FAMILY PARTNERS MANCHESTER, LLC.

PRINTED: 03/06/2024 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 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ; PROVIDER'S PLAN OF CORRECTION (X5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL i (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG i REGULATORY OR LSC IDENTIFY!NG INFORMATION) i I CROSS-REFERENCED TO THE APPROPRIATE DATE { ] DEFICIENCY) FAMILY PARTNERS MANCHESTER, LLC A4506) 19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to i having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include the following components: A. The responsibilities of specific staff positions in i an emergency specific to the individual; {I This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents who required more than minimal assistance to safely evacuate the facility had an individual evacuation ptan (IEP, the planning documented prepared by an assisted living facility which outlines the plan to safely evacuate the resident out of the facility in the event of an emergency) with responsibilities of specific staff positions, in an emergency, specific | to that resident with cognitive or other ! impairment, that cannot evacuate on their own, ; for three of three sampled residents with an {EP (Residents #3, #2 and #1). The census was 32. 1. Review of Resident #3's medical record, showed the facility admitted the resident on 8/14/23, with diagnoses which included Alzheimer's disease and atrial fibrillation (an irregular and often very rapid heart rhythm). Review of the resident's IEP dated 2/1/24, showed the following: -The resident required assistance of one staff member utilizing a wheelchair in an emergency/evacuation. The staff were required to Missouri Department of Health and Senior Services LABORATOF IRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6} DATE STATE FORM 6899 BP6011 If continuation sheet 1 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 provide verbal cues and reassurance as the resident did not understand what was happening when the fire alarm went off; -The IEP did not indicate which staff position would be assigned to the resident in the event of an emergency evacuation. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 9/28/23, with diagnoses which included advanced Alzheimer's disease, high blood pressure and gout (a form of arthritis which causes severe pain, swelling, redness and tenderness in joints). Review of the resident's IEP dated 2/1/24, showed the following: -The resident required assistance of one person into a Broda chair (a semi-reclining and tilting chair) and transport to the area of refuge; -The IEP did not indicate which staff position would be assigned to the resident in the event of an emergency evacuation. 3. Review of Resident #1's medical record, showed the facility admitted the resident on 1/29/24, with diagnoses which included Dementia, depression, anxiety, glaucoma, and osteopenia. Review of the resident's IEP dated 1/29/24, showed the following: -The resident required assistance of one person into a wheelchair and transport to the area of refuge; -The IEP did not indicate which staff position would be assigned to the resident in the event of an emergency evacuation. 4. During an interview on 2/28/24 at 4:08 P.M., the Nurse said she was aware of the IEP Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 components but was not aware a specific staff position was required to be documented on the resident's IEP. 5. During an interview on 2/28/24 at 4:10 P.M., the Administrator said he was not aware the resident's IEPs did not have the specific staff position listed on the resident's IEPs and he was not aware a specific staff position needed to be documented on the resident's IEP. 19 CSR 30-86.032(34) Hot Water 105-120 Degrees F Plumbing fixtures which are accessible to residents and which supply hot water shall be thermostatically controlled so that the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit (120°F) (49°C) and the water shall be at a temperature range between one hundred five degrees Fahrenheit (105°F) (41°C) and one hundred twenty degrees Fahrenheit (120°F) (49°C). I/II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to ensure water temperatures were maintained between 105 degrees Fahrenheit (F) and 120 degrees F, in resident bathrooms, for one of one day of observation. This had a potential to affect all residents. The census was 32. 