PARKWOOD MEADOWS ASSISTED LIVING.

PRINTED: 11/07/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (x3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING; B. WING 11/06/2025 23234C STREET ADDRESS, CITY, STATE, ZIP CODE 805 PARKWOOD DRIVE SAINTE GENEVIEVE, MO 63670 NAME OF PROVIDER OR SUPPLIER PARKWOOD MEADOWS:ASSISTED LIVING (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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. Il This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to follow appropriate infection prevention practices for nine out of ten employee tuberculosis (TB-a contagious lung disease) screenings when the facility failed to ensure each employee had their two-step tuberculin skin test (TST) read per regulatory guidelines. This had the potential to affect all residents through the increased risk of exposure to TB. The facility's census was 42. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities showed: - Long Term Care Employees and Volunteers: All new long-term care facility employees and volunteers who work ten (10) or more hours per week are required to obtain a Mantoux Purified Protein Derivative (PPD) (Mantoux, TB skin test, tuberculin skin test (TST), and PPDs are often used interchangeably. Mantoux refers to the technique for administering the test. Tuberculin (also called PPD) is the solution used to | administer the test) two (2)-step tuberculin test within one (1) month prior to starting employment in the facility. If the initial test is zero to nine millimeters (0-9 mm), the second test should be given as soon as possible within three (3) weeks | after employment begins, unless documentation is provided indicating a Mantoux PPD test in the | past and at least one (1) subsequent annual test | \ Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER) PLIER REPRESEWTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6VP511 if continuation sheet 1 of 4 PRINTED: 11/07/2025 FORM APPROVED and Senior Services (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: Missouri Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 41/06/2025 23234C STREET ADDRESS, CITY, STATE, ZIP CODE 805 PARKWOOD DRIVE SAINTE GENEVIEVE, MO 63670 NAME OF PROVIDER OR SUPPLIER PARKWOOD MEADOWS ASSISTED LIVING (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION . (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLE TE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4724 Continued From page 1 | A4724 within the past two (2) years. It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status. (E) Employees and volunteers with an initial zero to nine millimeters (0-9 mm) Mantoux PPD two (2)-Step test shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. Review of the facility's policy titled, "Employee TB Testing,” undated, showed results of all PPD testing will be documented in millimeters (mm) of induration (a firm, raised swelling at the injection site) on the form and kept in the employee's medical file. 1. Review of Facility Staff (FS) A's personnel file showed: - Ahire date of 10/13/25; - A first-step TST given 10/06/25 and read negative on 10/08/25; - Asecond-step TST given 10/22/25 and read negative on 10/24/25; - The facility failed to read the results of the TSTs in millimeters. | 2. Review of FS B's personnel file showed: - Ahire date of 07/14/25; - A first-step TST given 07/07/25 and read negative on 07/09/25; - Asecond-step TST given 07/23/25 and read negative on 07/25/25; - The facility failed to read the results of the TSTs in millimeters. 3. Review of FS C's personnel file showed: - Ahire date of 06/30/25; - A first-step TST given 06/25/25 and read 0 on 06/27/25; - Asecond-step TST given 07/15/25 and read Missouri Department of Health and Senior Services STATE FORM = 6VP511 If continuation sheet 2 of 4 PRINTED: 11/07/2025 FORM APPROVED Health and Senior Services (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: Missouri Department of STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 23234C 11/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 805 PARKWOOD DRIVE SAINTE GENEVIEVE, MO 63670 NAME OF PROVIDER OR SUPPLIER PARKWOOD MEADOWS ASSISTED LIVING (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION x6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE cana TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE t DEFICIENCY) Continued From page 2 negative on 07/17/25; - The facility failed to read the results of the TSTs in millimeters. 4. Review of FS D's personnel file showed: - Ahire date of 04/14/25; - A first-step TST given 04/09/25 and read negative on 04/11/25; - Asecond-step TST given 04/25/25/25 and read 0 on 04/27/25; - The facility failed to read the results of the TSTs in millimeters. 5. Review of FS E's personnel file showed: - Ahire date of 06/09/25; - A first-step TST given 05/20/25 and read | negative on 05/22/25; | - Asecond-step TST given 06/10/25 and read 0 | on 06/12/25; | - The facility failed to read the results of the TSTs in millimeters. 6. Review of FS F's personnel file showed: - Ahire date of 05/27/25; - A first-step TST given 05/21/25 and read negative on 05/23/25; - Asecond-step TST given 06/10/25 and read 0 on 06/12/25; - The facility failed to read the results of the TSTs in millimeters. 