documented review form, those indicated as "can" were residents that were able to make it to the nearest AOR not an exit to the exterior of the building, and those indicated as "verbal," were residents that needed verbal cues. During an interview on 07/17/24 at 11:05 A.M., the Administrator said: -He/She knew residents should have been able to make pathway to safety on their own without any verbal cues or physical assistance; -He/She knew pathway to safety meant exited from the building and not an AOR; -He/She had applied to transition the facility to an assisted living facility (ALF) since the initial inspection, and was hoping this request would be approved prior to investigators coming back onsite; -He/She knew Residents #1, #2, and #3 could not make path to safety on their own without verbal cues; -Plans were in place for becoming an ALF. Missouri Department of Health and Senior Services STATE FORM 6899 T72F12 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: Our Lady of Mercy Country Home Street Address, City, Zip: 2160 Mercy Drive, Liberty, MO 64068 Date of Survey: May 22, 2024 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A4259 Preparation and/or execution of this plan do 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. All residents will be tested periodically for the ability to negotiate 6/15/2024 a pathway to safety unassisted (other than telling them there is a fire in the building if the alarms are not used for the test) by the Director of Nursing or her designee. Pathway to safety is defined as being able to completely exit the building. This is in addition to monthly fire drills unless the testing date happens to fall on the same date that the Director of Plant Operations has scheduled a fire drill. Both resident #1 and resident #2 could have been affected 9/22/24 Because they were not able to demonstrate their ability to negotiate a pathway to safety on May 22, 2024. All residents, including residents #1 and #2, who cannot 6/20/24 negotiate a pathway to safety without assistance (other than telling them there is a fire in the building if the alarm is not sounded) will be given an involuntary discharge notice by the Administrator. While residents who cannot negotiate a pathway to safety 6/10/24 safely and without assistance are awaiting new placement,the facility will work with each resident on education to understand the importance of cooperating with the exercise, work with the resident to gain the physical strength to transfer self and/or move themselves to evacuate the building safely, and drilled on the process by the Director of Nursing or her designee.. cognitive ability, their involuntary notice to move out will be If a resident is able to change their physical_or rescinded by the Administrator. | Residents will continue to be tested on their ability 6/30/2024 to negotiate a pathway to safety unassisted. Residents will then be tested quarterly for their ability to negotiate a pathway to safety unassisted. 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; 08/01/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3} DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING: R-C 07/17/2024 06153D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 OUR LADY OF MERCY COUNTRY HOME (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BSE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} (A4259} 19 CSR 30-86.042(28) Negotiate Path to Safety - . {A4259} 5 minutes All residents shail be physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five (5) minutes of being alerted of the need to evacuate the facility as defined in subsection (1)({C) of this rule, HII This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 06/22/24. Based on observation, interview, and record review the facility failed to ensure three of ten sampled residents (Resident #1, #2, and #3) were physically and mentally capable of negotiating a normal path to safety unassisted or with the use of asistive devices within five minutes of being alerted of the need to evacuate the facility. The facility census was 40. Review of the facility's Pathway to Safety policy, dated 5/22/24, showed all residents should be physically and mentally capable of negotiating a normal path to safety unassisted or with the use of assistive devices within five (5) minutes of being alerted of the need to evacuate the community. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 06/10/23; -Diagnoses included heart failure, altered mental status, depression, and weakness. Review of monthly resident pathway to safety reviews for May, June, and July 2024, showed the resident could make path to safety but needed verbal cues. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE T72F12 IF continuation sheet 1 of 3 PRINTED: 08/01/2024 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 R-C 06153D — 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 (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) OUR LADY OF MERCY COUNTRY HOME {44259} | Continued From page 1 {A4259} During an interview on 07/17/24 at 9:52 A.M., Resident #1 said: -He/She doubted he/she would make it outside by himself/herself within five minutes if there were a fire; -He/She could walk a little but used the his/her wheelchair mostly. