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.