MARK TWAIN ASSISTED LIVING.

PRINTED: 01/10/2024 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 16369C B.WING 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} MARK TWAIN ASSISTED LIVING, INC 19 CSR 30-86.022(10)(A) Hazardous Area Requirements 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 shail 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 | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. [I This regulation is not met as evidenced by: Class II: Based on observation, records review, and interview on 1/3/24, facility fails to keep doors to hazardous areas closed, unless only kept open /oy an electromagnetic hold-open device connected to the fire alarm system. Facility census is thirty-one (31). Violation affects thirty-one (31) of thirty-one (31) residents. Observations showed: Both laundy room doors were held open by a cord, Kitchen door was propped open with a trash can Missour)Department of Health and Senior Services BOR, R TITLE (X6) DATE Ol- 1 §- lf continuation sheet 1 of 2 sees LIMR11 PRINTED: 01/10/2024 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 16369C B.WING 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE. DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 1 Interview with building maintenance director at 12:30 P.M. stated they are not usually propped open when he is there, but he would address the issue and inform staff again to keep them shut. Missouri Department of Health and Senior Services STATE FORM 6a89 LIMR11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Mark Twain Assisted Living, Inc. Name: 901 Union Avenue Moberly, Missouri 65270 Street Address, City, Zip: ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | 19 CSR 30-86.022(10)(A) Hazardous Area Requirements | Maintenance staff removed the cords from both laundry room doors. Maintenance staff directed signs be posted stating that the doors must be closed unless entering and exiting. Administrator directed staff to lock both doors to ensure the safety of all the Residents. 02-01-24 Administrator reviewed the regulation named above with all staff. They indicated that they understood and would comply. Maintenance staff will inspect the doors weekly for closure and for being locked. A2256 Maintenance staff removed the trash can that was sitting in front of the electromagnetic kitchen door. The trash can blocking the door could inhibit the door from closing once the electromagnetic hold open device was set off by the fire alarm. The Administrator offered staff information on the electromagnetic door and the importance of keeping any obstruction away that might inhibit proper closure during an emergency. Maintenance staff will check daily that no obstruction is near that door. 02-01-2024 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the pian of correction being submitted on this form.

Nov. 6. 2023%,12: 04PM Mark Twain Assisted Livingog ~yorny wth No 1285 PL 2 bo ~ poo TAA PE Net 523 *" "PRINTED: 10/34/2023 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x3) DATE SURVEY (X1) PROVIDER/SUPPLIER/CLIA COMPLETEO IDENTIFICATION NUMBER: 0) MULTIPLE CONSTRUCTION A, BUILDING: Cc B, WING 40/26/2023 16369C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 MARK TWAIN ASSISTED LIVING, INC SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} 19 CSR 30-86.022(10)(A) Hazardous Area Requiraments Protection from Hazards. (A) in assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than iwelve (12) beds, hazardous areas shall be separated by construction of at least 4 one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the oné- (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 parlitions and doors. The doors shall be self-closing or automatic-closing. Facliities formerly licensed as residential care facility | or il, and existing prior to Navember 13, 4980, shall be exempt from this requirement. Il This regulation is not met as evidenced by: Class il : Based on observation and an interview the facility failed to maintain the self-closing smoke partition doors. The facility census was 31. This potentially affected 31 of 31 residents. Observation on 10/26/23 at 10:40 A.M., showed the doors to the kitchen weré open and the serving window was open. Further observation showed ne self closing device on the kitchen doors or serving window. During an interview on 10/26/23 at 10:40 A.M., Department of Health and Senior Services PROVIQER/SUPPLIEP REPRESENTATIVE'S SIGNATURE (X6) DATE 5TOF11 if continuation sheet 1 of 12 11/06/2023 12:05PM (GMT-06:00) PRINTED: 10/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 10/26/2023 B. WING 16369C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MARK TWAIN ASSISTED LIVING, INC MOBERLY, MO 65270 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES : ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD 8E COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(10)(A) Hazardous Area Requirements 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 | or II, and existing prior to November 13, 4980, shall be exempt from this requirement. I] This regulation is not met as evidenced by: Class Il Based on observation and an interview the facility failed to maintain the self-closing smoke partition doors. The facility census was 31. This potentially affected 31 of 31 residents. Observation on 10/26/23 at 10:40 A.M., showed the doors to the kitchen were open and the serving window was open. Further observation showed no self closing device on the kitchen doors or serving window. During an interview on 10/26/23 at 10:40 A.M., Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE a ee STATE FORM 6899 5TOF 14 If continuation sheet 1 of 12 PRINTED: 10/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 10/26/2023 BWING 16369C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (x4) 1D 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) — TaG.