CENTURY PINES ASSISTED LIVING.

SEP-21-2823 14:27 From:Front Office Fax 4173814461 (41) PROVIDER/SUPPUER/CLIA AND PLAN OF CORRECTION IDENTIFIGATION NUMBER: 01200 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING To: 41 78956298 Page: 3°15 PRINTED: 09/20/2023 FORM APPROVED (X3) DATE SURVEY COMP! FTED Cc 08/16/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 709 EAST MCCRACKEN ROAD CENTURY PINES ASSISTED LIVING SUMMARY STATEMENT OF DLT ICIENCIES {EACH DEFICIENCY MUST HE PREGEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A4777| 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. HII This regulation is not met as evidenced by: Class I! Based on interview and record review, the facility staff failed to provide proper and timely care when staff waited approximately 12 hours to assess one resident (Resident #1) after ha/she suffered a fall with a facial laceration that required stitches. The facility census was 3. Review of the facility policy titled "Falls", dated December 2019, showed the following: -For an unwitnessed fall and/or head strike, take vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) at the time of ! the incident, then every four hours for 12 hours, then evary shift for 72 hours; -Fill out an incident report; -Notify the Director of Nursing (DON), family, and provider; -Entér 4 nurse's note with details of what happened, injuries, who was notified: -Make a follow up nurse note every shift for 72 hours with vital signs, concems, or complaint of pain: -Keep resident quiet until you have checked for injuries; «lf a resident hit their head, it is strongly encouraged to send the resident to the hospital for a scan: -If the resident sustained an injury, they should be sent out to be evaluated and staff should Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE CY f of Ze State of Missouri OZARK, MO 65721 PROVIDCR'S PLAN OF CORRECTION (FAGH CORRECTIVE ACTION SHOULD BE CROSS-REF ERFNCED TO THE APPROPRIATE DEFICIENCY) (X8) DATE 4178956290 09/21/2023 03:06PM Pg 03/15 PRINTED: 09/20/2023 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 2 01200 B. WING 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 709 EAST MCCRACKEN ROAD OZARK, MO 65721 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CENTURY PINES ASSISTED LIVING Continued From page 1 document. 1. Review of Resident #1's medical record showed the following: -Admission date of 02/27/15; -Diagnosis of cardiovascular disease (CVD - heart conditions that include diseased vessels, structural problems, and blood clots); -The resident has a legal guardian. Review of the resident's nursing notes showed the following: -On 04/08/23, at 9:00 P.M., Level One Medication Aide (LIMA) A documented he/she received a phone call at 6:10 P.M., from the resident's family member stating the resident fell and no one did anything about it; -Staff called the on-call staff to see what he/she advised to do; -Staff went to check on the resident and the resident did have a fall; -The resident had a small laceration by his/her left eyebrow and complained of a headache; -The resident said his/her family member said to send the resident to the hospital; -Staff called nonemergency EMS (emergency medical service) at 6:25 P.M.; -The resident left via ambulance to the hospital; -At 9:09 P.M., staff called the DON to state resident was sent to the hospital and that he/she had a fall; -On 04/09/23, at 12:05 A.M., the resident arrived home via ambulance at 11:35 P.M. The resident was diagnosed with a facial laceration and head injury closed. The resident had three stitches put in along with some glue. The resident is tired and took medication for a headache. The resident's vital signs (reflect essential body functions, Missouri Department of Health and Senior Services STATE FORM 6899 TD6K11 If continuation sheet 2 of 6 PRINTED: 09/20/2023 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 2 01200 B. WING 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 709 EAST MCCRACKEN ROAD OZARK, MO 65721 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CENTURY PINES ASSISTED LIVING Continued From page 2 including your heartbeat, breathing rate, temperature, and blood pressure) were taken and were within normal limits. Will pass on to the next shift and continue to monitor. (Staff did not document assessment or notifications after the resident fall that morning.) During an interview on 08/16/23, at 1:40 P.M., LIMAA said the following: -On 04/08/23, at 6:00 A.M., he/she worked the 6:00 P.M. to 6:00 A.M. shift; -The previous shift (6:00 A.M. to 6:00 P.M.) said the resident slipped out of bed at an unknown time; -The resident got back into bed and went to sleep; -LIMAA got a phone call from the resident's family member about 6:30 P.M. about the resident's fall; -The family member said the resident called him/her about a fall; -The family member asked if anyone checked on the resident since a staff member told the resident to go back to bed after his/her fall; -LIMAA told the family member he/she just arrived to work and would check on the resident; -When LIMAA checked on the resident, he/she noted a cut with dried blood above the resident's eyebrow, -LIMAA called the Nurse Practitioner (NP) since the resident hit his/her head; -The NP said to send the resident to the hospital; -It's the facility policy if a resident hits their head, they need to be sent out: -After a fall, staff chart for 24 hours each shift; -With a head injury, they check vital signs and do vitals every shift for 24 hours; -As soon as a resident falls, staff should assess, do vital signs, and ensure the resident is not hurt Missouri Department of Health and Senior Services STATE FORM 6899 TD6K11 If continuation sheet 3 of 6 PRINTED: 09/20/2023 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 2 01200 B. WING 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 709 EAST MCCRACKEN ROAD OZARK, MO 65721 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CENTURY PINES ASSISTED