ARROWHEAD SENIOR LIVING COMMUNITY.

PRINTED: 10/22/2024 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED (e) 265876 B. WING 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 (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 COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ARROWHEAD SENIOR LIVING COMMUNITY F 755 Pharmacy Srvcs/Procedures/Pharmacist/Records F #55 SS=F CFR(s): 483.45(a)(b)(1)-(3) §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b} Service Consultation. The facility | must employ or obtain the services of a licensed pharmacist who- §483.45(b){1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in | sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, facility staff failed to reconcile narcotics at | the change of shift when the medication cart | changed from one staff member to another, and TITLE (X6) DATE A Mlaenestretur te cy statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99} Previous Versions Opsolete Event ID:340811 Facility ID; 31536 If continuation sheet Page 1 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F755 Continued From page 1 to ensure medications were secured. The facility census was 46. 1. Review of the facility's policy titled "Controlled Medication Storage", dated 01/2021, showed the Director of Nursing (DON) and the consultant pharmacist maintain facility compliance with handling of controlled mediations. The medication nurse on duty maintains possession of the key to the controlled medication storage areas. There should be a system of medications records that enables accurate reconciliation and accounting of controlled medications. At change of custody, a physical inventory of all controlled medications is conducted and documented by two licensed staff. 2. Review of the facility's A Hall Nurse on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/02/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/07/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/14/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/16/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/17/24 at 7:00 A.M., and 7:00 P.M., did nat contain two licensed staff signatures; FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 2 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 2 -On 08/18/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/19/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/20/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/26/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/28/24 at 7:00 A.M., and 7:00 P.M., did nat contain two licensed staff signatures; -On 08/30/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's A hall Certified Medication Technician (CMT) on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/08/24 at 2:00 P.M., and 10:00 P_M., did not contain two licensed staff signatures; -On 08/09/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/09/24 at 2:00 P.M., and 10:00 P_M., did not contain two licensed staff signatures; -On 08/10/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/11/24 at 10:00 P.M., and 6:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 2:00 P.M., and 10:00 P_M., did not contain two licensed staff signatures; -On 08/14/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/15/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/16/24 at 6:00 A.M_, did not contain two FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 3 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 3 licensed staff signatures; -On 08/18/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/29/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/29/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/31/24 at 10:00 P.M., did not contain two licensed staff signatures. Review of the facility's B hall nurse on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/02/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/04/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 08/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/07/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/17/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/23/24 at 7:00 A.M., and 7:00 P.M., did nat contain two licensed staff signatures. Review of the facility B hall CMT on-coming and FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 4 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED Cc B. WING 10/10/2024 265876 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE ARROWHEAD SENIOR LIVING COMMUNITY OSAGE BEACH, MO 65065 (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Continued From page 4 off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/11/24 at 6:00 A.M_, did not contain two licensed staff signatures; -On 08/12/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/14/24 at 6:00 A.M_, did not contain two licensed staff signatures; -On 08/15/24 at 2:00 P.M., and 10:00 P.M., dic not contain two licensed staff signatures; -On 08/17/24 at 2:00 P_M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 2:00 P_M_., did not contain two licensed staff signatures; -On 08/30/24 at 10:00 P.M., did not contain two licensed staff signatures; -On 08/31/24 at 10:00 P.M_, and 6:00 A.M., did not contain two licensed staff signatures. Review of the facility C hall nurse on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/02/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/06/24 at 7:00 A.M., and 7:00 P.M., did not Event iD: 340811 FORM CMS-2567(02-99} Previous Versions Obsolete Facility 1D: 31536 if continuation sheet Page 5 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 5 contain two licensed staff signatures; -On 08/07/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/11/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/17/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/20/24 