«|~s CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 1 the dietary staff A said he/she kept the doors to the kitchen open as it was warm in the kitchen. He/She said staff cannot open the back door as it would let in flies. Dietary staff A verified there was no self closing device in place on the kitchen doors or serving window. During an interview on 10/26/23 at 11:00 A.M., the Administrator said she was not aware the facility exception had not been renewed for the open kitchen. 19 CSR 30-86.047(46) Safe & Effective Medication System 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 Missouri Department of Health and Senior Services STATE FORM 6899 5T0F11 If continuation sheet 2 of 12 PRINTED: 10/34/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1), PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2} MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 10/26/2023 B. WING —_ 16369C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES i 13) | 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 i CROSS-REFERENCED TO THE APPROPRIATE DATE i DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 2 medication technician or level | medication aide. Vil This regulation is not met as evidenced by: Class Il Based on observation, interview and record review, the facility failed to implement a safe and effective medication system which assured residents' medications were administered in accordance with physician orders for two residents (Residents #1 and #2) of four sampled residents. The facility census was 31. Review of the undated, facility medication administration policy showed the following: -It is the policy of this facility to administer medications and treatments by written order from the physician; -The Administrator is responsible for the medication distribution system and the safety of the operation; -This facility uses a packaged dose pill system for administering medications. This includes bubble packs, strip packs and cup dose packs. Narcotics shall be in single dose packaging. 1. Review of Resident #1's record showed he/she was admitted to the facility on 8/24/22 with diagnoses which included the following arteriosclerotic heart disease (heart disease where arteries become clogged with with fatty substance called plaques), history of stroke, occlusion and stenosis of left carotid artery (left artery in left side of neck becomes blocked), coronary artery bypass (artery bypass to improve blood flow), and atrial fibrillation (irregular heart beat). Review of the resident's hospital discharge Missourl Department of Health and Senior Services STATE FORM 6899 5TOF11 If continuation sheet 3 of 12 PRINTED: 10/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 10/26/2023 B. WING 16369C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MARK TWAIN ASSISTED LIVING, ING MOBERLY, MO 65270 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID | PROVIDER'S PLAN OF CORRECTION (%5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG DATE REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE : DEFICIENCY) Continued From page 3 summary dated 9/20/23, showed the following: -Resident arrived to the hospital on 9/19/23, when facility staff administered Resident #2's medication to Resident #1 and Resident #1's blood pressure was very low. -Resident #1 received eight of Resident #2's medications (furosemide (a diuretic) 20 milligrams (mg), carbidopa/levodopa (used to treat Parkinson's disease) 25-100 two and a half tablets, lostran (used to treat high blood pressure) 50 mg, levothyroxine (used to treat hypothyroidism), and ropinirole (used to treat Parkinson's disease); -Resident found to be bradycardic (slow heart rate) and hypotensive (low blood pressure); -Resident admitted for overnight observation, monitoring and management of symptoms; -On 9/20/23 the resident was discharged back to facility with orders to continue the previously ordered medications. During an interview on 10/26/23 at 9:20 A.M., Resident #2 said a month or two ago Certified Medication Aide (CMA) A gave Resident #1 his/her medications and Resident #2 took Resident #1's medications. Resident #2 said he/she had no symptoms or problems as a result of taking Resident #1's medication. He/She said CMA A was written up and now administers Resident #1's medication in their room and administers Resident #2's medications in the dining room. Review of CMAA's written warning, undated, showed CMAA reported the medication error to the Operations Manager. CMAA began 30 minute checks on each resident. As time passed, Resident #1 