1. Review of the facility's undated hot water temperature log, for house 351, showed the following: -The hot water temperature of the sink in Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 3 of 12 PRINTED: 03/06/2024 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 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 (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) FAMILY PARTNERS MANCHESTER, LLC Continued From page 3 bathroom #1, was 119 degrees F, and the shower hot water temperature was 119.2 degrees F; -The hot water temperature of the sink in bathroom #2, was 120 degrees F, and the shower hot water temperature was 119.6 degrees F; -The hot water temperature of the sink in bathroom #3, was 119 degrees F, and the shower hot water temperature was 119.2 degrees F; -The hot water temperature of the sink in bathroom #4, was 120 degrees F, and the shower hot water temperature was 120 degrees F. 2. Review of the facility's undated hot water temperature log, for house 357, showed the following: -The hot water temperature of the sink in bathroom #1, was 120 degrees F, and the shower hot water temperature was 119.4 degrees F; -The hot water temperature of the sink in bathroom #2, was 120 degrees F, and the shower hot water temperature was 119 degrees F; -The hot water temperature of the sink in bathroom #3, was 120 degrees F, and the shower hot water temperature was 120 degrees F; -The hot water temperature of the sink in bathroom #4, was 120 degrees F, and the shower hot water temperature was 120 degrees F. 3. Observation on 2/28/24 at 9:00 A.M., in house 351, showed an unknown resident leading another unknown resident into bathroom #4 and showed him/her where his/her toothbrush and tooth paste was located. No staff were present. Observation on 2/28/24 between 7:00 A.M. and 7:05 P.M., of house 351, showed the following: -At 7:00 A.M., of the sink in bathroom #1, showed the hot water temperature measured 126.3 degrees F, when recorded for two minutes with a calibrated digital thermometer; Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 If continuation sheet 4 of 12 PRINTED: 03/06/2024 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 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 (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) FAMILY PARTNERS MANCHESTER, LLC Continued From page 4 -At 7:05 A.M., of the sink in bathroom #2, showed the hot water temperature measured 123.8 degrees F, when recorded for two minutes with a calibrated digital thermometer. Observation on 2/28/24 at 3:10 P.M., of bathroom #1, in house 351, showed the sink hot water temperature measured 131.5 degrees F, when recorded for two minutes with a calibrated digital thermometer. Observation on 2/28/24 at 3:30 P.M., of the water tank in house 351, showed the knob on the bottom of the water tank was set between hot and warm. 4. Observation on 2/28/24 between 8:20 A.M. and 8:40 A.M., of house 357, showed the following: -At 8:20 A.M., of the sink, in bathroom #1, showed the hot water temperature measured 128.7 degrees F, when recorded for two minutes with a calibrated digital thermometer; -At 8:25 A.M., of the sink, in bathroom #2, showed the hot water temperature measured 124.6 degrees F, when recorded for two minutes with a calibrated digital thermometer; -At 8:30 A.M., of the sink, in bathroom #3, showed the hot water temperature measured 126.1 degrees F, when recorded for two minutes with a calibrated digital thermometer; -At 8:40 A.M., of the sink, in bathroom #4, showed the hot water temperature measured 128.8 degrees F, when recorded for two minutes with a calibrated digital thermometer. Observation on 2/28/24 between 12:20 P.M. and 12:22 P.M., of house 357, in bathroom #3, showed the following: -At 12:20 P.M., the shower hot water temperature measured 123.3 degrees F, when recorded for Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 If continuation sheet 5 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 two minutes with a calibrated digital thermometer; -At 12:22 P.M., the sink hot water temperature measured 125.5 degrees F, when recorded for two minutes with a calibrated digital thermometer. Observation of the water tank in house 357, showed the knob on the bottom of the water was set between hot and warm. 5. During an interview on 2/28/24 at 3:23 P.M., the Owner said on 2/26/24, some resident's family members complained the water was too cold, so the "handy" person turned the water temperature up. On 2/27/24, a Nurse Manager took the hot water temperature and realized it was hotter than 120 degrees F, and she turned the temperature down. The Owner said he guesses the Nurse Manager did not turn it down enough or take the temperature a second time to make sure it was not above 120 degrees F. 6. During an interview on 2/28/24 at 4:03 P.M., the Administrator said he was just informed of the hot water temperatures being too high a couple days ago. The Administrator said he was aware of the "handy" person raising the hot water temperature and he said the person did not know of the regulated water temperatures and how they are supposed to be between 105 degrees F and 120 degrees F. The Administrator said he knew the Nurse Manager turned the hot water temperature down, but she must not have turned it down enough. The Administrator said the hot water temperatures should not have been as high as they were. 19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 6 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (|) 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 regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure employees had a written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility and indicated any limitations, for three of four sampled employees. The census was 32. 