PARKSIDE MEMORY CARE.

PRINTED: 06/18/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1700 EAST 10TH STREET ROLLA, MO 65401 (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) ARBORS AT PARKSIDE-MEM CARE ASSTED L A4724! 19 CSR 30-86.047(19) TB Screen Residents & , Staff The facility shall screen residents and staff for | tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Class I] Based on interview and record review, facility : Staff failed to ensure the required two step ' tuberculosis ((TB) a communicable disease that affects the lungs characterized by fever, cough, i and difficulty in breathing) screening test was administered timely for three (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) of three sampled staff members and three (Resident #1, #2, and #3) of three sampled residents. The : facility census was 19. | 1. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux ' method purified protein derivative (PPD - a skin : test to determine if you have tuberculosis) two (2)-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; i -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux _ PPD test in the past and at least one (1) | subsequent annual test within the past two years. Missouri Department of Health and Senior Services (X6) DATE STATE FORM ~ : s899 YMOX11 If continuation sheet 1 of 17 NAME OF PROVIDER OR SUPPLIER Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 13589C {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 1700 EAST 10TH STREET ARBORS AT PARKSIDE-MEM CARE ASSTED L AAT24 ROLLA, MO 65401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Review of the facility's Policy for Employee TB Testing, undated, showed: -It is the Administrator's responsibility to assure the TB test is administered and results read prior to an employee beginning employment, and to assure annual testing is completed; -To assure that employees have been tested for Tuberculosis prior to working and do not have active disease along with annual surveillance in order to be in compliance with state regulations; -All prospective employees will have the first TB test administered prior to day 1 of employment. The TB test result may be read on the first day of employment; -lf an employee is unable to have the Tuberculin test administered because of a documented history/positive PPD test, a Chest x-ray is required, the report must state that evidence of active pulmonary disease has been ruled out. A copy of the Chest x-ray report which has been performed within the last 6 months is acceptable. Otherwise the facility will send the prospective employee to have a Chest x-ray completed, prior to beginning employment; -The second TB test is required for new employees and will be administered 7-21 days after the initial test. 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the file did not contain documentation of the results of the first or documentation of the second TB test. 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the file did not contain documentation of the results of the first test or documentation of the second TB test. Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE YMQX11 PRINTED: 06/18/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 06/04/2024 STREET ADDRESS, CITY, STATE, ZiP CODE PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} lf continuation sheet 2 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4724 Continued From page 2 4. Review of LIMA C's personnel file showed a hire date of 03/19/2024. Review showed the file did not contain documentation of the results of the first test or documentation of the second TB test. 5. Review of Resident #1's medical record showed an admit date of 08/31/2023. Review showed the record did not contain documentation of the results of the first test or documentation of the second TB test. 6. Review of Resident #2's medical record showed an admit date of 04/26/2024. Review showed staff documented the resident received his/her first step TB test on 05/02/2024. Review showed the record did not contain documentation of the first TB test results. Review showed staff documented the resident received his/her second TB test on 05/15/2024. Review showed the record did not contain documentation of the second TB test results. 7. Review of Resident #3's medical record showed an admit date of 02/06/2024. Review showed staff documented the resident received his/her first step TB test on 02/08/2024. Review showed the record did not contain documentation of the first TB test results. Review showed the record did not contain documetation of the second TB test as administered. 8. During an interview on 6/4/2024 at 3:00P_M., LPN D said he/she is filling in for the administrator. He/She said typically the first TB step is given and read before the employee is on the floor with resident contact. The LPN said he/she is unsure how often the administrator monitors the personnel files. He/She said the Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 3 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4724 Continued From page 3 administrator is responsible to ensure the personnel files are complete. 19 CSR 30-86.047(20)(I} Personnel Record-physician statement, employ The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (1) Written statement signed by a licensed physician or physician ' s designee indicating the person can work in a long-term care facility and indicating any limitations; Ill This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff had a written statement by a licensed physician or physician designee to ensure the staff are capable to work in a long-term care facility. The facility census was 19. 1. The facility staff did not provide a policy in regards to new employees required documentation of a physician statement to ensure the staff are capable to work in a long-term care facility. 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation from a physician or designee to ensure he/she was capable to work in a long-term care facility. Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 4 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4733 Continued From page 4 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation from a physician or designee to ensure he/she was capable to work in a long-term care facility. 