LIVING Continued From page 3 before helping the resident up then do the notifications. During an interview on 08/16/23, at 2:50 P.M., LIMA B said the following: -After a resident falls, staff should do physical assessments, if ok to move then get the resident up and do vital signs; -Staff should notify the physician, the DON and family. Residents that fall with a head injury have to be sent out if ordered by the physician, the DON, and family. During interviews on 08/16/23, at 1:15 P.M. and 2:05 P.M., the Nurse Manager said the following: -Staff should call her or the DON with any resident injuries; -After a fall, staff should assess the resident and check vital signs; -If a resident hits their head, staff should notify family and the facility will send the resident out if requested by family or the resident; -The resident fell in the early morning hour about 6:00 A.M. during shift change; -LIMAA started work at 6:00 P.M. and immediately called the nurse manager, the family and the resident was sent to the emergency room; -Staff did not document anything about the fall until 6:00 P.M. that evening; -When the resident fell at 6:00 A.M., staff did not assess, do vital signs, or notifications until 6:00 P.M. when LIMAA came to work; -The family and physician should be notified immediately after a fall with a head injury. M0O00216703 Missouri Department of Health and Senior Services STATE FORM 6899 TD6K11 If continuation sheet 4 of 6 PRINTED: 09/20/2023 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 2 01200 B. WING 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 709 EAST MCCRACKEN ROAD OZARK, MO 65721 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CENTURY PINES ASSISTED LIVING Continued From page 4 19 CSR 30-86.047(37) Appropriate Action & Notification In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the person listed in the resident ' s record as the legally authorized representative, designee or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medical examiner immediately upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home. I/II This regulation is not met as evidenced by: Class II Based on interviews and record reviews, the facility staff failed to notify the authorized representative, designee, or family member of one resident (Resident #2) of the resident's fall. The facility census was 3. Review of the facility policy titled, "Falls," revised December 2019 showed the following: -Staff to immediately notify families for all major falls. The family member will have to give approval for resident to be sent out if needed; -Staff to notify family during waking hours if non-injury fall during the night. Staff to ask oncoming shift to call as soon as possible. 1. Review of Resident #2's medical record showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 TD6K11 If continuation sheet 5 of 6 PRINTED: 09/20/2023 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 2 01200 B. WING 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 709 EAST MCCRACKEN ROAD OZARK, MO 65721 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CENTURY PINES ASSISTED LIVING Continued From page 5 -Admission date of 04/08/21; -Diagnoses included congenital hydrocephalus (a buildup of cerebrospinal fluid in the brain at birth). Review of the resident's nurse's note dated 07/16/23, at 5:02 P.M., showed Level One Medication Aide (LIMA) C documented the resident fell walking back to his room. (Staff did not document notification of the resident's family, designee, or representative of the fall.) During an interview on 08/16/23, at 1:40 P.M., LIMA A said staff were to notify the resident's family, representative, or designee of a fall. During an interview on 08/16/23, at 2:50 P.M., LIMA C said staff were to notify the resident's family, representative, or designee of a fall. During an interview on 08/16/23, at 2:15 P.M., the Nurse Manager said staff should be notifying the family, representative, or designee as who is on-call when a fall occurs. Staff should be doing follow up calls if not reached on the first attempt. Staff should document the contact in the nurses’ notes. M0O00216703 Missouri Department of Health and Senior Services STATE FORM 6899 TD6K11 If continuation sheet 6 of 6 OCT-13-2823 12:49 From:Front Office Fax 4173814461 To: 41 78956298 Page:e2*2 PLAN OF CORRECTION Provider/Supplier Name: Century Pines Assisted Living Street Address, . . 709 E McCracken Rd, Ozark, MO 65721 City, Zip: Date of Survey: 08/16/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Staff was given in service to review the fall protocols by manager of nursing. Staff was advised that they are to do an assessment of the resident after any fall. Staff are to disregard statements from residents that they are fine and do not want vitals,assessments completed. Emphasis was placed on staff contacting family/guardian after a resident has experienced a fall. The facility form used in conjunction with resident falls was updated to include a check list for staff. This will ensure the necessary protocols of our fall policy are consistently followed. (See Attached) New employees during orientation will be given this information. The manager of Nursing will be responsible to review the incidents of falls to ensure the policy is being followed _| when falls are reported. Staff was reminded again that family/quardian must be contacted when a fall occurs with a resident. Guardian of resident 2 was contacted as guardian confirmed with administrator but LIMA failed to document in resident's chart. Reviewed with staff the importance of documentation. Reviewed 08/17/23 the updated form used in conjunction with resident falls to include a check list for staff. This will ensure the necessary COMPLETION DATE 08/17/23 protocols of our fall policy are consistently followed. The manager of Nursing will be responsible to check this when falls are reported. mea ledivard? Tof3)22 State of Missouri 4178956290 10/13/2023 12:59PM Pg 02/02