LA BONNE MAISON ASSISTED LIVING.

PRINTED. 98/06.2024 FORM APPROVED iX1) PROVIDER/SUPPLIER: CA (X2) MULTIPLE CONSTRUCTION 1X9) DATS SURYE” AND BULAN OF CORRECTION {SENTIFICATION NUMBER A BLL NG , COMPLETE? BWING . 07/30/2024 NAME QF PROVIDER OR SLPALIER STREETADORESS CITY. STATE, ZIP CODE 226 PLAZA DRIVE LA BONNE MAISON - ASSISTED LIVING BY AMERICA SIKESTON, MO 63801 SUMMARY STATEMENT OF DEFICIENCIES: PROVADER'S PLAN OF CORRECTION wae ! A LHC = rk STON SPHOULD BF PREFIX (EACH De FICIENCY MUST BE PRECEDED BY FUL HEACH CURREG iE AN ate r REGULATORY OR SC IDENTIFYING INFORMATION: CQROSS-REF ERENT (6 TRE APPROP RATE “s DERICIENGY i As004. 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review i i Each resident admitted to the facility, or his or her . next of kin, legally authorized representative or designee, shail be fully informed of the individual's rights and responsibilities as a : resident. These rights shall be reviewed annually with gach resident, and-or his or her next of kon, legally authorized representative or designee, either in a group session or individually HHI This regulation 16 not met as evidenced by Class Ii! Based on interview and record review, the facility . Staff faited to ensure that three of three sampled ' residents (Resident #1, #2 and #3) or their legal representative had the:r residents rights rowewed annually. The facility census was 29. 1. Review of Residert #1 s medical recara showed. - Resident admitted an 08/11/2015: - Lagt updated Resident Rights document dated 02/27°2023. 2. Review of Resident #25 mecical record | showed: '. Resident admitted cn 08/02/2020; - Last updated Resident Rights document dated 06/27/2023. 3. Review of Resident #3's medical record showed: ' . Resident admitted on 01/28/2022: - Last updated Res:dant Rights document dated 02/27°2023. During an interview or 07/30/2024 at 11°30 AM, Facility Staft (FS) A said the resident ngnis are Miusoun Depanmert of 4eanh’: ang Senior Sutvicas LABORATORY OIRECTORE DR PROVIDERSUPPLIER REPRE SLNTATI (P'S SIGHATURE ius vat Gare STATE FORM vey WENN Premtumgatii ates Tne PRINTED: 08/06/2024 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 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 226 PLAZA DRIVE SIKESTON, MO 63801 (X4) ID 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) LA BONNE MAISON - ASSISTED LIVING BY AMERICA Continued From page 1 usually updated with the annual care plan review and since there was another staff take over this task, the annual review was not done at this time. FS A said this review would be done as soon as possible. The facility did not provide a written policy for the annual updates of the Resident Rights. 19 CSR 30-88.010(10) Advance Directive Requirements Prior to or upon admission and at least annually after that, each resident or his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding provision of emergency and life-sustaining care, of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents’ next of kin, legally authorized representatives or designees shall be informed, upon request, regarding state laws related to advance directives for health-care decision making as well as the facility's policies regarding the provision of emergency or life-sustaining medical care or treatment. If a resident has a written advance health-care directive, a copy shall be placed in the resident's medical record and reviewed annually with the resident unless, in the interval, he or she has been determined incapacitated, in accordance with section 475.075 or 404.825, RSMo. Residents’ next of kin, legally authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. Missouri Department of Health and Senior Services STATE FORM 6899 JVLE11 If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER LA BONNE MAISON - ASSISTED LIVING BY AMERICA (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 I/II This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to ensure that three of three sampled residents (Resident #1, #2 and #3) or their legal representative had their Advance Directive reviewed annually. The facility census was 29. 1. Review of Resident #1's medical record showed: - Resident admitted on 08/11/2015; - Last updated Advance Directive document dated 02/27/2023. 2. Review of Resident #2's medical record showed: - Resident admitted on 08/02/2020; - Last updated Advance Directive document dated 06/27/2023. 3. Review of Resident #3's medical record showed: - Resident admitted on 01/28/2022: - Last updated Advance Directive document dated 02/27/2023. During an interview on 07/30/2024 at 11:30 A.M., Facility Staff (FS) A said the Advance Directives are usually updated with the annual care plan review and since there was another staff take over this task, the annual review was not done at this time. FS A said this review would be done as soon as possible. The facility did not provide a written policy for the annual updates of the Advance Directives. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 JVLE11 PRINTED: 08/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/30/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 226 PLAZA DRIVE SIKESTON, MO 63801 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 3 Name: ; Provider/Supplier | PLAN OF CORRECTION La Bonne Maitson- Assisted Living by Americare 4 ——— — — | $treet Address, ; City, Zip: | 226 Plaza Drive, Sikeston MO 63801 i Date of Survey: 7/30/24 | | at ~ ~— wae - a ~~ a — ee ee | (DO PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION i SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) to | | 19 CSR 30-88.010 (4) Resident Rights- Admission/Annual | Review ; Each resident admitted to the facility, or his or her next of kin. ; | legally authorized representative or designee. shail be fully | informed of the individual's rights and responsibilities as a resident. These rights shalt be reviewed annually with each ; resident, and/or his or her next of kin, legally authorized representative or designee in a group session or individually. I/Il L COMPLETION _ DATE | 9/9/24 ' The facility will ensure that all residents or their legal ; representative have their residents’ rights reviewed upon admission and annually, |_this deficient practice. __ with the resident and/or their legal representative. “Resident #1's annual resident rights review has been ‘completed a + with the resident and/or their legal representative. ; a Resident #2's annual resident rights review has been completed Alt residents who reside at the facility areconsidered atrisk for. T Resident # 3's annual resident rights review has been | completed with the resident and/or their legal representative. ; Administrator and or designee has completed an audit of all residents’ medical records to ensure that residents rights have | been reviewed upon admission and annually with resident | and/or their legal representatives and record of this review is _| added to resident medical records. ft _, 1 @ group session or individually _ Director of Nursing on resident rights review to ensure that all | residents admitted to the facility or his or her next of kin, legally | authorized representative or designee, shall be fully informed of ; the individual's rights and responsibilities as a resident. These =; ; rights shail be reviewed annually with each resident, and/or his or her next of kin, legaliy authorized representative or designee | residents’ charts monthly to ensure that resident rights review ' has been completed upon admission and annually with the resident and/or legal representative. Director of Nursing will , feport Continued compliance to the Administrator monthly on the | DON report. , Director of Nursing and or Designee will audit new and current —. ~ enn ee ——- aoe — , A8010 a a 19 CSR 30-88.010 (10) Advanced Directive Requirements Prior to or upon admission and at least annually after that, each resident or his or her next of kin. legally authorized representatives or designees shail be informed of facility policies : regarding provision of emergency and life-sustaining care. ofan | individual’s right to make treatment decisions for himself or herself and of state laws related to advance directives for health- : care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents’ net of kin, ' legally authorized representatives or designees shall be , informed upon request, regarding state faws related to advance. ! directives for health-care decision making as well as the facility's | | policies regarding medical care or treatment. if a resident has a written advance health-care directive, a copy shall be placed in . the resident's medical record and reviewed annually with the | resident unless in the interval, her or she has been determined . incapacitated. in accordance with section 475.075 or 404 825, | RSMo Residents’ next of kin, legally authorized representatives | or designees shall be contacted annually to assure their | accessibility and understanding of the facility policies regarding emergency and life-sustaining care_ ‘T'The facility will ensure that Advanced Directives have been reviewed upon admission and annual with ail residents and or 9/9/24 _ | their legal representatives. . | All residents who reside at the Community are considered at risk _for this deficient practice. Resident #1's Annual Advanced Directive review has been ! completed with the resident and or his/her legal representative | and documentation has been uploaded in resident medical __{ record. + | Resident #2's Annuai Advanced Directive review has been i completed with the resident and or his/her legal representative and documentation has been upioaded in resident medical | record. i Resident #3’s Annual Advanced Directive review has been completed with the resident and or his/her legal representative | and documentation has been uploaded in resident medical recog. a oo , Administrator and or designee has completed an audit of all residents’ medical records to ensure that Advanced Directives , have been reviewed upon admission and annually with resident | and/or their legal representatives and record of this review is _; added to resident medical records. ; Regional Nurse Consultant and/or designee will in-service : Director of Nursing on ensuring that all residents admitted to i facility and annually their after will have their Advanced | Directives reviewed with the resident and/or their legal , fepresentative._ Director of Nursing and or Designee ‘will audit new and current — | residents’ charts monthly to ensure that Advanced Directives i | review has been completed upon admission and annually with =| | the resident and/or legal representative. Director of Nursing will: | report continued compliance to the Administrator monthly on the , _ DON report -— ~~ we ee . one + es — apo : _ es Ln 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.

