LAKEVIEW BEND MEMORY CARE.

PRINTED: 11/05/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY. COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 13544C 10/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 ASBURY CIRCLE WEST MEXICO, MO 65265 ARBORS AT LAKEVIEW BEND-ASSISTED LIV | (X4) 10 SUMMARY STATEMENT OF DEFICIENCIES a) PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | {EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ; A4796 19 CSR 30-86.047(45) Injections, Insulin : Administration ' Injections shall be administered only by a physician or licensed nurse, except that insulin | injections may also be administered by a certified | medication technician or level | medication aide who has successfully completed the | State-approved course for insulin administration, ' taught by a department-approved instructor. | Anyone trained prior to December 31, 1990, who completed the state-approved insulin ; administration course taught by an approved ' instructor shall be considered qualified to | administer insulin in an assisted living facility. A resident who requires insulin, may administer his | or her own insulin if approved in writing by the : | resident's physician and trained todosobya | licensed nurse or physician. The facility shall _ monitor the resident 's condition and ability to continue self-administration. [/Il | This regulation is not met as evidenced by: , Based on record review and interview, the facility ’ failed to ensure that the administration of insulin : Was conducted and documented in the electronic medication record by the staff members who were trained and certified to administer insulin for | one resident (Resident #1) of four sampled | residents. The facility census was 16. 1. Review of the facility policy titled "Insulin Injections" dated 6/10/2019 showed the following: | -The policy guideline called for insulin dependent | _ diabetic residents to receive their prescribed i insulin injections according to physician orders | | _ and given by licensed nursing personnel or | insulin-certified Certified Medication Aides (CMAs); -Documentation in the resident's Medication Administration Record (MAR) should include the Missouri Depariment of Health and Senior Service a F s WLIER REPRESENTATIVE'S SIGNATURE (X6) DATE {€ continuation sheet 1 of 6 3EDS11 PRINTED: 11/05/2024 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 13544C B. WING 10/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 ASBURY CIRCLE WEST MEXICO, MO 65265 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | (EACH CORRECTIVE ACTION SHOULD BE i COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | CROSS-REFERENCED TO THEAPPROPRIATE =———DATE i ARBORS AT LAKEVIEW BEND-ASSISTED LIV | DEFICIENCY) 44796; Continued From page 1 initials of the nurse or CMA administering the insulin, the site of the injection, and the blood sugar reading if applicable. 2, Review of Level One Medication Aide (LIMA) A's personnel file showed the following: -LIMA A was hired on 11/15/23; -LIMAA's certification to administer medication was active with an expiration date of 2/7/26; -LIMAA had no documentation to show he/she had been trained and certified to administer insulin. 3. Record review of Resident #1's face sheet showed: -Admission date of 6/4/24. -Diagnoses included diabetes mellitus type 2 (blood sugar disorder) and unspecified dementia | (brain disorder affecting thinking and memory). Review of the resident's Physician Order Sheets (POS) for September and October 2024 showed the following: | -Basaglar Kwikpen (insulin glargine)(a medication | to treat blood sugar disorders), 100 units per 10 milliliters (ml), 10 units to be injected subcutaneously (beneath the skin), every day at bedtime; -Basaglar Kwikpen, 100 units per 10 ml, 30 units to be injected subcutaneously every day in the morning with breakfast; Review of the resident's POS for September 2024 showed an order for Flaps FlexTouch {insulin apart with niacinamide), 100 units per mi, to be administered subcutaneously according to the following sliding scale of blood sugar readings with meals and at bedtime: -151 to 200 milligrams per deciliter (mg/dL) administer 3 units Missouri Department of Health and Senior Services STATE FORM 6ag9 3EDS11 if continuation sheet 2 of 6 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ARBORS (x4) ID PREFIX TAG Missouri Department of Health and Senior Services