PARKSIDE ASSISTED LIVING.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31191 NAME OF PROVIDER OR SUPPLIER PARKSIDE-ASSISTED LIVING BY AMERICARE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A4511| 19 CSR 30-86.045(3)(A)(9) Resident Evacuation - Plan - Readily Available : General Requirements. | (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely _ evacuating the facility, the facility shall: - 9. Acopy of the resident ' s evacuation plan shall be readily available to all staff; II | This regulation is not met as evidenced by: Class II Based on observation, interview, and record review, the facility staff failed to maintain a copy of the Individual evacuation plan ((IEP) a plan based on a resident's assessed abilities and needs which includes the resident's risk of ‘ resistance, need for additional staff support, consciousness, response to instructions, and response to alarms and fire drills to communicate to staff the actions required to evacuate the resident in an emergency situation) readily available to all staff for residents who required more than minimal assistance to evacuate the facility for one resident (Residents #3) of three residents sampled. The facility census was 22. ' The facility staff did not provide a policy for developing IEP's. 1. Review of Resident #3's medical record showed the resident admitted to the facility on 07/29/2024. Review showed the resident's primary diagnosis as deblity. | Review of the Resident Care Survey showed staff _ documented the resident required more than Missouri Department of Health and Senior Services LABORATO RY DIRECTOR'S OR PROVIDER/SUP. STATE FORM | LIER REPRESENTATIVE'S SIGNATURE 6899 B. WING | A451 {X2) MULTIPLE CONSTRUCTION A, BUILDING: STREET ADDRESS, CITY, STATE, ZIP CODE 2100 PARKSIDE AVE ROLLA, MO 65401 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DATE PRINTED: 02/20/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/04/2025 COMPLETE DEFICIENCY) TITLE (X6}) DATE If continuation sheet 1 of 8 PRINTED: 02/20/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31191 B. WING 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 PARKSIDE AVE ROLLA, MO 65401 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) PARKSIDE-ASSISTED LIVING BY AMERICARE Continued From page 1 minimal assistance in order to safety evacuate the facility. Review of the resident's monthly summary, dated 11/26/2024 and 12/26/2024, showed staff documented the resident's Individual Evacuation Plan (IEP) in place. Review of the facility's IEP's binder did not contain a copy of the resident's IEP. During an interview on 2/4/2025 at 2:00 P.M., the DON said he/she is responsible to ensure the resident's IEP's are in the binder. The DON said he/she did not have a specific time frame he/she monitors the binders. The DON said the resident's IEP should be in the binder and is not sure why they weren't completed. 19 CSR 30-86.047(28)(D) Complete a Premove-in Screening The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (D) Completes a premove-in screening conducted as required by section 198.073.4 (4), RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)). II This regulation is not met as evidenced by: Class II Based on interview and record review, facility staff failed to complete the required premove-in screening to determine if residents were eligible to admit in the assisted living facility for two Missouri Department of Health and Senior Services STATE FORM 6899 G7GU11 If continuation sheet 2 of 8 PRINTED: 02/20/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31191 B. WING 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 PARKSIDE AVE ROLLA, MO 65401 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) PARKSIDE-ASSISTED LIVING BY AMERICARE Continued From page 2 (Residents #1 and #2) out of three sampled residents. The facility census was 22. The facility staff did not provide a policy for pre-move-in screening. 1. Review of Resident #1's medical record showed an admission date of 10/21/24. Review showed the medical record did not contain documentation of a premove-in screening. 2. Review of Resident #2's medical record showed an admission date of 01/30/2025. Review showed the medical record did not contain documentation of a premove-in screening. During an interview on 2/4/2025 at 2:00 P.M., the director of nursing (DON) said he/she was responsible to ensure the premove-in screens were completed for new admit residents. The DON said he/she is unsure why these are not located in the resident's chart. The DON said the prescreens are completed on paper and then uploaded in the computer system. The DON said he/she uploads the documents in the resident's file. 19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: Missouri Department of Health and Senior Services STATE FORM 6899 G7GU11 If continuation sheet 3 of 8 PRINTED: 02/20/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31191 B. WING 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 PARKSIDE AVE ROLLA, MO 65401 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) PARKSIDE-ASSISTED LIVING BY AMERICARE Continued From page 3 1. Time frame requirements for assessment shall be: C. Whenever a significant change has occurred in the resident's condition, which may require a change in services. II This regulation is not met as evidenced by: Class II Based on interview and record review, facility staff failed to update the community based assessment ((CBA) a required assessment tool completed by certified facility staff) for one (Resident #1) of three sampled residents, when the resident had a significant change in condition. The facility census was 22. 