PRINTED: 06/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B.WING 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 226 PLAZA DRIVE SIKESTON, MO 63801 LA BONNE MAISON - ASSISTED LIVING BY AMERICA (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) 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) 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III Based on observation and interview on June 11, | 2024 the facility failed to store portable oxygen | cylinders in accordance with NFPA 99, 1999 Edition. The facility census was twenty five (25). This deficiency affects twenty five (25) of twenty five (25) residents. Observation showed two (2) oxygen cylinders, Standing upright and not stored in an approved rack, or secured by a chain or band in the oxygen storage room located located in the east hall. | During an interview on June 11, 2024 at 10:30 A.M. the maintenance director said he was not aware of the cylinder being stored in the rooms | without a rack. He will have them removed and/or | Stored properly. A3201) 19 CSR 30-86.032(2) Substantially Constructed & A3201 Maintained | The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class Ill Missouri Department of Health and Senior Services LABO! ORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Tt. MN Zr STATE FORM 6899 TUTY11 If continuation sheet 1 of 2 PRINTED: 06/14/2024 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 8. WING ££___ mm 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 226 PLAZA DRIVE SIKESTON, MO 63801 (x4) ID 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) LA BONNE MAISON - ASSISTED LIVING BY AMERICA Continued From page 1 Based on observation and interview on June 114 2024 the facility failed to ensure the building was being maintained in good repair and in | accordance with the construction and fire safety rules in effect at time of initial licensing. The census was twenty five (25). This deficiency affects twenty five (25) of twenty five (25) residents. Observation showed a light fixture in resident room D two (D2) was hanging from the electrical wiring. With the light fixture not secured to the | Ceiling, this left a three (3") inch hole in the ceiling above where the fixture was mounted. This hole | leaves the attic exposed for fire and hot gases to be able travel to the attic area if there were a fire in the this room. The fixture hanging from the | electrical wiring could cause a fire and/or shock | hazard. During an interview on June 11, 2024 at 11:00 | A.M. the maintenance supervisor said he would have the light and hole repaired. Missouri Department of Health and Senior Services STATE FORM om TUTY11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier La Bonne Maison- Assisted Living by Americare Name: Street Address, City, Zip: 226 Plaza Drive Sikeston, MO 63801 Date of Survey: 6/11/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 28804 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 19 CSR 30-86.022 (17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. I/II The facility will store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. All residents that reside at the facility are considered at risk for this deficient practice. The two (2) oxygen cylinders located in the east hall storage room have been stored in a approved rack. Administrator has completed walk through of the community and ensured that all oxygen cylinders are stored in an approved rack. Administrator and/or designee will in-service maintenance director and Director of Nursing on ensuring oxygen cylinders are stored in an approved rack, or secured by chain or band in the oxygen storage room. Director of Nursing and/or designee will in-service all staff at facility on ensuring oxygen cylinders are stored in an approved rack, or secured by a chain or band in the oxygen storage room. Director of Nursing or designee will perform visual checks of the oxygen storage room weekly ensuring that oxygen cylinders are Stored in an approved rack, or secured by a chain or band in the oxygen storage room until substantial compliance has been met and then monthly after. Director of Nursing will report continued compliance to the Administrator monthly on monthly DON report. 7/22/2024 A2298 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be A3201 maintained in good repair and in accordance with the 7/22/2024 construction and fire safety rules in effect at the time of initial licensing. The facility will ensure the building is being maintained in good repair and in accordance with the construction and fire safety rules in effect at time of initial licensing. All residents that reside in the facility are considered at risk for this deficient practice. The light fixture in resident room D2 has been secured properly to the ceiling in accordance with the construction and fire safety rules in effect at the time of initial licensing by the facility maintenance director. Administrator has completed visual walk through of entire facility as of 6/21/24 ensuring that all light fixtures are properly secured to the ceiling and not leaving any holes that could potentially allow for fire or hot gases to be able to ravel to the attic area. Administrator and/or designee will in-service facility maintenance director on ensuring ensure the building is being maintained in good repair and in accordance with the construction and fire safety rules in effect at time of initial licensing and when Maintenance director is completely weekly checks to make sure light fixtures are properly secured to the ceiling. Administrator and/or designee will in-service all staff by 6/28/24 on reporting any observations made of light fixtures not being secured to ceiling correctly immediately so they can be corrected. Maintenance supervisor will complete weekly visual checks of the facility to ensure that all light fixtures are secured to the ceiling correctly and report continued compliance monthly on maintenance report. Maintenance will report to the Administrator immediately if any found not secured and ensure it is properly secured. 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.