had symptoms of low blood pressure and was sent out to the hospital. Resident #1's physician contacted the facility and reported Missourl Department of Health and Senior Services STATE FORM GRo9 5TOF 11 If continuation sheet 4 of 12 PRINTED: 10/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING: (X3) DATE SURVEY COMPLETED Cc 40/26/2023 16369C B.WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MARK TWAIN ASSISTED LIVING, INC MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID | PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX i (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG { CROSS-REFERENCED TO THE APPROPRIATE DATE i \ DEFICIENCY) Continued From page 4 Resident #2 said CMAA had mixed up Resident #1 and Resident #2's medications before. Resident #2 said he/she did not report it before as he/she did not want to make trouble. Education offered to CMAA and observations of CMA A's medication passes were completed on 9/20/23, 9/23/23 and 9/27/23. During an interview on 10/26/23 at 11:50 AM., CMAA said he/she took Resident #1 and Resident #2's medication cups into the room and set them down. Resident #1 picked up Resident #2's medication cup and took the medications. CMAA said he/she now administers medications for Resident #1 in the resident's room and administers Resident #2's medications in dining room. CMAA said he/she was written up by the Administrator, received education, and had another staff watch his/her medication passes. 3. Observation of the medication pass on 40/26/23, completed by CMAA, showed the following: -At 11:50 A.M., CMAA opened the top drawer of the medication cart which contained medication cups with medications inside and the residents' name paper clipped to cups; -The medication cup and card listing the resident's name did not include the name of the medication or dosage: -At 12:05 P.M., CMAA removed a paper medication cup from the top drawer of the medication cart which contained one tablet; -The medication cup was not labeled with the medication name, or dosage; -CMAA identified the tablet as Resident #5's Tylenol (pain reliever); -CMAA said he/she removed the Tylenol tablets from the resident's prepackaged pharmacy strip and placed it in the medication cart in the Missouri Department of Health and Senior Services STATE FORM 6699 5T0F11 If continuation sheet 5 of 12 PRINTED: 10/31/2023 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 Cc 40/26/2023 B.WING 16369C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MARK TWAIN ASSISTED LIVING, INC MOBERLY, MO 65270 (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) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 5 medication room prior to the medication pass, -At 12:05 P.M., CMAA removed a medication cup from the top drawer of the medication cart which contained one tablet; -The medication cup was not labeled with the medication name, or dosage, -CMAA identified the medication as Resident #6's Tylenol; - At 12:06 P.M. CMAA removed a paper medication cup from the top drawer of the medication cart which contained two tablets, -The medication cup was not labeled with the medication name or dosage; -CMAA identified the tablets as Resident #3's Tylenol; -At 12:06 P.M. CMAA removed a paper medication cup from the top drawer of the medication cart which contained two tablets; -The medication cup was not labeled with the medication name or dosage; -CMAA identified the tablets as Resident #2's Tylenol; -At 12:07 P.M. CMAA removed a paper medication cup from the top drawer of the medication cart which contained one tablet, -The medication cup was not labeled with the medication name or dosage, -CMAA was not able to identify the tablet administered to Resident #7 without referring to the medication administration record (MAR); -At 12:08 P.M. CMAA removed a paper medication cup from the top drawer of the medication cart which contained two tablets; -The medication cup was not labeled with the medication name or dosage; -CMAA identified the tablets as Resident #8 antibiotic and Carb/Levo (used to treat Parkinson disease); -At 12:09 P.M. CMAA removed a paper medication cup from the top drawer of the Missouri Department of Health and Senior Services STATE FORM 6899 5TOF 11 If continuation sheet 6 of 12 PRINTED: 10/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}, PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION (DENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 10/26/2023 B. WING 16369C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (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) "Tae | GROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 6 medication cart which contained one tablet; -The medication cup was not labeled with the medication name or dosage; -CMAA identified the tablets as Resident #9's Folic Acid (used to treat anemia); - At 12:10 P.M. CMAA removed a paper medication cup from the top drawer of the medication cart which contained three tablets; -The medication cup was not labeled with the medication names or dosage; -CMAA identified the tablets as Resident #10's vitamins, Folic Acid, but CMA A was unsure of the other medication names without review of the MAR. During interview on 10/26/23 at 12:10 P.M., CMA