1. Review of the policy for Community Based Assesments change in condition, dated 06/10/2019 showed the facility director of nursing (DON) is responsible to complete an evaulation of a resident's change in condition and to update the resident's CBA. 2. Review of Resident #1's medical record showed the resident admitted to the facility on 10/21/2024. Review of the resident's monthly summary, dated 12/21/2024 and 01/21/2025, showed staff documented the resident had a small open area to the upper left gluteal area near the coccyx (tailbone). Review of the resident's CBA, dated 10/21/24, showed the CBA did not contain documentation of the resident's wound and treatments. During an interview on 2/4/2024 at 2:00 P.M., the director of nursing (DON) said he/she is Missouri Department of Health and Senior Services STATE FORM 6899 G7GU11 If continuation sheet 4 of 8 PRINTED: 02/20/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31191 B. WING 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 PARKSIDE AVE ROLLA, MO 65401 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) PARKSIDE-ASSISTED LIVING BY AMERICARE Continued From page 4 responsible to ensure the CBA's are completed with a change in a resident's condition. The DON said he/she did not update the resident's CBA's as it was an oversight on his/her part. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident "s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility staff failed to develop individualized service plans ((ISP) a document which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) to include resident needs and services to be provided by staff for two (Residents #1 and #2) out of three sampled residents. The census was 22. 1. The facility staff did not provide a policy for ISP's. 2. Review of Resident #1's medical record Missouri Department of Health and Senior Services STATE FORM 6899 G7GU11 If continuation sheet 5 of 8 PRINTED: 02/20/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31191 B. WING 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 PARKSIDE AVE ROLLA, MO 65401 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) PARKSIDE-ASSISTED LIVING BY AMERICARE Continued From page 5 showed the resident admitted on 10/21/2024. Review of the facility ISP binder did not contain an ISP for the resident to address the needs, prefrences, services provided or goals. 3. Review of Resident #2's medical record showed the resident admitted on 01/20/2025. Review of the facility ISP did not contain an ISP for the resident to address the needs, prefrences, services provided or goals. 4. During an interview on 02/04/2025 at 2:00 P.M., the DON said he/she was not aware the ISP had not been completed and in the binder for Resident's #1 and Resident #2. He/She said there should be an ISP in the binder. The DON said he/she is responsible to complete the ISP's and is unsure why Resident's #1 and #2 ISP's are not in the binder. The DON said he/she has not completed a fully audit of the binder. 19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident "s condition which may require a change in services; Il This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services STATE FORM 6899 G7GU11 If continuation sheet 6 of 8 PRINTED: 02/20/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31191 B. WING 02/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2100 PARKSIDE AVE ROLLA, MO 65401 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) PARKSIDE-ASSISTED LIVING BY AMERICARE Continued From page 6 Based on interview and record review, facility staff failed to update a change in condition of the resident's Individual Service Plan ((ISP) a required assessment tool identifying the individual needs of the residents and completed by qualified facility staff) who had significant changes in their condition which required additional services and treatment. (Resident #1) out of three sampled residents when the residents had significant changes in their condition. The facility census was 22. 1. Review of the facility policy for Individual Service Plan change in condition, dated 06/10/2019 showed the facility director of nursing (DON) is responsible to complete an evaulation of a resident's change in condition and to update the resident's ISP. 2. Review of Resident #1's medical record showed the resident admitted to the facility on 10/21/2024. Review of the resident's monthly summary, dated 12/21/2024 and 01/25/2025, showed staff documented the resident has a small open area to uppler left gluteal near the resident's coccyx (tailbone). Review of the facility's ISP binder showed the binder did not contain an updated ISP to include the resident's open wound and treatment services. During an interview on 2/4/2024 at 2:00 P.M., the director of nursing (DON) said he/she is responsible to update the ISP's for each resident with a change in condition. The DON said he/she did not update the resident's ISP. The DON said Missouri Department of Health and Senior Services STATE FORM 6899 G7GU11 If continuation sheet 7 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31191 B. WING NAME OF PROVIDER OR SUPPLIER 2100 PARKSIDE AVE PARKSIDE-ASSISTED LIVING BY AMERICARE ROLLA, MO 65401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 7 he/she can not recall a specific time when he/she monitors the resident's ISP's. Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: CROSS-REFERENCED TO THE APPROPRIATE G7GU11 PRINTED: 02/20/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 8 of 8 PLAN OF CORRECTION Provider/Supplier Name: Parkside Assisted Living Street Address, . . 2100 Parkside Ave, Rolla, MO 65401 City, Zip: Date of Survey: 02/04/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The filing of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the Summary Statement of Deficiencies dated 02/20/2025 by the Missouri Department of Health and Senior Services. This plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. In response to A4511 19CSR 30-86.045(3)(A)(9) Resident Evacuation Plan — Readily Available Immediate Action: The Regional Operations Director will Inservice the Administrator and Director of Nursing on Policy & Procedure for individual Evacuation Plans (IEP); which includes developing an IEP for any resident whom requires more than minimal assistance due to having a physical, cognitive or other impairment the prevents them from safely evacuating the facility and assuring the JEP is available to all staff. Inservicing to be completed on or before 3/7/2025. Administered and or Director