1. Review of Level One Medication Aide (LIMA) F's personnel file, showed the following: -Start date 5/28/22: -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 2. Review of LIMA H's personnel file, showed the following: -Start date 8/12/22: -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 3. Review of Activity Assistant G's personnel file, showed the following: -Start date 3/27/23; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 4. During an interview on 2/28/24 at 3:40 P.M., Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 7 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 the Operations Manager said she was not aware the employees required a written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 5. During an interview on 2/28/24 at 3:41 P.M., the Community Relations Director said she was not aware the employees required a written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 6. During an interview on 2/28/24 at 3:45 P.M., the Manager said he was not aware the employees required a written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 7. During an interview on 2/28/24 at 3:48 P.M., the Administrator said he was not aware the employees required a written statement by a licensed physician or physician's designee indicating the person can work in a long-term care facility. 19 CSR 30-87.030(20) Frozen Food at Zero Degrees F or Below Frozen food shall be kept frozen and should be stored at a temperature of zero degrees Fahrenheit (0°F) or below. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure the temperature of the upright freezer in the kitchen was maintained at 0 degrees Fahrenheit or below. This had the Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 8 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 potential to affect all residents in the facility. The census was 32. 1. Observation on 2/28/24 at 7:17 A.M., in house 351, showed the small upright freezer in the back dry storage area of the kitchen, did not have a thermometer present. At 2:00 P.M., the same freezer had a thermometer present that had a temperature of 12 degrees Fahrenheit. The freezer contained items that included one package of frozen sausage patties, one package of chocolate covered ice cream bars, one pack of hamburger buns and two bottles of water. 2. Observation on 2/28/24 at 7:53 A.M., in building 363, showed the deep freezer in the back dry storage area of the kitchen had a thermometer that read 12 degrees Fahrenheit. At 2:17 P.M., the small upright refrigerator/freezer in the back dry storage area of the kitchen had a thermometer that read 16 degrees Fahrenheit. The freezer contained items that included two Red Barron frozen pizzas, four Marie Calendar pies, one case (eight total) Marie Calendar chicken pot pies, and two packages of bacon. The large deep freezer had a thermometer that read 12 degrees Fahrenheit. The deep freezer contained items that included large packages of frozen vegetables and gallon size containers of ice cream. 3. During an interview on 2/28/23 at 3:50 P.M., the Operations Manager said it was the overnight shift's responsibility to check the temperatures and log them in a binder. She said she was unaware that there were missing thermometers in any of the refrigerators or freezers and she expected them all to have thermometers. She was aware a freezer temperature should be 0 degrees Fahrenheit or below and was unaware Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 9 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 any of the freezers had a temperature above 0 degrees Fahrenheit. 4. During an interview on 2/28/24 at 3:50 P.M., the Administrator said he was unaware there were missing thermometers in any of the freezers and he expected them all to have thermometers. He was aware a freezer temperature should be 0 degrees Fahrenheit or below and was unaware any of the freezers had a temperature above 0 degrees Fahrenheit. 19 CSR 30-88.010(36) Personal Clothing/Possessions Each resident shall be permitted to retain and use personal clothing and possessions as space permits. Personal possessions may include furniture and decorations in accordance with the facility's policies and shall not create a fire hazard. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to the resident during his or her stay in the facility, which are to be returned to the resident or responsible party upon discharge, transfer, or death. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to ensure personal inventory lists were completed for three of three sampled residents (Residents #3, #2 and #1). The census was 32. 1. Review of Resident #3's medical record, showed the facility admitted the resident on 8/14/23. Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 10 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 Review of the resident's inventory sheet dated 7/2/23, showed the following: -ltems: -Cash (greater than $50): No; -Credit cards: No; -Wedding ring: No; -Wallet: No; -Other valuables: No. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 9/28/23. Review of the resident's inventory sheet dated 9/28/23, showed the following: -ltems: -Cash (greater than $50): No; -Credit cards: No; -Wedding ring: No; -Wallet: No; -Other valuables: No. 3. Review of Resident #1's medical record, showed the facility admitted the resident on 1/29/24. Review of the resident's inventory sheet dated 1/29/24, showed the following: -ltems: -Cash (greater than $50): No; -Credit cards: No; -Wedding ring: Yes: Description: Band; -Wallet: No; -Other valuables: No. 4. During an interview on 2/28/24 at 2:10 P.M., the Community Relations Director (CRD) said the facility used the current inventory sheet for about a year and she did not ask anyone in corporate if Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 11 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 351 FOREST SUMMIT COURT MANCHESTER, MO 63021 FAMILY PARTNERS MANCHESTER, LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 there was another inventory document the facility could use which would show specific items the resident had in their possession. The CRD thought the inventory sheets could use a little more information than what was currently listed and it would be best if the facility had more details on the resident's inventory sheets. 5. During an interview on 2/28/24 at 2:14 P.M., the Managing Director (MD) said the CRD should have checked off items the resident had in their possession. The MD said she was not aware the CRD was not listing specific items on the inventory sheets. The MD said the facility used the current inventory sheets until 2019, when a new Nurse came who told the facility they did not have to list all of the resident's items. The MD said there was an older form the facility used in the past which listed every item the resident had. The MD said the current inventory sheets for the residents would not show the residents had any pants, blouses, shirts, pajamas, etc. 6. During an interview on 2/28/24 at 4:05 P.M., the Administrator said he was not aware the facility's inventory sheets lacked detail of the resident's belongings. The Administrator said the facility's inventory sheets should list the resident's belongings. *The higher the classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 BP6011 PRINTED: 03/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 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 12 of 12 PLAN OF CORRECTION Provider/Supplier | Family Partners Manchester LLC Name: Street Address, 351 Forest Summit Court City, Zip: Date of Survey: 02/28/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 32473 ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION: (EACH CORRECTIVE COMPLETION ACTION SHOULD BE CROSS-REFERENCED TO THE DATE APPROPRIATE DEFICIENCY) A4506 19 CSR 30-86.045 (3)(A)(6){A) Individual Evacuation Plan— Staff Requirements General Requirements. {A) if the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include the following components: A. The responsibilities of specific staff positions in an emergency specific to the individual; II Director of Nursing has reviewed all resident’s IEPs-including 3/12/24 those for residents numbered 3,2, and 1-and updated all to reflect the specific staff positions responsible for assisting each resident who has an IEP. Staff are indicated by: ¢ = Cart Staff (staff member on medication cart) ¢ Kitchen Staff (staff member assigned to kitchen) Upon admission to the community and semi- annual/significant changes of IEPs, the Director of Nursing will complete the IEPs identifying the staff members responsible to assist the identified resident(s). Administrator and/or designee will review IEPs monthly to ensure compliance. A3235 19 CSR 230-86.032(34) Hot Water 105-120 Degrees F Plumbing fixtures which are accessible to residents and which supply hot water shall be thermostatically controlled so that the water temperature at the fixture does not exceed one Page 1]4 hundred twenty degrees Fahrenheit (120°F) (49°C) and the water shail be at a temperature range between one hundred five degrees Fahrenheit (105°F) (41°C) and one hundred twenty degrees Fahrenheit {120°F) (49°C). It! In-service will be provided to all current staff, including the 4/1/24 “handy” person, and future staff in orientation on daily monitoring of water temperature by the Director of