STATE FORM Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 13544C (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 11/05/2024 FORM APPROVED {X3) DATE SURVEY COMPLETED 40/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1700 ASBURY CIRCLE WEST AT LAKEVIEW BEND-ASSISTED LIV | MEXICO, MO 65265 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 -201-250 mg/dL administer 5 units; -251-300 mg/dL administer 8 units; -301-350 mg/dL administer 10 units; -351-400 mg/dL administer 12 units; and -Caill physician if blood sugar greater than 400 mg/dL. Review of the resident's POS for October 2024 the previous order was discontinued on 10/1/24 and restarted on 10/7/24 for Fiasp FlexTouch i {insulin apart with niacinamide), 100 units per ml, to be administered subcutaneously according to | the following sliding scale of blood sugar readings | with meals and at bedtime: -151 to 200 milligrams per deciliter (mg/dL) administer 3 units -201-250 mg/dL administer 5 units; -251-300 mg/dL administer 8 units; ~301-350 mg/dL administer 10 units; -351-400 mg/dL administer 12 units; and -Call physician if blood sugar greater than 400 mg/dL. Review of the resident's Electronic Medication Administration Record (eMAR) for September 2024 showed the following: -Basaglar KwikPen, 10 units administered at bedtime by LIMAA on 9/2/24, 9/3/24, 9/7/24, 9/8/24, 9/12/24, 9/13/24, 9/16/24, 9/17/24, 9/24/24, 9/22/24, 9/26/24, 9/27/24, and 9/30/24; -Basaglar KwikPen, 30 units administered at breakfast by LIMAA on 9/3/24, 9/4/24, 9/9/24, 9/12/24, 9/13/24, 9/17/24, 9/1/24, 9/19/24, 9/22/24, 9/23/24, 9/26/24, 9/27/24, and 9/28/24. Review of the resident's eMAR for October 2024 showed the following: -Basaglar KwikPen, 10 units administered at bedtime by LIMAA on 10/1/24, 10/6/24, 10/10/24, 10/11/24, 10/14/24, 10/15/24, 10/19/24, 10/20/24; -Basaglar Kwikpen, 30 units administered at PROVIDER'S PLAN OF CORRECTION i (X5) (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE CROSS-REFERENCED TO THE APPROPRIATE | DATE 3EDS11 DEFICIENCY) If continuation sheet 3 of 6 PRINTED: 11/05/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 13544C 10/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 ASBURY CIRCLE WEST MEXICO, MO 65265 ARBORS AT LAKEVIEW BEND-ASSISTED LIV | SUMMARY STATEMENT OF DEFICIENCIES ip | PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) ' TAG | -« CROSS-REFERENCED TO THEAPPROPRIATE ———s~DATE DEFICIENCY) (X4) ID PREFIX TAG Continued From page 3 breakfast by LIMAA on 10/1/24, 10/2/24, 10/7/24, | 10/24, 10/11/24, 10/12/24, 10/16/24, 10/17/24, 10/21/24. ) | | | Review of the resident's eMAR for September 2024 showed the administration of Fiasp | FlexTouch by LIMAA as follows: | -On 9/2/24 at bedtime, 0 units due to blood sugar | of 149 mg/dL; | | -On 9/3/24, 3 units at breakfast due to blood sugar of 161 mg/dL and 0 units at bedtime due to blood sugar of 81 mg/dL; -On 9/4/24, 0 units at breakfast due to blood sugar of 123 mg/dL and 10 units at bedtime due to blood sugar of 338 mg/dL; -On 9/7/24, 12 units at bedtime due to blood sugar of 400 mg/dL; -On 9/8/24, 5 units at bedtime due to blood sugar of 279 mg/dL; -On 9/9/24, 0 units at breakfast due to blood sugar of 41 mg/dL; -On 9/12/24, 8 units at breakfast due to blood sugar of 259 mg/dL and 3 units at bedtime due to blood sugar of 175 mg/dL; -On 9/13/24, 0 units at breakfast due to blood sugar of 106 mg/dL and 3 units at bedtime due to blood sugar of 195 mg/dL; -On 9/16/24, 3 units at bedtime due to blood sugar of 188 mg/dL; -On 9/17/24, 5 units at breakfast due to blood sugar of 239 mg/dL and 5 units at bedtime due to blood sugar of 201 mg/dL; i -On 9/18/24, 3 units at breakfast due to blood sugar of 175 mg/dL; ; i -On 9/19/24, 5 units at breakfast due to blood i sugar of 201 mg/dL; -On 9/21/24, 0 units at bedtime due to blood sugar of 107 mg/dL; | | -On 9/22/24, 3 units at breakfast due to blood sugar of 194 mg/dL and 5 units at bedtime due to Missouri Department of Health and Senior Services STATE FORM 6899 3EDS11 if continuation sheet 4 of 6 PRINTED: 11/05/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 135446 B, WING 10/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 ASBURY CIRCLE WEST MEXICO, MO 65265 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION : (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS-REFERENCED TO THE APPROPRIATE I DATE j i DEFICIENCY) : ARBORS AT LAKEVIEW