FREMONT SENIOR LIVING, THE.

An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 09/12/2025 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 28782 B. WING 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET FREMONT SENIOR LIVING, THE SPRINGFIELD, MO 65804 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) 19 CSR 30-86.022(7)(E) Locked Exit Doors Exits, Stairways, and Fire Escapes. (E) If it is necessary to lock exit doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the building. Only one (1) lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA 101 shall be permitted, provided that not more than one (1) such device is located in any egress path. Self-locking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. Wl This regulation is not met as evidenced by: Class II Based on observation and interview on May 22, 2025, the facility failed to provide delayed egress locks in compliance with National Fire Protection Association (NFPA) 101, Section 7.2.1.6.1, 2000 edition. The facility also failed to ensure locks on exit doors shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the building. The facility census on May 22, 2025 was 60. This deficiency affects 60 of 60 residents. Observation of the delayed egress exit door by the maintenance office on May 22, 2025, at 9:06 A.M., showed a magnetically locked exit door that failed to open or set off any any audible signal in six (6) out of six (6) attempts of pushing, with greater than 15 pound-force (Ibf), on the fire exit hardware of the door for more than three seconds. Further observation showed a door code needed to be entered on a keypad before the exit door would open. This special knowledge of the door code would delay an egress from the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM oa 3Q1G11 If continuation sheet 1 of 2 PRINTED: 09/12/2025 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 28782 B. WING 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 (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) FREMONT SENIOR LIVING, THE Continued From page 1 building in the event of an emergency. During an interview on May 22, 2025, at 9:06 A.M., a maintenance worker said he/she did not know why the delayed egress function of the door did not work and a code has to be entered before the exit door will open. NFPA 101, 2000 edition, Section 7.2.1.6.1 (c) states: "An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 Ibf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only." Missouri Department of Health and Senior Services STATE FORM 6899 3Q1G11 If continuation sheet 2 of 2

PRINTED: 02/06/2025 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 S 28782 B.WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | xs} 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) FREMONT SENIOR LIVING, THE | A4778 19 CSR 30-86.047(37) Appropriate Action & | A4778 Notification In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the person listed in the resident ' s record as the legally authorized representative, designee or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medical examiner immediately upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home. I/il This regulation is not met as evidenced by: Class II Based on interviews and record review, facility staff failed to take appropriate action and promptly attempt to contact the person listed in the resident's record as the legally authorized representative for a change of medication when staff failed to notify ane resident's (Resident #1) family regarding an order for a new medication. | The facility census was 55. Review showed the facility did not provide a policy regarding notifications of changes in medications. 1. Review of the Resident #1's face sheet (a brief resident profile) showed the following: -Admission date of 04/04/24; -Diagnoses included vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE /4 UL, f _ Ann stroke 01/16/25 STATE FORM P 6899 TOXK11 If continuation sheet 1 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 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) FREMONT SENIOR LIVING, THE Continued From page 1 brain), depression, and dementia; -Resident had a durable power of attorney (DPOA - a person who has been granted authority to make decisions for another person). Review of the resident's service plan, last review on 09/21/24, showed the following: -Resident moved into memory care on 04/04/24, due to elopement risk and cognitive deficits; -Resident has power of attorney for making decisions and advance directives; -Resident has expression/mood problems related to cognitive deficits, history of wandering, exit seeking, aggression, and resistance to cares; -Resident will utilize a wander management system for safety; -Education will be provided to resident or responsible party per resident needs as required; -Resident will receive assistance with medication management. Provide medications as ordered. Staff manage medication orders and administration. Review of the facility Physician/Practitioner Telephone/Verbal Order Form, dated 08/16/24, showed a request from the facility to the resident's physician for an order of Lorazepam (a drug used to treat anxiety and sleeping problems related to anxiety) 1 milligram (mg)/diphenhydramine (antihistamine)12.5 mg/haloperidol (antipsychotic drug) 2 mg. Administer one milliliter (ml) topically every six hours as needed for agitation and exit seeking. Review of the resident's current physician order sheet showed the following: -An order, dated of 08/16/24, with a start date of 08/17/24, for ABH Gel (a gel of Lorazepam, Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 2 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET FREMONT SENIOR LIVING, THE SPRINGFIELD, MO 65804 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) Continued