BRADFORD COURT ASSISTED LIVING.

Apr. 16.2025 10:53AM No. 0167 P. 2 PRINTED: 04/15/2025 FORM APPROVED Missouri Department of Health and Sentor Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 17732 |B Wing 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 902 NORTH MAIN NIXA, MO 65714 (X4) [ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST 8& PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ‘A CROSS-REFERENCED TO THE APPROPRIATE | DEFICIENCY) BRADFORD COURT-ASSISTED LIVING BY AMI A4714) 19 CSR 30-86.047(13)(B) EDL Inquiry Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, thé employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as provided in section 660.315, RSMo, as to whether the person Is listed on the EDL. Each facility shal] maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. Tha inquiry may be made through the department's website: I//III This regulation is not met as evidanced by: Class II* Based on interview and record review, facility staff failed to document a check of the employee | disqualification list (EDL - a list of individuals unable to work in long-term care settings) for three staff members (Personal Care Aide (PCA) A, PCAB, and Dietary C) of three sampled newly hired staff members prior to the staff member beginning ernploymenit with resident contact. The | facility census was 29. Review of the facility policy titled "Employee Disqualification List/Abuse Registry," dated 05/10, showed the following: -All employees are expected to not have been placed on the Employee Disqualification List by Missouri Department of Health and Senior | Services; -Go online to www.dhss.mo.gov/EDL/ and follow prompts to obtain verification that the employee is Missour! Department of Health and Senior Services lof at OR ai Plo REPRESENTATIVE'S SIGNATURE N H. AS df Yj (X6) DATE STATE FORM : 5888 HBO7 14 Hf continuation sheet 1 of 3 State of Missouri 4178956290 O4/16/2025 09:46AM Pg 02/06 PRINTED: 04/15/2025 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 17732 B. WING 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 902 NORTH MAIN NIXA, MO 65714 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRADFORD COURT-ASSISTED LIVING BY AMI Continued From page 1 clear on the EDL list; -Once verification is obtained, print and place in the yellow employee file if hired; -Check the Employee Disqualification list on a quarterly basis to ensure no current employees have been added to the list. 1. Review of PCAA's personnel record showed the following: -Hire date of 01/03/25 with a start date of 01/13/25; -The file did not contain an EDL check before the start date; -Staff documented an EDL check completed on 04/09/25. 2. Review of PCA B's personnel record showed the following: -Hire date of 02/13/25 with a start date of 02/17/25; -The file did not contain an EDL check before the start date; -Staff documented an EDL check completed on 04/09/25. 3. Review of Dietary C's personnel record showed the following: -Hire date of 02/26/25 with a start date of 03/01/25; -The file did not contain an EDL check before the start date; -Staff documented an EDL check completed on 04/09/25. 4. During an interview on 04/09/25, at 3:15 P.M., the Administrator said the following: -It is the Administrator's responsibility to complete EDL checks; -He/She could not find the EDL checks for PCAA, PCA B, and Dietary C Missouri Department of Health and Senior Services STATE FORM 6899 HBO711 If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 17732 NAME OF PROVIDER OR SUPPLIER 902 NORTH MAIN BRADFORD COURT-ASSISTED LIVING BY AMI NIXA, MO 65714 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 *The higher class merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 B. WING (X2) MULTIPLE CONSTRUCTION A. BUILDING: CROSS-REFERENCED TO THE APPROPRIATE HBO711 PRINTED: 04/15/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/09/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY) If continuation sheet 3 of 3 Apr. 16. 2025 10:54AM No. 0167 P. 5 PLAN OF CORRECTION Provider/Supplier Bradford Court Assisted Living by Americare Name: Street Address, 902 N. Main St. City, Zip: Nixa, MO 65714 Date of Survey: April 9, 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The filling of this plan of correction does not constitute any a admission by the facility regarding the alleged violation stated in the summary Statement of Deficiencies date April 9, 2025 by the 4/10/2025 Missouri Department of Health and Senior Services. This plan of 1D PREFIX TAG correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. Administrator and/or designee will verify that any individual is not listed on the Employee Disqualification Lis/Abuse Registry prior to being hired for any type of position at the facility. This verification will be printed and placed in the employee's file, An audit was completed of all current employee files to ensure the EDL is documented. Any that weren't documented were checked immediately tc verify that they were not on the Employee Disqualification LisVAbuse Registry. Administrator and/or designee will review the list of quarterly additions to the Employee Disqualification List to verify that none of our current employees have been added to this list after being hired. After reviewing, this document will be signed, dated, and placed in file/binder, A4714 State of Missouri 4178956290 04/16/2025 09:46AM Pg 05/06 Apr. 16. 2925 10:54AM No. 0167 OP. 6 The Administrator signing and dating the first page of the OMS:ZRET/ State Form is inc heoein their approval of the plan of correction being submitted on this form. State of Missouri 4178956290 04/16/2025 09:46AM Pg 06/06