at 7:00 A.M., and 7:00 P.M., did nat contain two licensed staff signatures; -On 08/31/24 at 7:00 P.M., did not contain two licensed staff signatures. Review of the facility C hall CMT on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/03/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/04/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/05/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/06/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/07/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/08/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 6:00 A.M., and 2:00 P.M., did nat contain two licensed staff signatures; -On 08/09/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 6 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 6 -On 08/10/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/11/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/11/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/13/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/14/24 at 2:00 P_M., did not contain two licensed staff signatures; -On 08/15/24 at 6:00 A.M., and 2:00 P.M., did nat contain two licensed staff signatures; -On 08/16/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/17/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/20/24 at 2:00 P.M., and 10:00 P.M., dic not contain two licensed staff signatures; -On 08/21/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/23/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/24/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/24/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/26/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/26/24 at 2:00 P.M., and 10:00 P_M., did not contain two licensed staff signatures; -On 08/27/24 at 2:00 P.M., and 10:00 P.M., did nat contain two licensed staff signatures; -On 08/28/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/29/24 at 2:00 P.M., and 10:00 P_M., did FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 7 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F755 Continued From page 7 not contain two licensed staff signatures; -On 08/31/24 at 10:00 P.M, did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. 3. Review of the facility's A hall nurse on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/04/24 at 7:00 A.M., and 7:00 P.M., did nat contain two licensed staff signatures; -On 09/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/11/24 at 7:00 A.M., and 7:00 P_M., did not contain two licensed staff signatures; -On 09/13/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/14/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 09/25/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/27/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's A hall CMT on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page § of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 8 -On 09/02/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/03/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/05/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/16/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 10:00 P.M_, did not contain two licensed staff signatures; -On 09/23/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 09/26/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review of the facility's B hall nurse on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/04/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/14/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 09/24/24 at 7:00 A.M., and 7:00 P.M., did nat contain two licensed staff signatures; -On 09/25/24 at 7:00 A.M., and 7:00 P.M., did not FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 9 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F755 Continued From page 9 contain two licensed staff signatures; -On 09/26/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/27/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/30/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's B hall CMT on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/05/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 10:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 6:00 A.M., did not contain two licensed staff signatures. Review of the facility's C hall nurse on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/22/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 09/30/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's C hall CMT on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 10 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 10 sheet: -On 09/04/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/05/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/06/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/06/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/07/24 at 2:00 P_M., and 10:00 P.M., did nat contain two licensed staff signatures; -On 09/08/24 at 6:00 A.M., and 2:00 P.M., did nat contain two licensed staff signatures; -On 09/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/16/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 10:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/24/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/25/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/27/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. 