Nursing or her designee that covers: e Temps are between 105 degrees Fahrenheit (F) and 120 degrees F ¢ Day Supervisor is responsible for weekly water temperature testing and documenting on water temperature logs for 90-days, then bi-weekly for another 90-days, then monthly thereafter. ® How and to whom to report discrepancies in temperature Water temperature logs will be kept and dated at time of Current and entry in the kitchen binder. ongoing Operations Manager or designee will be responsible for Current and reviewing documented temperatures and dates. ongoing The above applies to all plumbing fixtures accessible to residents including but not limited to the sink fixtures in bathrooms #1 ad #2 in house 351; and, the sink fixtures in bathrooms #1, 2,3, and 4 in house 357; and the shower fixture in bathroom #3 in 357. Administrator and/or designee will review water temperature | Current and logs monthly to ensure documentation compliance and ongoing conduct random monthly testing. 19CSR 30-86.047(20)(1) Personnel Record-physician statement, employee 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; Il Medical Director has provided written permission designating | 3/12/24 the Director of Nursing to review eligibility of current staff to work ina LTC community. Director of Nursing has provided a written statement indicating all current personnel can work in a long-term care community. These statements are kept in Page 2|4 the employees’ medical files. This includes but is not limited to the medical files for employees F, H, and G. Physicals and a written statement by a licensed physician or Current and physician’s designee indicating the employee can work in a ongoing long-term care community will be included in all newly hired employees upon hire. Administrator and/or designee will review employees’ files Current and monthly to ensure compliance. ongoing 19CSR 30-87.030(20) Frozen Food at Zero Degrees F or Below Frozen food shall be kept frozen and should be stored at a temperature of zero degrees Fahrenheit (0°F) or below. III Operations Manager ensured working thermometers were 3/1/24 placed in each freezer and refrigerator at the three homes on Family Partners Manchester campus. Operations Manager or designee will conduct an in-service 4/1/24 with all staff and will orient new staff to train them on daily temperature recordings and how/ when/ and to whom to report discrepancies in temperatures to and if a thermometer is missing upon inspection. Freezers will be checked monthly for a build-up of any frost or | 3/15/24 ice that may inhibit proper temperature maintenance. Freezers will be defrosted as necessary to ensure proper temperature maintenance. Night staff will be responsible for documenting temperatures and monthly frost/ice checks on the log in the Kitchen Binder. Operations Manager or designee will take charge of defrosting freezers. Night Supervisor will review documentation upon rounds and | Current and conduct weekly random checks to ensure temperatures are ongoing appropriately documented. Any temperature issues will be reported to the Operations Manager and/or Administrator for proper maintenance or appliance replacement. The above applies to all freezer units including but not limited to the small upright freezer in the dry storage unit of house 351; the deep freezer in the dry storage room of house 363; and, the small upright fridge/freezer in house 363. Page 3|4 Administrator and/or designee will review documentation Current and monthly and provide random checks throughout the month to | ongoing ensure compliance. 19 CSR 30-88.010 (36) Personal Clothing/Possessions Each resident shall be permitted to retain and use personal clothing and possessions as space permits. Personal possessions may include furniture and decorations in accordance with the facility's policies and shall not create a fire hazard. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to the resident during his or her stay in the facility, which are to be returned to the resident or responsible party upon discharge, transfer, or death. Ii/Il Director of Nursing will create new, more detailed inventories | 5/1/24 for all current residents and have all Responsible Parties sign them. Inventories will include: e Personal clothing e Furniture e Decorations Other personal Items This will be applicable to all residents, including but not limited to residents #3, 2, and 1. Community Relations Director will use the new inventory form | 3/12/24 moving forward for all new admissions and be responsible for completing the inventory on day of admission. Responsible party will sign-off on inventory sheet verifying (s)he agrees with the items on the list. Administrator and/or designee will review all current and Current and admitting inventories to ensure compliance ongoing Administrator's Signature: VW, GD) PAD BE iy (xtitb es. Date: L ay, S- Hee ‘e Page 4|4