NORTHPARK VILLAGE ASSISTED LIVING.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER NORTHPARK VILLAGE-ASSISTED LIVING BY é (X4) ID PREFIX TAG AATIOT (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 20003C B. WING {X2) MULTIPLE CONSTRUCTION A. BUILDING: 4449 NORTH HIGHWAY NN SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ‘s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Wl This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to ensure a safe and effective medication system was in place when Level One Medication Aide (LIMA) A passed medications to residents with an expired Level One Medication Aide (LIMA) certification. The facility census was 24. Review of the facility policy titled Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE ~ Us _ ‘Ay 4-5-5 STATE FORM OZARK, MO 65721 A4797 6899 6WF111 CROSS-REFERENCED TO THE APPROPRIATE PRINTED: 05/01/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/23/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE DEFICIENCY) If continuation sheet 1 of 3 PRINTED: 05/01/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20003C I 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4449 NORTH HIGHWAY NN OZARK, MO 65721 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) NORTHPARK VILLAGE-ASSISTED LIVING BY / A4797| Continued From page 1 "Licensure/Certification/Registration” undated, showed the following: -lf an employee is hired in a position or job classification that requires licensure, certification, or registration, they must present original documentation showing current licensure or eligibility at the time of hire; -An employee must provide copies of updated or renewed license upon receipt of issuing agency; -A copy of this documentation will be maintained in the personnel file; -An employee must notify their supervisor immediately of any change in their licensure, certification, or registration status; -Compliance with this policy is a necessary condition for continued employment. Review of 19 CSR 30-84.030 Level | Medication Aide Training Program showed the following: -LIMAs shall participate in a minimum of four hours of medication administration training every two years in order to administer medications in an Residential Care Facility (RCF) or an Assisted Living Facility (ALF); -The training shall be completed by the biennial anniversary date of the original issue of the LIMA certificate; -LIMAs who fail to submit to the department the documentation required by training by the biennial anniversary date of issue of their original LIMA certification will be removed from the LIMA active registry and will not be eligible to be employed as a LIMA in an RCF or ALF. 1. Review of LIMAA's personnel file showed the following: -Hire date of 10/21/24; -LIMA Certification with Biennial Training, issued by State of Missouri Department of Health and Senior edad ici 04/12/23; STATE FORM e800 6WF111 If continuation sheet 2 of 3 PRINTED: 05/01/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20003C I 04/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4449 NORTH HIGHWAY NN OZARK, MO 65721 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) NORTHPARK VILLAGE-ASSISTED LIVING BY / A4797| Continued From page 2 -The certification/training noted a minimum of four hours must be completed by the anniversary date of the initial certification. LIMA's who do not participate in at least four hours of training every two years will not be allowed to administer medication in accordance with 19 CSR 84.030. -LIMA A's personnel record did not contain verification of the required training completed or a copy of a renewal of his/her LIMA license. During an interview on 04/25/25, at 2:56 P.M., LIMAA said the following; -He/She worked the night shift, 6:00 P.M. to 6:00 A.M.; -He/She did not know his/her LIMA certification expired on 04/12/25; -He/She did pass medications on 04/15/25, 04/16/25, 04/19/25, and 04/22/25 during his/her shift. During an interview on 04/23/25, at 1:00 P.M., the Director of Nursing (DON) said the following: -He/She did not know that LIMAA's certification had expired; -He/She was responsible for keeping track of LIMA certifications; -This was an oversight on his/her part; -LIMAA administered medications during his/her shift on 04/15/25, 04/16/25, 04/19/25, and 04/22/25. STATE FORM e800 6WF111 if continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: Northpark Village Assisted Living Street Address, . . 4449 N state HWY NN—Ozark, MO. 65721 City, Zip: Date of Survey: 4/23/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D0913056 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE DON passed meds/ and other staff was scheduled until Staff member completed LIMA cert on 4/30/25. This information was AATST emailed to and will be attached to this email. DON wil 4/30/20 keep updated records in office to ensure all staff are up to date. Michele Hare 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.