4. Review of the facility's A hall nurse on-coming and off-going narcotic count sheets, dated 10/01/24 through 10/08/24, showed the narcotic count sheet: -On 10/05/24 at 7:00 A.M., and 7:00 P.M., did not FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 11 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F755 Continued From page 11 contain two licensed staff signatures; -On 10/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility A hall CMT on-coming and off-going narcotic count sheets, dated 10/01/24 through 10/08/24, showed on 10/08/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review of the facility C hall nurse on-coming and off-going narcotic count sheets dated 10/01/24 through 10/08/24, showed the narcotic count sheet: -On 10/04/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 10/05/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 10/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 10/08/24 at 7:00 P.M_, did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. 5. During an interview on 10/09/24 at 5:40 ALM, LPN J said two licensed staff are to count narcotics at the change of shift with the off-going and on-coming staff member to ensure there are no discrepancies. During an interview on 10/09/24 at 9:40 A.M_, Registered Nurse (RN) N said he/she is a charge nurse at the facility. RN N said two licensed staff are to count narcotics at the change of shift with the off-going and on-coming staff member to FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 12 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F755 Continued From page 12 ensure there are no discrepancies. During an interview on 10/09/24 at 9:45 A.M., LPN E said he/she is a charge nurse at the facility and works all the halls. LPN E said narcotics are to be counted by two licensed staff at the change of each shift. LPN E said the staff counting should be the off-going and on-coming staff members. LPN E said this is done to ensure the narcotic count is correct before accepting the keys to the cart. During an interview on 10/09/24 at 9:50 A.M., RN A said he/she is a charge nurse at the facility. RN A said staff are expected to count narcotics at the change of shift or anytime there is a change of staff on the medication cart. RN A said two licensed staff should count the narcotics on the medication cart and sign the narcotic count log verifying the count is correct. RN A said the two licensed staff counting need to be the off-going and on-coming staff member. During an interview on 10/09/24 at 10:00 A.M., the Minimum Data Set (MDS) Coordinator said two licensed staff should count narcotics at each change of shift fo ensure the count is correct and no discrepancies are found. The MDS Coordinator said the two staff counting should be the off-going and on-coming staff member accepting the keys to the medication cart. The MDS Coordinator said after the two licensed staff count, they are responsible to sign the narcotic count log, he/she said if something is not charted it was not done. During an interview on 10/09/24 at 10:20 A.M., the DON said he/she expects two licensed staff to count the narcotics on each medication cart at FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 13 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F755 Continued From page 13 the change of shift, or if the keys for the cart change staff members. The DON said it is the licensed staff members responsibility to count and sign the narcotic count log verifying the count. The DON said he/she is responsible to over see the floor staff and ensure staff are doing their jobs correctly. The DON said when two licensed staff count it should be the off-going and on-coming staff member counting. The DON said he/she has educated staff previously on counting each shift and ensuring the narcotic count log is signed at the time of the count. The DON said he/she can't verify a narcotic count had been completed on the dates the narcotic log is not signed by two licensed staff members. During an interview on 10/09/24 at 10:25 A.M., the administrator said he/she expects two licensed staff to count at the change of shift or change of cart assignment and sign the logs. The Administrator said it should be the off-going and on-coming licensed staff counting. The Administrator said staff are responsible to complete the narcotic counts. During an interview on 10/09/24 at 12:35 P_M., Certified Medication Technician (CMT) M said licensed staff are responsible to count the narcotics on a medication cart before staff change the keys from one staff member to another. CMT M said the cart should be counted by the off-going and on-coming staff member at the change of shift, or anytime the medication cart changes staff hands. CMT M said once staff count they are responsible to sign the narcotic count log to verify the count was completed. CMT M said if something is not documented there is no proof it is done. FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: 340811 PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 10/10/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 14 of 15 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: PRINTED: 10/22/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING Cc 10/10/2024 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} i F755 Continued From page 14 During an interview on 10/09/24 at 12:47 P_M., CMT L said licensed staff are responsible to count the narcotics on a medication cart before staff change the keys from one staff member to another. CMT L said the cart should be counted by the off-going and on-coming staff member and sign the narcotic count log to verify the count was completed. CMT L said if something is not documented there is no proof it is done. FORM CMS-2567(02-99} Previous Versions Obsolete Event iD:34Q811 Facility 1D: 31536 If continuation sheet Page 15 of 14 PRINTED: 10/22/2024 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 (e 31536 B. WING 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 (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) ARROWHEAD SENIOR LIVING COMMUNITY A4071 19 CSR 30-85.042(62) Controlled Substance | A4071 