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 08/20/15; -Diagnoses included dementia (disease characterized by impairment of at least two brain functions, memory loss and judgment) and depression. Review of monthly resident pathway to safety reviews for May, June, and July 2024, showed the resident could make path to safety, but needed verbal cues. Observation on 07/17/24 at 10:15 A.M. showed: -Resident #2 laying in his/her bed, hollering, and speaking to himself/herself incoherently; -Resident #2 was not interviewable; -A wheelchair was pulled up to the side of Resident #2's bed. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 07/13/23; -He/She was on hospice; -Diagnoses included Type II diabetes mellitus (condition where body has difficulties regulating blood sugars), and chronic kidney disease with heart failure. Review of monthly resident pathway to safety reviews for May, June, and July 2024, showed the resident was bed bound. Missouri Department of Health and Senior Services STATE FORM 6899 T72F12 If continuation sheet 2 of 3 PRINTED: 08/01/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION A. BUILBING: R-C 07/17/2024 06153D BaWING.__ STREET ADDRESS, CITY, STATE, ZIP CODE 2160 MERCY DRIVE LIBERTY, MO 64068 NAME OF PROVIDER OR SUPPLIER OUR LADY OF MERCY COUNTRY HOME (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PREGECED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A4259} Continued From page 2 {A4259} During an interview on 07/17/24 at 9:31 A.M. Resident #3 said: -He/She got out of bed occasionally, but not often; -He/She thought he/she could get out of bed by himself/herself, but the staff tell him/her not to. 4. During an interview on 07/17/24 at 11:00 A.M., the Director of Nursing (DON) said: -He/She completed the monthly pathway reviews; -During the reviews, he/she had the residents run the drill to see if they could make it to the nearest area of refuge (AOR), not to an exit to the outside; -On the documented review farm, those indicated as "can" were residents that were able to make it to the nearest AOR not an exit to the exterior of the building, and those indicated as "verbal," were residents that needed verbal cues. During an interview on 07/17/24 at 11:05 A.M., the Administrator said: | -He/She knew residents should have been able to make pathway to safety on their own without any verbal cues or physical assistance; -He/She knew pathway to safety meant exited from the building and not an AOR; -He/She had applied to transition the facility to an assisted living facility (ALF) since the initial inspection, and was hoping this request would be approved prior to investigators coming back onsite; -He/She knew Residents #1, #2, and #3 could not make path to safety on their own withaut verbal cues; -Plans were in place for becaming an ALF. Missouri Department of Health and Senior Services STATE FORM 5899 T72F12 If continualion sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: Our Lady of Mercy Country Home Street Address, City, Zip: 2160 Mercy Drive, Liberty, MO 64068 Date of Survey: July 17, 2024 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A4259 Preparation and/or execution of this plan do 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. All residents will be tested periodically for the ability to negotiate 6/15/2024 a pathway to safety unassisted (other than telling them there is a fire in the building if the alarms are not used for the test) by the Director of Nursing or her designee. Pathway to safety is defined as being able to completely exit the building. This is in addition to monthly fire drills unless the testing date happens to fall on the same date that the Director of Plant Operations has scheduled a fire drill. The community was approved as an ALF Il on August 19, 2024. 8/16/24 All residents can remain at the facility despite their ability or Inability to negotiate a pathway to safety. Residents who cannot negotiate a pathway to safety without assistance will have an {EP. While residents who cannot negotiate a pathway to safety 6/10/24 safely and without assistance are awaiting new placement, the facility will work with each resident on education to understand the importance of cooperating with the exercise, work with the resident to gain the physical strength to transfer self and/or move themselves to evacuate the building safely, and drilled on the process by the Director of Nursing or her designee.. if a resident can change their physical or cognitive ability, their involuntary notice to move out will be rescinded by the Administrator. Residents will continue to be tested on their ability 6/30/2024 | to negotiate a pathway to safety unassisted. Residents will then be tested quarterly for their ability to negotiate a pathway to safety unassisted. 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.