BEND-ASSISTED LIV | Continued From page 4 212 mg/dL; -On 9/23/24, 0 units at breakfast due to blood sugar of 135 mg/dL; -On 9/26/24, 0 units at breakfast due to blood sugar of 82 mg/dL and 8 units at bedtime due to blood sugar of 282 mg/dL; -On 9/27/24, 0 units at breakfast due to blood sugar of 145 mg/dL and 8 units at bedtime due to | blood sugar of 266 mg/dL; : -On 9/28/24, 8 units at breakfast due to blood sugar of 272 mg/dL; -On 9/30/24, 8 units at bedtime due to blood sugar of 289 mg/dL. Review of the resident's eMAR for October 2024 showed the administration of Fiasp FlexTouch by LIMAA as follows: -On 10/10/24, 0 units at breakfast due to blood sugar of 136 mg/dL and 12 units at bedtime due to blood sugar of 399 mg/dL; ~On 10/11/24, 0 units at breakfast due to blood sugar of 107 mg/dL and 0 units at bedtime due to biood sugar of 140 mg/dL; -On 10/12/24, 3 units at breakfast due to blood sugar of 161 mg/dL; -On 10/14/24, 3 units at bedtime due to blood sugar of 198 mg/dL; -On 10/15/24, 0 units at bedtime due to blood sugar of 120 mg/dL; -On 10/16/24, 0 units at breakfast due to blood sugar of 104 mg/dL; -On 10/17/24, 0 units at breakfast due to blood sugar of 204 mg/dL; -On 10/19/24, 12 units at bedtime due to blood sugar of 360 mg/dL; -On 10/20/24, 8 units at bedtime due to blood sugar of 293 mg/dL; -On 10/21/24, 3 units at bedtime due to blood sugar of 163 mg/dL. Missouri Department of Health and Senior Services STATE FORM 689g 3EDS11 if continuation sheet 5 of 6 PRINTED: 11/05/2024 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 13544C B. WING 10/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 ASBURY CIRCLE WEST MEXICO, MO 65265 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES i ID PROVIDER'S PLAN OF CORRECTION (X5)} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | {EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) : CROSS-REFERENCED TO THE APPROPRIATE DATE i i DEFICIENCY) ARBORS AT LAKEVIEW BEND-ASSISTED LIV | A4796 | Continued From page 5 4, During interview on 10/22/24 at 1:38 P.M., the administrator said the following: -He was unaware that a CMA who was not trained and certified administration of insulin had documented administration of insulin to a resident in September and October 2024, ~ It was the responsibility of the director of nursing and the administrator to audit and verify all staff administering medications were properly trained and certified; -The facility had scheduled an upcoming class to make sure all CMAs were insulin-certified; -It was his expectation that all staff administering medications, including insulin injections, were properly trained and certified before administering any medications. Missouri Department of Health and Senior Services STATE FORM &899 3EDS11 If continuation sheet 6 of 6 PLAN OF CORRECTION Rrovider/Supplier The Arbors at Lakeview Bend-Assisted Living by Americare Street Address, | 4700 Asbury Circle West Mexico, MO 65265 City, Zip: Date of Survey: 10/22/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 13544C COMPLETION DATE 12/1/2024 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: The filing of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the summary Statement of Deficiencies dated 10/22/2024 by the Missouri Department of Health and Senior Services. This plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. A4796 The facility will ensure facility staff maintain proper certification requirements for administering insulin. Resident’s affected: 1, Resident #1 will be administered insulin by an insulin certified staff member. Measure taken to assure continued compliance with the cited requirement, for all residents with the potential to be affected: The Administrator and/or DON will enroll L1MA A in insulin certification class conducted 10/28 2.__The Administrator and/or DON will provide an in-service to all staff to review insulin injections policy, electronic signature policy, and medication administration policy on 10/24 3, Administrator will audit all current employee files to verify insulin certification for all L{MA's. 4. Administrator and/or DON will ensure proper insulin certification for all future employees responsible for resident care to ensure continued compliance. All the above measures will be accomplished by 12/1/2024 The Administrator signing and dating the first page of the CIiS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.