From page 2 diphenhydramine, and haloperidol used in treating agitation) apply 1 milliliter topically every six hours as needed for agitation/exit seeking (indicators for use: agitation or exit seeking and unable to redirect). Review of the resident's progress notes showed the following: -On 08/16/24, at 10:01 A.M., a fax communication to the resident's physician office noted resident with a primary diagnosis of vascular dementia with behavioral disturbance has been prescribed Seroquel (an antipsychotic medication) by mouth, as needed for agitation. However, he/she refuses to take oral medication most of the time and not when agitated. Please consider discontinuing oral medications and adding the topical cream of ABH cream topical (Lorazepam 1 mg/diphenhydramine 12.5 mg/haloperidol 2 mg, 1 ml topically every six hours as needed for agitation or exit seeking. -On 08/27/24, at 9:53 A.M., a communication via Mediprocity (a system used for communicating with healthcare providers) to the pharmacy showed ABH cream order was entered on 08/17/24. Review of the resident's progress notes showed the staff did not document notifying the resident's DPOA of the new order for ABH cream. Review of the resident's September 2024 Medication Administration Record (MAR) showed ABH Gel administered on 09/08/24 at 3:06 P.M., on 09/26/24 at 10:08 A.M., and on 09/27/24, at 10:46 A.M. Review of the resident's October 2024 MAR showed ABH Gel administered on 10/03/24 at Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 3 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET FREMONT SENIOR LIVING, THE SPRINGFIELD, MO 65804 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) Continued From page 3 09:58 A.M., and on 10/06/24 at 11:43 A.M. During interviews on 12/17/24, at 1:40 P.M. and 4:53 P.M., Medication Partner (MP) A said the following: -Staff should notify the resident's DPOA of any medication changes or new orders for medications prior to sending the order to the pharmacy and/or administrating to the resident; -He/she would contact the physician and supervisor before holding or administering the medication if a resident's DPOA refused a medication ordered by the physician. During interviews on 12/17/24, at 2:25 P.M., and 4:55 P.M., MP B said the following: --Staff should notify the resident's DPOA of any medication changes or new orders for medications prior to sending the order to the pharmacy and/or administrating to the resident; -He/she would contact the physician if a resident's DPOA refused a medication ordered by the physician. During interviews on 12/17/24, at 2:49 P.M. and 4:57 P.M., Wellness Nurse Manager (WNM) C said the following: -Staff should notify the resident's DPOA of any medication changes or new orders before requesting the medication from the pharmacy; -He/she would not request a new order for medication if the resident's DPOA did not want the resident taking the medication; -He/she would send a request to the physician or nurse practitioner (NP) to hold or discontinue a medication if a resident's DPOA declined the medication ordered by the physician. Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 4 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET FREMONT SENIOR LIVING, THE SPRINGFIELD, MO 65804 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) Continued From page 4 During an interview on 12/17/24, at 3:21 P.M., the Memory Care Director (MCD) D said the following: -The nurse should notify the resident's DPOA of a change in medication; -He/she would notify the nurse of a resident's DPOA did not want the resident on a specific medication; -The resident's DPOA has not advised him/her of any issues with ABH cream. During interviews on 12/17/24, at 3:21 P.M. and 4:21 P.M., the Director of Wellness (DOW) said the following: -Staff should notify the DPOA if there is a medication change or a new order prior to sending the order to the pharmacy; -Staff should notify the physician if a resident's DPOA declines a medication ordered by the physician, and the physician typically will discontinue the medication. During an interview on 12/17/24, at 3:38 P.M., the Executive Director said the following: -Staff should notify the physician if a resident's DPOA does not want the resident taking a specific medication and place on hold until receives an answer from the physician who will typically discontinue the medication; -Staff did not document discussing the request for an order for ABH cream with the resident's DPOA and should have prior to sending a request to the physician. MO00244797 Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 5 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 (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) FREMONT SENIOR LIVING, THE Continued From page 5 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident 's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if nota physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Vl This regulation is not met as evidenced by: Class II Based on interviews and record review, the facility staff failed to ensure a safe and effective medication system was implemented when staff requested and administered a medication which contained a drug on the resident's allergy list for one resident (Resident #1). The facility census Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 6 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 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) FREMONT SENIOR LIVING, THE Continued From page 6 was 55. Review showed the facility did not provide a policy regarding medication administration related to resident allergies. 