7. Review of FS G's personnel file showed: - Ahire date of 08/11/25; - A first-step TST given 08/04/25 and read negative on 08/06/25; - Asecond-step TST given 08/20/25 and read negative on 08/22/25; - The facility failed to read the results of the TSTs in millimeters. Missouri Department of Health and Senior Services STATE FORM a 6VP511 If continuation sheet 3 of 4 PRINTED: 11/07/2025 FORM APPROVED h and Senior Services (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: Missouri Department of Healt! STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 11/06/2025 23234C STREET ADDRESS, CITY, STATE, ZIP CODE 805 PARKWOOD DRIVE SAINTE GENEVIEVE, MO 63670 NAME OF PROVIDER OR SUPPLIER PARKWOOD MEADOWS ASSISTED LIVING (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 8) : PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE ins TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE D DEFICIENCY) A4724 Continued From page 3 A4724 8. Review of FS H's personnel file showed: - Arehire date of 05/29/25; - An annual TST given 02/19/25 and read negative on 02/21/25; - The facility failed to read the results of the TST in millimeters. 9. Review of FS I's personnel file showed: - Ahire date of 10/23/25; - A first-step TST given 10/14/25 and read negative on 10/16/25; - Asecond-step TST given 10/29/25 and read negative on 10/31/25; - The facility failed to read the results of the TSTs in millimeters. During an interview on 11/06/25 at 12:45 P.M., the Director of Nursing (DON) said she is solely responsible for doing the TB testing of the residents and employees as she is the only nurse in the building. She documents the results as negative if there is no induration and would document the measurement of the induration if the test was positive. She was not aware that the results of a negative test had to be documented in millimeters. During an interview on 11/06/25 at 1:30 P.M., the Administrator and DON said that they see the policy shows to document the results of the TB test in millimeters. The DON said she had been documenting them as negative. Missouri Department of Health and Senior Services STATE FORM eee 6VP511 if continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Parkwood Meadows Assisted Living Name: | Street Address, 805 Parkwood Drive City, Zip: Ste. Genevieve, MO 63670 Date of Survey: + 11/06/2025 | ID PREFIX TAG — PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 23234C COMPLETION PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE r— A4724 | test (TST), and PPDs are often used interchangeably. Mantoux | shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. _| 19 CSR 30-86.047 (19) TB Screen Residents & Staff Long Term care Employees and Volunteers: All new long-term care facility employees and volunteers who work ten (10) or more hours per week are required to obtain a Mantoux Purified Protein Derivative (PPD). Mantoux, TB Skin test, tuberculin skin refers to the technique for administering the test. Tuberculin (also called PPD) is the solution used to administer the test. Two (2)-step tuberculin test within one (1) month prior to starting employment in the facility. If the initial test is zero to nine millimeters (0-9 mm), the second test should be given as soon as possible within three (3) 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 (2) years. It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status. (E) Employees and volunteers with an initial zero to nine millimeters (0-9 mm) Mantoux PPD two (2)-step test 12/22/25 al 7 a guidelines. The facility will ensure to follow appropriate infection prevention practices for employee tuberculosis (TB-a contagious lung disease screenings. The facility will ensure each employee had their two-step tuberculin skin test (TST) read per regulatory All residents who reside in the facility are considered at risk for this deficient practice. + — of Nursing to be in-serviced by Regional Nurse Consultant or designee by 11/14/25 on following appropriate infection prevention practices for employee tuberculosis screening. —— | Director of Nursing to be in-serviced by Regional Nurse | had their two-step tuberculin skin test read per regulatory Consultant or designee by 11/14/25 on ensuring each employee guidelines documenting the results in millimeters (mm) of | induration on the form and kept in the employee's medical file. Director of Nursing has completed an audit of all employee TB records to ensure that all results are documented in millimeter mm) of induration per this plan of correction. Facility Staff A’s TST read on 10/8/25 & 10/24/25 both with | negative results have been corrected based on this plan of correction by Director of Nursing to reflect 0 mm induration. Facility Staff B’s TST read on 07/09/25 & 07/25/25 both with | negative results have been corrected based on this plan of | | correction by Director of Nursing to reflect 0 mm induration. Facility Staff C’s TST read on 06/27/25 & 07/17/25 both with 0 & negative results have been corrected based on this plan of correction by Director of Nursing to reflect 0 mm induration. Facility Staff D's TST read on 04/11/25 & 04/27/25 both with negative results and 0 have been corrected based on this plan of correction by Director of Nursing to reflect 0 mm induration. Facility Staff E’s TST read on 05/22/25 & 06/12/25 both with negative & 0 results have been corrected based on this plan of | correction by Director of Nursing to reflect 0 mm induration. | Facility Staff F's TST read on 05/23/25 & 06/12/25 both with negative & 0 results have been corrected based on this plan of correction by Director of Nursing to reflect 0 mm induration. | Facility Staff G’s TST read on 08/06/25 & 08/22/25 both with | negative results have been corrected based on this plan of | correction by Director of Nursing to reflect 0 mm induration. Facility Staff H’s TST read on 02/21/25 with negative results have been corrected based on this plan of correction by Director of Nursing to reflect 0 mm induration. Facility Staff I's TST read on 10/16/25 & 10/31/25 both with negative results have been corrected based on this plan of correction by Director of Nursing to reflect 0 mm induration. Director of Nursing or designee will review employee TB records quarterly to ensure continued compliance and report compliance to facility Administrator on DON report. 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.