4. Review of LIMA C's personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation from a physician or designee to ensure he/she was capable to work in a long-term care facility. 5. During an interview on 06/04/2024 at 5:00 P.M., the LPN D said the administrator is responsible to ensure the employees receive their physician's statment fo work in long-term care. The LPN said the director of nursing (DON) is new and is unfamiliar with the requirements of the employee personnel files. The LPN said he/she is unsure why the statements were not in the file and is unsure how often the administrator monitors the employee files. 19 CSR 30-86.047(62)(A) Orientation - job responsibilities Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: {A) Job responsibilities; I/II This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 5 of 17 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ARBORS A4B46 Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 13589C {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 1700 EAST 10TH STREET AT PARKSIDE-MEM CARE ASSTED L ROLLA, MO 65401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff received orientation training for job responsibilities. The facility census was 19. 1. The facility staff did not provide a policy in regards fo orientation training for job responsiblities for new employees. 2. Review of LPN A’s personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for job responsiblities . 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for job responsiblities. 4. Review of LIMA C’s personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation he/she received orientation training for job responsiblities. 5. During an interview on 06/04/2024 at 5:00 P_M., the LPN D said the administrator is responsible to ensure the employees receive orientation training for job responsibilities. The LPN said typcially the employees go through a three day training course, however he/she is unable to locate the training in the file. The LPN said he/she is unsure how often the employee files are monitored. Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE YMQX11 PRINTED: 06/18/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 06/04/2024 STREET ADDRESS, CITY, STATE, ZiP CODE PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} lf continuation sheet 6 of 17 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ARBORS A4B47 A4847 IDENTIFICATION NUMBER: 13589C {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET AT PARKSIDE-MEM CARE ASSTED L ROLLA, MO 65401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 19 CSR 30-86.047(62)(B) Orientation - emergency response procedures Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (B}) Emergency response procedures; Hi/lll This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff,received orientation training for emergency response procedures. The facility census was 19. 1. The facility staff did not provide a policy in regards to orientation training for emergency response procedures for new employees. 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for emergency response procedures . 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for emergency response procedures . 4. Review of LIMA C's personnel file showed a hire date of 03/19/2024. Review showed the Missouri Department of Health and Senior Services STATE FORM 6899 PRINTED: 06/18/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 06/04/2024 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE YMQX11 lf continuation sheet 7 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4847 Continued From page 7 personnel record did not contain documentation he/she received orientation training for emergency response procedures . 5. During an interview on 06/04/2024 at 5:00 P_M., the LPN D said the administrator is responsible to ensure the employees receive orientation training for emergency response procedures . The LPN said he/she is unable to locate the training in the file. The LPN said he/she is unsure how often the employee files are monitored. 19 CSR 30-86.047(62)(C) Orientation - infection control/handwashing Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (C) Infection control and handwashing procedures and requirements; I/II This regulation is not met as evidenced by: Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff, received orientation training for infection control and handwashing procedures and requirements. The facility census was 19. 1. The facility staff did not provide a policy in regards to orientation training for infection control and handwashing procedures and requirementsfor new employees. Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 8 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4848 Continued From page 8 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for infection control and handwashing procedures and requirements. 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for infection control and handwashing procedures and requirements. 4. Review of LIMA C's personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation he/she received orientation training for infection control and handwashing procedures and requirements. 5. During an interview on 06/04/2024 at 5:00 P_M., the LPN D said the administrator is responsible to ensure the employees receive orientation training for infection control and handwashing procedures and requirements. The LPN said he/she is unable to locate the training in the file. The LPN said the administrator is responsible to ensure the employee files are complete but is unsure how often the employee files are monitored. 19 CSR 30-86.047(62)(E) Orientation - resident A4850 dignity Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 9 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4850 Continued From page 9 his or her job function. This shall include at least the following: (E) Preservation of resident dignity; H/Il This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff receive resident dignity training. The facility census was 19. 1. The facility staff did not provide a policy in regards to orientation training for resident dignity training requirements for new employees. 