1. Review of the Resident #1's face sheet (a brief resident profile) showed the following: -Admission date of 04/04/24: -Allergies included dextromethorphan (antitussive cough medicine), iodine | 131 tositumomab (a drug used with another drug to treat certain types of cancer), penicillin, sulfamethoxazole (antibiotic used to treat bacterial infections), Tetracycline (antibiotic), trimethobenzamide (drug used to treat nausea and vomiting after surgery), tetanus toxoids (vaccine used to manage and treat tetanus), latex, adhesive tape, antihistamines (a class of drugs that treat allergy symptoms and other conditions by blocking the effects of histamine), and Dimacol (medication used to treat cough, chest congestion and stuffy nose); -Diagnoses included vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain), depression, and dementia; -Resident had a durable power of attorney (DPOA - a person who has been granted authority to make decisions for another person). Review of the resident's service plan, last review on 09/21/24, showed the following: -Resident moved into memory care on 04/04/24, due to elopement risk and cognitive deficits; -Resident has power of attorney for making decisions and advance directives; -Resident has expression/mood problems related Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 7 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 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) FREMONT SENIOR LIVING, THE Continued From page 7 to cognitive deficits, history of wandering, exit seeking, aggression, and resistance to cares; -Resident will receive assistance with medication management. Provide medications as ordered. Staff manage medication orders and administration; -Resident will have consistent pharmacy services. Resident uses community pharmacy vendor. Community staff manage new orders, changes and refills; -Allergies included dextromethorphan, iodine | 131 tositumomab), penicillin, sulfamethoxazole Tetracycline, trimethobenzamide, tetanus toxoids, latex, adhesive tape, antihistamines, and Dimacol. Review of the facility's Physician/Practitioner Telephone/Verbal Order Form, dated 08/16/24, showed a request from the facility to the resident's physician for an order of Lorazepam (a drug used to treat anxiety and sleeping problems related to anxiety) 1 milligram (mg)/diphenhydramine (antihistamine)12.5 mg/haloperidol (antipsychotic drug) 2 mg. Administer 1 milliliter (ml) topically every six hours as needed for agitation and exit seeking. Review of the resident's current physician order sheet showed the following: -Allergies included dextromethorphan, iodine | 131 tositumomab, penicillin, sulfamethoxazole Tetracycline, trimethobenzamide, tetanus toxoids, latex, adhesive tape, antihistamines, and Dimacol; -An order, dated of 08/16/24, with a start date of 08/17/24, for ABH Gel (a gel of Lorazepam, diphenhydramine, and haloperidol used in treating agitation) apply 1 ml topically every six hours as needed for agitation/exit seeking. Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 8 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET FREMONT SENIOR LIVING, THE SPRINGFIELD, MO 65804 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) Continued From page 8 Review of the resident's progress notes showed the following: -On 08/16/24, at 10:01 A.M., a fax communication to the resident's physician office noted resident with a primary diagnosis of vascular dementia with behavioral disturbance has been prescribed Seroquel (an antipsychotic medication) by mouth, as needed for agitation. However, he/she refuses to take oral medication most of the time and not when agitated. Please consider discontinuing oral medications and adding the topical cream of ABH cream topical (Lorazepam 1 mg/diphenhydramine 12.5 mg/haloperidol 2 mg, 1 ml topically every six hours as needed for agitation or exit seeking. -On 08/27/24, at 9:53 A.M., a communication via Mediprocity (a system used for communicating with healthcare providers) to the pharmacy showed ABH cream order was entered on 08/17/24. Review of the resident's progress notes showed the staff did not document notifying the resident's DPOA of the new order for ABH cream. Review of the resident's September 2024 Medication Administration Record (MAR) showed ABH Gel administered on 09/08/24 at 3:06 P.M., on 09/26/24 at 10:08 A.M., and on 09/27/24, at 10:46 A.M. Review of the resident's October 2024 MAR showed ABH Gel administered on 10/03/24 at 09:58 A.M., and on 10/06/24 at 11:43 A.M. During an interview on 12/17/24, at 1:40 P.M., Medication Partner (MP) A said he/she would contact the pharmacy if a resident's medication Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 9 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 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) FREMONT SENIOR LIVING, THE Continued From page 9 contained a drug on the resident's allergy list. During an interview on 12/17/24, at 2:25 P.M., MP B said the following: -He/she would contact the physician if he/she discovered a medication ordered for a resident contained a component on the resident's allergy list; however, the physician and pharmacy should catch this type of issue; -He/she thinks the resident did have an order for ABH cream, but he/she did not request the order and does not believe he/she had administered the cream to the resident. During an interview on 12/17/24, at 2:49 P.M., Wellness Nurse Manager (WNM) C said the following: -He/she would contact the pharmacy or physician if a resident was ordered a medication containing a component on the resident's allergy list, the pharmacy usually catches this type of issue; -He/she did not realize there was an allergy associated with the medication when he/she requested it. The pharmacy did not catch it, and it was only administered a few times to the resident with no issues. During an interview on 12/17/24, at 3:21 P.M., the Memory Care Director (MCD) D said the following: -The resident's DPOA has not