of Nursing will inservice all staff on IEP policy and procedure and will define the location in which IEP information for each resident is located for easy access in the even of emergency or other need to evacuate. Inservicing to be completed on or before 3/3/14/2025. A4511 03/14/2025 Administrator and/or designee will review all resident charts for individual Evacuation Plans, and ensure that all residents requiring an IEP are completed and located in a central location for staff review to be completed on or before 3/7/2025. Ongoing Compliance: Director of Nursing and/or designee in absence of will ensure ongoing IEP’s, and subsequent future IEP’s, are completed in accordance with both state regulation and company policy, and are located in the central location with all other IEP’s. Director of A4747 AA751 Nursing and/or designee in absence of will complete Monthly audits of resident charts to assure required IEP’s are present and located in the central location for all staff to access to assure ongoing compliance. Compliance Date: 3/14/2025 | | In response to A4747 19 CSR 30-86.047(28)(D) Complete a Premove- in Screening H Immediate Action: The Regional Operations Director will Inservice the Administrator and Director of Nursing on Policy & Procedure for Pre-Move In Screening/Assessments which includes completing a Pre-move -in Screening on any potential admission prior to move in to determine that the individual is appropriate for Assisted Living level of care. Inservicing to be completed on or before 3/7/2025. Administrator and or Director of Nursing to review current resident charts for to assure all residents including resident #1 & #2 as well as all other residents have a completed pre- admission pre-screening forms completed. Any found missing will be entered into resident chart no later than 03/14/2025. Ongoing Compliance: Administrator and/or designee in absence of will assure on going compliance by utilizing the Admission Checklist on each new admission, which includes conducting the Pre-move-in Screening, and auditing new admission chart every 3 months to assure all new admissions have appropriate pre-move in screenings. Compliance Date: 03/14/2025 In response to A4751 19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change Immediate Action: Resident # 1 Community Based Assessment has been completed to reflect the change in condition of a small open area to the upper left gluteal area near the coccyx and ISP updated to reflect the open area an appropriate intervention to manage the open area as well as to decrease the risk of future skin break down. All residents Community Based Assessments have been reviewed to assure accuracy and appropriate interventions in their Individual Service Plans. The Director of Nursing will be inserviced by Regional Nurse Consultant on identifying change in condition and 03/14/2025 3/14/2025 what constitutes a change in condition requiring a Community Based Assessment to be completed updating the Individual Service Plan. Inservicing to be completed on or before 3/14/2025. Ongoing Compliance: Director of Nurses or designee for in absence of will assure ongoing compliance through monthly reviews of each resident chart to assure all Community Based Assessments and Individual Service Plan reflect the needs and appropriate level of care for each resident, Compliance Date: 3/14/2024 In response to A4754 19CSR 30-86.047(28)(G) Individual Service Plan- Develop The Regional Operations Director will Inservice the Administrator and Director of Nursing on Policy & Procedure on developing a Individualized Service Plan for each resident that outlines the resident’s needs, preference, services to be provided and goals expecied by the resident or the residents legal representative in partnership with the facility. Inservicing to be completed on or before 3/7/2025 Resident #1 & #2 ISP’s will be developed which will outline the residents needs, preference, services to be provided and goals expected by the resident or the resident's legal representative in partnership with the facility on or before 3/14/2025. All other current resident will have their charts reviewed to assure that each resident has an ISP that meets the needs, preference, services to be provided and goals expected by the resident or the resident’s legal representative in partnership with the facility, on or before 3/14/2025. A4754 03/14/2025 Ongoing Administrator and/or designee in absence of will complete monthly audit of Individual Service Pian (ISP) binder for any missing ISP’s for current residents. Administrator and/or designee will audit ISP binder monthly to ensure ISP binder is up to date. Compliance Date: 3/14/2025 In response to A4755 19 CSR 30-86.047(28)(H) Individual Service Plan — Review Requirements Immediate Action: A4755 3/14/2025 Resident #1 ISP has been updated to reflect the open area and the appropriate interventions put in place to manage the open area, promote healing as well as decrease the risk of further breakdown of skin. The Director of Nursing will be inserviced by Regional Nurse Consultant on policy and procedure for reviewing residents Individual Service Plans which includes reviewing them with each Monthly Review, change of condition and semiannual Community Based Assessment. Any identified change in resident’s condition, needs, preferences, services needing provided and or change in goals should be updated immediately to reflect the appropriate interventions or goals at that time. Inservicing to be completed on or before 3/14/2025. Ongoing Compliance: The Director of Nursing or designee in absence of will assure ongoing compliance through monthly review of all residents Individual Service Plans at the time of the residents Monthly Summary Review. Any identified change in condition or need of change in needs, preferences, interventions or goals will be addressed at that time and will involve the resident and or the residents legal representative in partnership with the facility and updated on the residents ISP. Compliance Date: 3/14/2025 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.