Reconcile/Record The facility must establish a system of records of | receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The system must enable the facility to determine that drug records are in order and that an account of all controlled drugs is | maintained and reconciled. IHI/Ill | This regulation is not met as evidenced by: Class Ill Refer to F755 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE h, TITLE hh PU c ng dv. RM se09 340811 iFcontinuation sheet 1 of 1 PLAN OF CORRECTION pense ans sae Arrowhead Senior Living Name: Street Address, : : 6100 Arrowhead Dr, Osage Beach, MO 65065 City, Zip: Date of Survey: October 10, 2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Il. The DON or designee will assess resident having the potential to be affected by this practice including: A) Narcotic counts will be completed and signed by both licensed staff members reconciling the count. Ill. The DON or designee will implement measures to ensure that the deficient practice does not recur including: A) Daily review of narcotic count reconciliation sheets. B) In-service to license staff. 11/13/24 F755 A 4071 IV. The DON or designee will monitor corrective actions to ensure the effectiveness of these actions including: A) QA study on proper narcotic reconciliation completion implemented in 30 days — then monitored monthly x 3. 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.

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG PRINTED: 10/12/2023 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/27/2023 09-26-2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (x5) COMPLETION DATE DEFICIENCY) Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(5)(ii)(iii) §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d) (3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. This REQUIREMENT is not met as evidenced by: Based on interview and record review, facility staff failed to follow their policy as directed to check the Certified Nurse Assistant (CNA) | Registry for all staff to ensure they did not have a | Federal Indicator (a marker given by the federal government to individuals who have committed LABORATORY:DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Any defici tatement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CM4111 Facility ID: 31536 If continuation sheet Page 1 of 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED Cc B. WING 09/26/2023 265876 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE ARROWHEAD SENIOR LIVING COMMUNITY (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} i F 607 Develop/Implement Abuse/Neglect Policies SS=E_ CFR(s): 483.12(b)(1)-(5)Gi)qdii) §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(6)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b}(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b}(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d) (3) of the Act. §483.12(b)(5)(ili) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1} and (2) of the Act. This REQUIREMENT is not met as evidenced by: Based on interview and record review, facility staff failed to follow their policy as directed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal indicator (a marker given by the federal government to individuals who have committed LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (x6) DATE 10/23/2023 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection fo the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2587{62-99} Previous Versions Obsolete Event iD: CM4H1 Facility 1D: 31536 lf continuation sheet Page 1 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED Cc B. WING 09/26/2023 265876 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE ARROWHEAD SENIOR LIVING COMMUNITY (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} i F 607 Continued From page 1 abuse and/or neglect) for two of six sampled employees (Licensed Practical Nurse (LPN) C and The Infection Preventionist) as directed in their policy. The facility census was 38. 1. Review of the facility's policy, titled "Abuse, Neglect, Exploitation”, undated, showed staff were directed to conduct employee reference checks and perform Certified Nursing Assistant CNA and Certified Medication Aide (CMA) registry, licensing board, and state approved background checks. The state nurse aide registry or state licensure body will be contacted before staff provides direct care, if there are prohibitive findings on the registry or the professional licensing body, employment will not proceed. 2. Review of LPN C's employee file showed: -Hire date of 01/06/23; -The file did not contain documentation of the Nurse Aide registry check. 3. Review of Infection Preventionist employee file showed: -Hire date of 12/28/22: -The file did not contain documentation of the Nurse Aide registry check. During an interview 09/26/23 at 12:37 P.M., the Director of Nursing (DON) said the business office manager (BOM) was responsible for all background checks. He/She said everyone that worked in nursing needed a nurse aide registry check. During an interview on 09/26/23 1:03 P.M., the BOM said he/she did the background screenings Event iD: CM4i11 FORM CMS-2567(02-99} Previous Versions Obsolete Facility 1D: 31536 if continuation sheet Page 2 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED Cc B. WING 09/26/2023 265876 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE ARROWHEAD SENIOR LIVING COMMUNITY (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} i F 607 Continued From page 2 for new hires. He/She ran the nurse aide registry check for CNAs and the Nursys for the Nurses. He/She was not aware that all employees needed the nurse aide registry check and had not run them for nurses since he/she started helping as the BOM because he/she is the full time dietary manager. During an interview on 09/26/23 at 1:50 P.M., the Administrator said the Nurse aide registry check should be run on every employee. It was the responsibility of the BOM to run all background checks and he/he did not know why it would not be done. Bedrails CFR(s)}: 483.25(n)}(1)-(4) §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed’s dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers’ recommendations and specifications for installing FORM CMS-2567(02-99} Previous Versions Obsolete Event iD: CM4i11 Facility ID: 31536 if continuation sheet Page 3 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 700 Continued From page 3 and maintaining bed rails. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments and obtain physician orders for bed rails for four residents (Resident #5, #28, #30 and #32). The facility census was 38. 1. Review of the facility's Bed Mobility Device, revised November 28, 2017, directed staff as follows: -All residents will be evaluated for the need for bed mobility devices; -The bed mobility device assessment will be completed on admission, readmission, quarterly and with a significant change in status. The assessment form will be completed prior to utilization of any such device, including: short side rails containing bed control, bed cane, transfer pole, trapeze, other adaptive equipment utilized to aid in repositioning. 2. Review of Resident #5's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as: -Cognitively impaired; -Diagnoses of Dementia (loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), Other fracture (a break in the bone), Malnutrition (lack FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 4 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 700 Continued From page 4 of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat); -Required limited one person assistance for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed an entraoment assessment or obtained a physician's order for the use of the bed rails. Observation on 09/24/23 at 11:19 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 09/25/23 at 9:45 A.M., showed the resident in bed with the left bed rail in the upright position. 3. Review of Resident #28's quarterly MDS, dated 09/07/23, showed staff assessed the resident as follows: -Cagnitively intact; -Required limited one person physical assistance with bed mobility, transfer, toileting, and bathing; -Diagnosis of hemiparesis (weakness or the inability to move on one side of the body), hip fracture. Review of the resident's Physician Order Sheet (POS), dated 09/2023, showed the record did not contain an order for the bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 5 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 700 Continued From page 5 Observation on 09/25/23 at 1:30 P.M., showed the right assist bar rail in the upright position. Observation on 09/26/23 at 10:30 A.M., showed the right assist bar rail in the upright position. 4. Review of Resident #30's Admission MDS, dated 8/08/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive two plus person assistance with bed mobility, transfer, dressing, and toileting; -Diagnosis of dementia. Review of the resident's POS, dated 09/25/23, showed the record did not contain an order for bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/24/23 at 12:44 P.M., showed the resident in bed with bilateral side rails in the upright position. Observation on 09/25/23 at 10:48 A.M., showed the resident in bed with bilateral side rails in the upright position. 5. Review of Resident #32's Admission MDS, dated 08/16/23, showed staff assessed the resident as follows: -Severe Cognitive impairment; -Required extensive two plus person assistance with bed mobility, transfer, dressing, and toileting; FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 6 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 700 Continued From page 6 -Diagnosis of dementia and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the resident's POS, dated 09/25/23, showed the record did not contain an order for bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/24/23 at 12:10 P.M., showed the resident in bed with the right assist bar rail in the upright position. Observation 09/25/23 at 10:02 A.M., showed the resident in bed with the right assist bar rail in the upright position. 6. During an interview on 09/25/23 at 12:41 P.M., the administrator said he/she had paperwork to see what the measurements shauid be in each zone but did not have entrapment assessments for each individual resident quarterly because the beds had never changed and they are not full bed rails, they are cane rails. He/She said they were "checking" the beds weekly but no measurements were taken. During an interview on 09/26/23 at 12:01 P_M., Licensed Practical Nurse (LPN) A said the nurse was required fo do initial assessment and consent upon admission but they did not do anything with measurements. He/She said there were no other interventions tried before the resident had a bed cane because every bed has FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 7 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 700 Continued From page 7 “at least one bed cane. They could take them off but normally don’t have too." He/She said therapy might be in charge of taking measurements for the residents because their department determines if a second bed cane is needed. During an interview on 09/26/23 at 12:06 P_M., the maintenance director said their system was dictated by their corporate office and provided him/her with tasks: weekly, monthly, semi-annual and annual. At one time they had bed inspection and device rail inspection generate every week but it just said “pass