A said the following: -CMAA had removed the medications for each resident for the noon medication pass from the residents’ prepackaged pharmacy strips and placed them in the medication cups inside the locked medication cart; -Most residents’ medications were provided in sealed strip-packs labeled with the resident's name, medication name, dosage, and date and time to be administered; -CMAA documented administration of medications on the quick MAR after the medication pass was completed. During an interview on 10/26/23 at 12:15 P.M., the Administrator said the following: -She expected staff to have the medication administration book (MAR) to refer to when medications were administered; -CMAA should have written down the medications including dosage on the resident name card attached to the medication cup; -Medications come prepackaged from the pharmacy; Missouri Department of Health and Senior Services STATE FORM 6899 5TOF 14 If continuation sheet 7 of 12 PRINTED: 10/31/2023 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 46369C B. WING 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (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) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE } DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 7 -There was prior incident with CMAA giving a resident another resident's medications. While investigating that incident the resident reported that this had happened previously but he/she did not report it: -The administrator expected staff to administer medications following physician orders and using acceptable nursing techniques. MO00216433 19 CSR 30-86.052(8)(B) Modified Diets-Diet/Food Ortly Review if a physician prescribes in writing a modified diet for a resident, the resident may be accepted or remain in the facility if- (B) The diet, food preparation and serving is reviewed at least quarterly by a consulting nutritionist, dietitian, registered nurse or physician and there is written documentation of the review; a This regulation is not met as evidenced by: Class III Based on record review and interview the facility failed to ensure that a resident's, physician ordered, modified diet, food preparation, and serving were reviewed at least quarterly for three residents (Resident #1, #2, and #3) of four sampled residents. The facility census was 31. 1. Record review on 10/26/23 showed the following for Resident #1: - Physician ordered a mechanical soft diet dated 8/24/22; -The most recent quarterly review was completed on 4/30/23. Missouri Department of Health and Senior Services STATE FORM sao 5TOF11 If continuation sheet 8 of 12 PRINTED: 10/31/2023 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 C 16369C B.WING 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES : ID { PROVIDER'S PLAN OF CORRECTION (X5} PREFIX {EACH DEFICHKENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG i CROSS-REFERENCED TO THE APPROPRIATE DATE { i DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 8 2. Record review on 10/26/23 showed the following for Resident #2: -Physician ordered a 1800-2000 calorie low concentrated sweet diet dated 12/13/22; -The most recent quarterly review was completed 4/20/23. 3. Record Review on 10/26/23 showed the following for Resident #3: -Physician ordered a diabetic diet dated 11/20/21; -The most recent quarterly review was completed 4/30/23. During an interview on 10/26/23 at 2:50 P.M., Tithe Administrator said the Registered Nurse was responsible for completing the quarterly dietary reviews. The Administrator searched the residents’ records and other files but was not able to find any dietary reviews. During an interview on 10/26/23 at 3:10 P.M., the registered nurse said he/she had not completed the quarterly dietary reviews. 19 CSR 30-87.030(7) Food Prep & Storage Separate From Other Areas Food preparation and storage shall not be conducted in any room used as living or sleeping quarters. In a facility licensed for more than twelve (12) residents, except in an existing residential care facility, food service operations shall be separated from living or sleeping quarters by complete partitioning and solid, self-closing doors. Nothing in this section shall prohibit an assisted living facility from providing kitchen and family style eating areas for use by residents. Ill Missouri Department of Health and Senior Services STATE FORM 6899 5T0F11 If continuation sheet 9 of 12 PRINTED: 10/31/2023 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 16369C B. WING 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX {EACH DEFICIENCY MUST 8& PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 9 This regulation is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that an open kitchen with an operable stove was separated from the open living area. This deficient practice had the potential to affect all residents residing within the facility. The facility census was 31 residents. 1. Observation of the open kitchen on 10/26/23 at 10:40 A.M., showed an open kitchen serving window without a closure device. During an interview on 10/26/23 at 10:40 A.M., the dietary staff A was not aware a facility exception was expired. During an interview on 10/26/23 at 11:00 A.M., the Administrator said she was not aware the facility exception had not been renewed for the open kitchen. 