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident dignity training requirements. 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident dignity training requirements. 4. Review of LIMA C's personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident dignity training requirements. During an interview on 06/04/2024 at 5:00 P_M., Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 10 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4850 Continued From page 10 the LPN D said the Administrator is responsible to ensure the employees receive orientation training for resident dignity training. The LPN said he/she is unable to locate the employee received this training in his/her file. The LPN said the administrator is responsible to ensure the employee files are complete. He/she is unsure how often the employee files are monitored. 19 CSR 30-86.047(62)(H) Orientation - resident rights/property Prior to or on the first day that anew employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (H) Instruction regarding the rights of residents and protection of property, HI/I! This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff receive resident rights and protection of property training. The facility census was 19. 1. The facility staff did not provide a policy in regards to orientation training for resident resident rights and protection of property training requirements for new employees. 2. Review of LPN A's personnel file showed a Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 if continuation sheet 11 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4853 Continued From page 11 hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident resident rights and protection of property training requirements. 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident resident rights and protection of property training requirements. 4. Review of LIMA C’s personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident resident rights and protection of property training requirements. During an interview on 06/04/2024 at 5:00 P_M., the LPN D said the administrator is responsible to ensure the employees receive orientation training for resident resident rights and protection of property trainingtraining. The LPN said he/she is unable to locate the employee received this training in his/her file. The LPN said the administrator is responsible to ensure the employee files are complete. He/she is unsure how often the employee files are monitored. 19 CSR 30-86.047(62)(I) Orientation - resident A4854 mental illness Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 12 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4854 Continued From page 12 () Instruction regarding working with residents with mental illness; l/l This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff receive resident menial illness training . The facility census was 19. 1. The facility staff did not provide a policy in regards to orientation training for resident mental illness training requirements for new employees. 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident mental illness training requirements. 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident menial illness training requirements. 4. Review of LIMA C's personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident mental illness training requirements. 5. During an interview on 06/04/2024 at 5:00 P.M., the LPN D said the administrator is Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 13 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4854 Continued From page 13 responsible to ensure the employees receive orientation training for resident mental iliness training. The LPN said he/she is unable to locate the employee received this training in his/her file. The LPN said the administrator is responsible to ensure the employee files are complete. He/she is unsure how often the employee files are monitored. 19 CSR 30-86.047(62)(J) Orientation-person centered care/social model Prior to or on the first day that anew employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (J) Instruction regarding person-centered care and the concept of a social model of care, and techniques that are effective in enhancing resident choice and control over his or her own environment. {IH This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff receive resident person centered care training . The facility census was 19. 1. The facility staff did not provide a policy in regards to orientation training for resident person centered care training requirements for new employees. Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 14 of 17 PRINTED: 06/12/2024 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: COMPLETED A. BUILDING: Cc 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET 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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4855 Continued From page 14 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident person centered care training requirements. 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident person centered care training requirements. 4. Review of LIMA C’s personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident person centered care training requirements. 5. During an interview on 06/04/2024 at 5:00 P.M., the LPN D said the administrator is responsible to ensure the employees receive orientation training for resident person centered care training. The LPN said he/she is unable to locate the employee received this training in his/her file. The LPN said the administrator is responsible to ensure the employee files are complete. He/she is unsure how often the administrator monitors the employee files. 