or fail" for all. He/She would check the beds, the entire operation: wheel, head and footboard and mattresses but no actual measurements were taken. He/She said in July corporate changed the weekly task to annually, he/she said he/she knew the regulation was quarterly. He/She said there was no process to alert him/her if the residents had a significant change. Only if there was a mattress change. During an interview on 09/26/23 at 12:13 P.M., LPN B said that the facility did not use bed rails, they used bed canes. He/She said the nurses were in charge of getting consents signed and assessments but the assessments did not have measurements. He/She said he/she did not know who completed measurements for the bed canes. During an interview on 09/26/23 at 12:37 P_M., the Director of nursing (DON) said bedrails assessments are completed upon admission and quarterly. The MDS coordinator was in charge of bedrail assessments. He/She did not know why they were not done. During an interview on 09/26/23 at 1:00 P.M., the MDS coordinator said he/she was in charge of FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page § of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 700 Continued From page 8 quarterly bed rail assessments but did not provide measurements. Entering into Binding Arbitration Agreements CFR(s): 483.70(n}\(2){i)(i)(3)-(5) F 847 SS=C §483.70(n) Binding Arbitration Agreements if a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section. §483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission fo, or as a requirement to continue to receive care at, the facility. §483.70(n\(2) The facility must ensure that: (i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; (ii) The resident or his or her representative acknowledges that he or she understands the agreement; §483.70(n)\(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. §483.70(n) (4) The agreement must explicitly state that neither the resident nor his or her FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 if continuation sheet Page 9 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 847 Continued From page 9 representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. §483.70(n) (5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the arbitration agreement was explained to two residents (Resident #9, and #29) and/or to their representative in a form and manner that he/she understood. The census was 38. 1. Review of the facility's policies showed staff did not provide a policy for Arbitration Agreements. Review of the facility's Admission Agreement showed page 8 the Arbitration Agreement as a single paragraph that did not contain a place to decline, or agree to the arbitration. Further review showed there was one signature page at the end of the agreement used to sign for everything listed in the admission agreement. 2. Review of the Resident's #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 08/24/23 showed the resident was cognitively intact. FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 10 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 847 Continued From page 10 Review of the resident's Admission Agreement, dated 03/23/20 showed the signature page was signed. During an interview on 09/26/23 at 1:10 P.M., the resident said he/she did not remember signing the arbitration agreement. He/She said they don't know if they would have signed it, because if something serious or important happened "1 would want my own lawyer.” 3. Review of Resident #29’s admission MDS, dated 06/07/23, showed staff assessed the resident as cognitively intact. Review of the resident's Admission Agreement, dated 06/06/23 showed the signature page was signed. During an interview on 09/26/23 at 01:21 P.M, the resident said he/she has issues with his/her vision and he/she knows he/she would not have been able to read the arbitration agreement himself/herself. He/She said he/she does not remember if he/she was read that portion or if it was explained. He/She said if he/she had to sign it today he/she would not sign it. 4. During an interview on 09/26/23 at 12:40 A.M., the Social Services Director (SSD) said she was responsible for going over the arbitration agreement with the resident and/or their representative upon admission. SSD said they have never had a resident decline signing the Admission Agreement. The SSD said there is not a separate signature page to accept or decline the arbitration agreement. FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 11 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 847 Continued From page 11 During an interview on 09/26/23 at 1:50 P.M., the Administrator said there was only the one signature page at the end of the Admission Agreement. He said there was not a separate form used to agree or decline the arbitration agreement. The administrator said if the resident or their representative would not agree they would need to sign something to say they don't. Hospice Services CFR(s)}: 483.70(0}(1}-(4) §483.70(0) Hospice services. §483.70(0)(1) Along-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (it) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist fhe resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(0)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (0)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 12 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 849 Continued From page 12 at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) Acommunication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need fo alter the plan of care. (3) Aneed to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of haspice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) Adelineation of the hospice’s responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 