19 CSR 30-88.020(14) Resident Fund Bond Requirements The bond required by section 198.096, RSMo, for operators holding personal funds of residents shall be in a form approved by the department and shall provide that residents who allege that they have been wrongfully deprived of moneys held in trust may bring an action for recovery directly against the surety. The bond shall be in an amount equal to at least one and one-half (1 1/2) times the average monthly balance of the residents ' personal funds, including residents ' petty cash, or the average total of the monthly balances for the preceding twelve (12) months. The average monthly balance(s) or the average Missouri Department of Health and Senior Services STATE FORM 6899 5TOF11 lf continuation sheet 10 of 12 PRINTED: 10/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 10/26/2023 16369C B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 901 UNION AVENUE MARK TWAIN ASSISTED LIVING, INC MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (XS) 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 i DEFICIENCY) Continued From page 10 total of the monthly balance(s) shall be rounded to the nearest one thousand dollars ($1,000). One (1) bond may be used to cover the residents ' funds in more than one (1) facility operated by the same operator, if the facility is a multilicensed facility on the same premises. If not on the same premises, then one (1) bond may be used if the bond specifies the amount of coverage provided for each individual facility and the coverage for each facility is a minimum of one thousand dollars ($1,000). IN/ill This regulation is not met as evidenced by: Class Ill Based on interview and record review, the facility failed to purchase a surety bond in an amount equal to at least one and one-half times the average monthly balance of the residents’ personal funds. The facility census was 31. 4. Review of the facility's resident trust account reconciled bank statements showed the following: -October 2022 balance of $4537.08; -November 2022 balance of $ 4208.19; -December 2022 balance of $5393.17; -January 2023 balance of $6386.83; -February 2023 balance of $9293.90; -March 2023 balance of $13,825.16; -April 2023 balance of $ 8822.88; -May 2023 balance of $8647.20; -June 2023 balance of $10,621.80; -July 2023 balance of $4472.56 -August 2023 balance of $4197.82; -September 2023 balance of $5507.24. Review showed the total of the resident trust fund account balance from October, 2022 through September, 2023 was $85,917.83 for a monthly average of $7,159.82. Missouri Department of Health and Senior Services STATE FORM 6899 5TOF11 if continuation sheet 11 of 12 PRINTED: 10/31/2023 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 16369C B. WING 40/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 901 UNION AVENUE MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES ID i 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 j CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) MARK TWAIN ASSISTED LIVING, INC Continued From page 11 Review of the Resident Bond Fund Worksheet showed that the average of the resident trust fund account balance from October 2022 through September 2023, when rounded to the nearest thousand was $7,000.00. Review of the Resident Bond Fund Worksheet formula showed the rounded up average, $7000.00, multiplied by 1.5 resulted in $10,500.00 as the required bond amount. Review of the facility surety bond on the Department of Health and Senior Services database showed a surety bond in the amount of $10,000 which was $500.00 below the required bond amount. During interview on 10/26/23 at 3:30 P.M., the office manager said the increase was due to a resident's account that discharged and when facility sent a check of the balance to the family and the family member lost the check. He/She said the facility stopped the check and was sending out a new check today. During an interview on 10/26/23 at 4:00 P.M. the Administrator said that she had not been aware that the average in the resident trust fund bank account had increased and she was planning on pursuing a higher bond amount. Missouri Department of Health and Senior Services STATE FORM 6899 5TOF 11 if continuation sheet 12 of 12 P L A N Provider/Supplier Name: Street Address, City, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED 10 THE APPROPRIATE DEFICIENCY) co sare 1ON 19 CSR 30-86.022(10)(A). The kitchen/dining room pass through opening exception was not current. All 31 residents were affected by the expired exception. There are one 1 pass through and two (2) kitchen entry doors. The kitchen entry door between the dining room and the kitchen has an electromagnetic hold open device which is connected to the fire alarm system. The kitchen door (opening to the hallway) has self closing hinges and will remain closed. A notice will be posted to keep the door closed except when exiting/entering. A notice will be posted on the closed pass-through door to remain A2256 closed until an exception can be obtained. The Administrator Kathryn Miller will alert all staff to this change. The Administrator Kathryn