advised him/her of any issues with ABH cream; -The NP visits the residents and notes what the resident is allergic to and would not order if there was an issue with an allergy. During an interview on 12/17/24, at 3:21 P.M., the Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 10 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET FREMONT SENIOR LIVING, THE SPRINGFIELD, MO 65804 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) Continued From page 10 Director of Wellness (DOW) said the following: -Staff should notify the physician before administering a medication containing a component on the resident's allergy list; -He was not made aware of the issue with the resident's allergy to a component of the ABH cream; -If a physician orders a medication with a component on the resident's allergy list the pharmacy will message the facility to please send a verification, which flags the medication and makes the physician aware. During an interview on 12/17/24, at 4:29 P.M., the pharmacist said the following: -The system did not catch the medication order for ABH cream contained antihistamine, which is on the resident's allergy list; -This issue should have been caught by the physician or the pharmacist, but he/she depended on the system to assist with flagging allergy concerns due to the quantity of orders; -He/she would have reached out to the facility and advised to monitor the resident for an allergic reaction, but would not have recommended discontinuing the medication. During interviews on 12/17/24, at 3:38 P.M., and 5:13 P.M., the Executive Director said the following: -The physician and pharmacy both have a list of residents’ allergies, and medications ordered that are on the allergy list are flagged by the pharmacy and the physician makes the decision on continuing the medication or discontinuing; -The physician should check allergy list when prescribing medication; Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 11 of 12 PRINTED: 02/06/2025 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 C 28782 B. WING 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1520 EAST BATES STREET SPRINGFIELD, MO 65804 (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) FREMONT SENIOR LIVING, THE Continued From page 11 -All staff are responsible to check medications against a resident's allergy list. M000244797 Missouri Department of Health and Senior Services STATE FORM 6899 TOXK11 If continuation sheet 12 of 12 PLAN OF CORRECTION PROMIGEr/ Stipe? Name: Street Address, City, Zip: Fremont Senior Living 1520 East Bates Springfield Missouri 65804 Date of Survey: ID PREFIX TAG 12.17.24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER . PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employée, agent, officer, director, attorney, or shareholder of the -eommunityoraffiliated companies. COMPLETION DATE A4778 A4778 Correction of Cited Deficiency: On 1/10/2025, the POA was also notified of the community's plan to immediately inform the responsible party of any medication changes. Additionally, all medication changes will be included in the monthly wellness report, which will also detail allergies documented in the clinical record. The POA confirmed receipt of the monthly wellness report. Assessment to Identify other Residents that may be affected: On 1/10/2025, all resident responsible parties were notified that monthly wellness reports are distributed electronically through the Arrow App, unless they prefer to receive them via email. These reports include updates on medication changes, care adjustments, and documented allergies. All responsible parties confirmed their preferred method of communication and acknowledged receipt of the information. 1/15/2025 A4778 Procedure to ensure ongoing compliance: The Director of Wellness, or their designee, will perform a wéekly audit of new medication orders entered into the electronic order system. This audit will verify that the resident or their responsible party has been notified of any changes to current medication orders. Audit findings will be reviewed with the Executive Director during the weekly one-on-one meeting, A staff in-service session was conducted on 1/10/2025 to re- educate the team on the importance of notifying the resident's family or responsible party prior to administering any new medication. The Wellness Nurse or Med Partner is responsible for ensuring this notification is completed. A4778 Monitoring for Ongoing Compliance: The weekly audit will be reviewed during the Department Head 1/15/2025 Meeting by the Director of Wellness for three months to ensure compliance. Correction of Cited Deficiency: Resident #1's order for ABH cream was discontinued on 12/18/2024. The cream was prescribed as PRN and had not been used during December. Assessment to Identify other Residents that may be affected: The pharmacy conducted an audit to verify medications in the system against documented allergies. While the system automatically triggers a warning for any allergies, we specifically requested a detailed review of compound medications to cross- check against the allergy list. No issues were identified. Procedure to ensure ongoing compliance: No other residents are receiving compound medication. The pharmacy will implement a double-check process for all outsourced compound medications ordered in the future. The Director of Wellness will audit new medications, including a thorough review of allergy lists, to ensure residents do not receive medications they are allergic to. This audit will be reviewed weekly with the Executive Director during 1:1 meeting. Monitoring for Ongoing Compliance: The Director of Wellness will review the weekly audit during the Department Head Meeting for the next three months to ensure compliance. 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.