13 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 849 Continued From page 13 supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (1) Aprovision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. {K) Adelineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(0)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability fo assess the resident or have access to someone that has the skills and capabilities to assess the FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 14 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 849 Continued From page 14 resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific fo each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. {E) Instructions on how to access the hospice's 24-hour on-call system. {F) Hospice medication information specific to each patient. {G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 15 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 849 Continued From page 15 furnishing care to LTC residents. §483.70(0)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care anda description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care and communication between the facility and their two hospice providers for two out of three residents (Resident #27, and #31) receiving Hospice services. The facility census was 38. 1. Review of the facility's Hospice Services Agreement, undated, showed: -Plan of Care. Hospice will collaborate with Facility on a coordinated Plan of Care developed jointly between Hospice and Facility. -Resident Chart. Facility and Hospice will prepare and maintain complete medical records for Hospice Patients receiving Facility services in accordance with this Agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Copies of all documents of services provided by Hospice will be filed and maintained in the Facility chart. 2. Review of Resident's #27's Quarterly Minimum Data Set (MDS), a federally mandated FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 16 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 849 Continued From page 16 assessment instrument completed by facility staff, dated 08/10/23, showed: -The resident was on Hospice; -The resident had a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 09/27/23, showed the resident was on Hospice services. Review of the resident's Progress Notes, dated 09/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 02/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. Review of the facility's Hospice binder, undated, showed the record did not contain documentation of communication or a coordinated plan of care between the facility and the hospice provider. 3. Review of Resident #31's Admission MDS, dated 08/15/23, showed staff assessed the resident as: -The resident was on Hospice; -The resident had a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on haspice, provided by the facility on 09/27/23, showed the resident was on hospice services. Review of the resident's Progress Notes, dated FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 17 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 849 Continued From page 17 09/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 02/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. Review of the facility's Hospice binder, undated, showed the record did not contain documentation of communication or a coordinated plan of care between the facility and the hospice provider. 4. During an interview on 09/26/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said the communication with the hospice team is verbal, there is no binder for documentation but staff sometimes charted it in point click care (electronic health records system.) During an interview on 09/26/23 at 12:13 P.M., LPN B said there wais no documentation or binders for communication with hospice, or at least not that he/she fills out, "maybe | should be." During an interview on 09/26/23 at 12:37 P.M_., the Director of Nursing (DON) said hospice care workers and the facility staff have verbal checks and updates. He/She said the hospice communication binder for documentation was put in place before him/her and it should be completed by the nurse staff but they may need more education on it. He/She said it was imperative to document communication with the hospice team to collaborate and agree on plans and provide the resident the best care. During an interview on 09/25/23 at 1:50 P.M., the FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 18 of 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (Xi) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 265876 NAME OF PROVIDER OR SUPPLIER ARROWHEAD SENIOR LIVING COMMUNITY SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG i F 849 Continued From page 18 Administrator said the facility's care plan should mirror Hospice's care plan, a plan of care specifically to that resident. The administrator said communication between the facility staff and the hospice clinic was expected to be documented. FORM CMS-2567(62-99} Previous Versions Obsolete Event iD: CM4i11 PRINTED: 02/13/2024 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED Cc 09/26/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} Facility 1D: 31536 If continuation sheet Page 19 of 19 PRINTED: 10/24/2023 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 e: 31536 B. WING 09/2742023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 09-26-2023 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 (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) ARROWHEAD SENIOR LIVING COMMUNITY | 19 CSR 30-85.042(65) Protective Oversight, | Voluntary Leave Each resident shall receive twenty-four- (24-) hour protective oversight and supervision. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II | This regulation is not met as evidenced by: Class II Refer to F700 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE Adan Sdrtor- CM4111 (X6) DATE If continuation sheet 1 of 4 PRINTED: 02/13/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA {X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 31536 B.WING 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 6100 ARROWHEAD DRIVE OSAGE BEACH, MO 65065 (X4) 1D 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} ARROWHEAD SENIOR LIVING COMMUNITY A4074 19 CSR 30-85.042(65) Protective Oversight, 11/6/23 Voluntary Leave Each resident shall receive twenty-four- (24-) hour protective oversight and supervision. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II This regulation is not met as evidenced by: Class Il Refer to F700 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) DATE 10/23/23 STATE FORM sao CNM4i14 If continuation sheet 1 of 4 PLAN OF CORRECTION Provider/Supplier Weremae Arrowhead Senior Living Street Address, City, Zip: 6100 Arrowhead Dr, Osage Beach, MO 65065 Date of Survey: September 27, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER = + ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION | oe CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) fe na PATE | #5 affected by this Resident #5: A) Bed cane was removed. Resident: #28, #30 and #32 have discharged practice including: ‘|. The OON or designee will implement corrective actions for resident ' F700 A4074 Il. The DON or designee will as affected by this practice includi Sess resident having the potential to be ng: ‘ A) All patients with a bed cane will have completed and PO obtained. It. The DON or designee will implement measures to ensure that the deficient practice does not recur including: A) In-service to MDS coordinator and maintenance director regarding entrapment completion and bed cane policy/procedures, B) An entrapment assessment will be completed and a PO obtained prior to the installation of a bed cane. an entrapment assessment 1 IV. The DON or desi gnee will monitor corrective actions to ensure the | effectiveness of these actions including: A) QA study on completion of entra Prior to installation of bed canes im pment assessment and PO obtained plemented in 30 days — then monitored monthly x 3. 11/6/23 The Administrator signing and dating the first the plan of correction being submitted on this form. page of the CMS-2567/State Form is indicating their approval of . Provider/Supplier ' Name: - Street Address, i City, Zip: Arrowhead Senior Living 6100 Arrowhead Dr, Osage Beach, MO 65065 a’ +... — a a : Date of Survey: September 27, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER , IDPREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE ! COMPLETION | | CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE i. The Administrator or designee will implement corrective actions for Staff member LPN C & Staff Preventionist affected by this practice including: LPN C & Staff Preventionist: A) CNA Registry was run on both. Il. The Administrator or designee will assess all staff having the potential to be affected by this practice including: A) All staff were audited for the CNA Registry. None were missing. | F607 - No state tag Il. The Administrator or designee will implement measures to ensure 11/6/23 : given w/ SOD | that the deficient practice does not recur including: A) In-service to BOM regarding CNA registry. IV. The Administrator or designee will monitor corrective actions to ensure the effectiveness of these actions including: | A) All new hires will be audited for CNA registry before they're hired. | B) QA study on CNA registration completion implemented in 30 days — | then monitored monthly x 3. 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. PLAN OF CORRECTION Provider/Supplier Arrowhead Senior Living Name: } Street Address, ts By 6100 Arrowhead Dr, Osage Beach, MO 65065 City, Zip: { Date of Survey: September 27, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD COMPLETION BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE hk. —+ yaA Signature line to decline the arbitration agreement was added to | the arbitration section of the contract. F847 2. The arbitration agreement will be explained in detail, once again, to "NG state resident #9 & #29. iven wii -- 3. Education will be provided to social worker regarding new 11/6/23 arbitration section in the contract. 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, PLAN OF CORRECTION Provider/Supplier Arrowhead Senior Living Name: Street Address, , . 6100 Arrowhead Dr, Osage Beach, MO 65065 City, Zip: Date of Survey: September 27, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE I. The DON or designee will implement corrective actions for resident #27 & #31 affected by this practice including: Resident #27 & #31: A) Hospice visits will be documented. B) A coordinated plan of care will be created and documented between the facility and hospice. il. The DON or designee will assess resident having the potential to be affected by this practice including: A) All patients on hospice will be reviewed to ensure they have a F849 coordinated plan of care between the facility and the hospice provider. ee beer ooo lll. The DON or designee will implement measures to ensure that the UGS deficient practice does not recur including: A) In-service to MDS coordinator and licensed nurses on the hospice policy/procedure focusing on documentation of the coordination of care. IV. The DON or designee will monitor corrective actions to ensure the effectiveness of these actions including: A) Monthly review of all hospice patients during our Residents at Risk meeting. 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.