Miller and Operations Manager Kendall Price will monitor the doors for compliance each day they are on site to ensure compliance of this regulation and to O F Cc O R R EC T 1 ON Mark Twain Assisted Living, Inc. 901 Union Avenue Moberly, MO 65270 41-13 - 23 ensure all 31 residents of the facility are safe from kitchen dangers. The State exception forms have been requested to allow the pass through sliding door to remain open when the area is in use. a a 19 CSR 30-86.047(46) The Administrator Kathryn Miller shail develop and implement a safe and effective system of medication control and use, which assures that all residents’ medications are administered, according to regulation, in accordance with physicians’ instructions using acceptable nursing techniques. The Administrator directs all staff administering medications that her preference of administration of meds is to deliver directly from the strip packages to the residents’ hand with the MAR open to that resident's med orders. Also acceptable is removing from the pharmacy package to a small cup. The resident should be given the medication with the MAR open showing the orders and/or individual med cards with the cup. Continued from page 1. CMA A was reported to have switched medication doses between Resident #1 and Resident #2 on Sept. 19, 2023. A warning was issued by the Administrator along with education and separate dates for follow ups. Medication administration by CMA A was found acceptable at that time. 3. CMA Aon 10-26-23 abandoned her previous training and proceeded to administer medications to Residents’ # 5, # 6, # 3, #2,#7, #8, #9 and #10 in an unapproved manner. Due to the severity of the error, the Administrator directed CMA A to leave the med room. The Administrator feels that in the short time since CMA A’s training had occurred and this error was committed, this CMA was not going to be allowed to administer medications at Mark Twain Assisted Living again. The plan for compliance with medication administration in the future is the Administrator or a Nurse will conduct a monthly observation of a medication pass. This may occur on rotating med pass shifts. If discrepancies are found, that staff person will receive correction and training. Administrator has asked all 31 Residents to observe what medications they are taking and ask any questions they have before they take their medication. Administrator directs all med staff to keep the individual med cards up to date. The Nurse will be responsible to see that this is compliant for all shifts. 19 CSR 30-86.052(8)(B). Dietary Reviews. Administrator directs the Nurse to review any physician prescribed modified diets for residents at least quarterly. The diet, food preparation and serving will be observed and documented. Residents’ # 1, #2, and # 3 had their last review by the Nurse in April, 2023. The Nurse stated that she was late in preparing them. The Administrator directed the Nurse to catch up the past due Dietary Reviews for all Residents. The Administrator or the Activity Director will monitor the progress and timeliness of the dietary reports. In the event the reviews are going fo be late, the consulting Nurse will be called to complete the reports. The Administrator will be responsible to see that the Dietary reviews 11-13-23 are completed on a quarterly basis. eS 19 CSR 30-87.030(7). The Exception for the kitchen/dining room pass- through opening was not current. All 31 Residents were affected by the expired exception. The Administrator has requested (11-2-23) a consideration for another Exception from DHSS. To meet compliance currently, the Administrator closed the pass through opening and posted signs to keep the door closed pending approval of an Exception. The door from the kitchen to the dining room has an electromagnetic device to hoid the door open until the fire alarm sounds and automaticaily close the door. The door between the kitchen and the hallway has self closing hinges on it. The Administrator closed the door and posted a sign to keep the door closed except to enter and/or exit. The Administrator will communicate to ail staff about keeping the pass-through door closed until an Exception can be obtained. The Administrator and Operations Manager will observe the doors each time they are on site to ensure 11-13-2023 11-13-2023 Continued from page 2 compliance and safety for all Residents. Pp 19 CSR 30-88.020(14). Bond. The facility shall purchase a Co | surety bond in an amount equal to at least one and one-half times the average monihly balance of the residents’ personal funds. The Administrator contacted the Bond company to increase the Bond coverage. The Bond was increased to $15,000 effective October 27, 2023. The Administrator directs the Financial Officer to do a monthly calculation after the bank reconciliation each month to ensure the amount of the Resident Funds Account does not exceed one and one-half times the $15,000. If the reconciled amount gets close to one and one- half times the $15,000, the Financia! Officer will report this to the Administrator. Action will be taken immediately to increase the 10-27-2023 e as needed. (Copy of the Rider is attached 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.