19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr in addition to the orientation training required in section (62) of this rule any facility that provides care fo any resident having Alzheimer ' s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer ' s disease and Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 15 of 17 NAME OF PROVIDER OR SUPPLIER Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 13589C {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 1700 EAST 10TH STREET ARBORS AT PARKSIDE-MEM CARE ASSTED L (X4) ID PREFIX TAG A4B56 ROLLA, MO 65401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 related dementias as follows: (A) For employees providing direct care to such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer's disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues; and HII This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure three staff (Licensed Practional Nurse (LPN) A, Personal Care Aide (PCA) B and Level One Medication Aide (LIMA) C) out of three sampled staff, receive resident alzheimer or dementia care training . The facility census was 19. 1. The facility staff did not provide a policy in regards to orientation training for resident alzheimer or dementia care training requirements for new employees. 2. Review of LPN A's personnel file showed a hire date of 04/24/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident alzheimer or dementia care training requirements. Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE YMQX11 PRINTED: 06/18/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 06/04/2024 STREET ADDRESS, CITY, STATE, ZiP CODE PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} If continuation sheet 16 of 17 PRINTED: 06/12/2024 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 13589C B.WING 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1700 EAST 10TH STREET ROLLA, MO 65401 (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} ARBORS AT PARKSIDE-MEM CARE ASSTED L A4856 Continued From page 16 3. Review of PCA B's personnel file showed a hire date of 05/07/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident alzheimer or dementia care training requirements. 4. Review of LIMA C's personnel file showed a hire date of 03/19/2024. Review showed the personnel record did not contain documentation he/she received orientation training for resident alzheimer or dementia care training requirements. 5. During an interview on 06/04/2024 at 5:00 P.M., the LPN D said the Administrator is responsible to ensure the employees receive orientation for alzheimer or dementia care training. The LPN said he/she is unable to locate the employee received this training in his/her file. The LPN said the administrator is responsible to ensure the employee files are complete. He/she is unsure how often the administrator monitors the employee files. Missouri Department of Health and Senior Services STATE FORM 5899 YMOX11 If continuation sheet 17 of 17 SEE rar eter PLAN OF CORRECTION provider Supplier Arbors at Parkside Memory Care Assisted Living by Americare Street Address, 1700 East 10° Street City, Zip: Rolla, MO 65401 Date of Survey: June 4, 2024 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 filling 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 6/18/24 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. Administrator and/or designee to review all employee files and resident charts to ensure TB screenings are up to date and A4724 complete. Administrator will ensure ongoing TB screenings are 06/26/24 completed in accordance with both state regulation and company policy for all future hires. Administrator and/or designee completed an audit of all employee’s personnel files to ensure that all have an employee health examination signed by a licensed physician/physician designee indicating the employee can work in a long-term care A4733 facility and indicating any limitations and a copy is in employee's personnel file. Employees that didn’t have the physician 06/28/24 statement in their personnel record were given statement and asked to return statement no later than 06/30/24 Administrator will ensure ongoing compliance with employee physician statements in accordance with both state regulation and company policy for all future hires. Administrator and/or designee completed audits of all employee personnel files to ensured that all employees have received job A4846 responsibility training and documentation of training is in employee personnel file. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. Administrator and or Designee completed employee personnel file audit and ensured that all employees have emergency response training and documentation of training is in their employee personnel records. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. Administrator and or Designee completed employee personnel file audit and ensured that all employees have infection control/handwashing training and documentation of this training 6/14/24 A4847 6/14/24 A4848 6/14/24 A4850 A4853 A4854 A4855 A4856 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of is in their employee personnel records. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. Administrator and or Designee completed employee personnel file audit and ensured that all employees have resident dignity training and documentation of this training is in their employee personnel records. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. Administrator and or Designee completed employee personnel file audit and ensured that all employees have resident rights/property training and documentation of this training is in their employee personnel records. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. Administrator and or Designee completed employee personnel audit and ensured that all employees have resident menial illness training and documentation of this training is in their employee personnel records. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. Administrator and or Designee completed employee personnel audit and ensured that all employees have person centered care/social model training and documentation of it is in their employee personnel records. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. Administrator and or Designee completed employee personnel audit and ensured that all employees have Alz/dementia training of at least 3 hours and documentation of this is in their employee personnel records. Administrator will also ensure ongoing compliance of this training in accordance with both state regulation and company policy for all future hires. the plan of correction being submitted on this form. 6/14/24 6/14/24 6/14/24 6/14/24 6/14/24