LAKEWOOD ASSISTED LIVING.

PRINTED: 11/21/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3} DATE SURVEY COMPLETED Cc 10/23/2024 Nn pus B. WING 23613D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 LAKEWOOD-ASSISTED LIVING BY AMERICAR (X4) iD SUMMARY STATEMENT OF DEFICIENCIES 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 30-86.047(28)(G) Individual Service Plan | ~ Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does nat require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by | an assisted living facility which outlines a resident “s needs and preferences, services to be provided, and goals expected by the resident or ine resident ' s legal representative in partnership with the facility; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to complete Individual Service Plans (ISP - the planning document prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the | goals expected by the resident or the resident's legal representative in partnership with the facility) for five residents (Resident #1, #2, #3, #4, and #5) upon admission to the facility. The facility | | Census was 45. Review of the facility pol icy titled, "Plan of Care/ISP," effective 06/10/19, showed the following: -The Plan of Care/ISP for the resident should be completed upon admission, re-admission, change of condition and every six months. The individualized plan of care is a communication tool among caregivers and it directs the care; -An evaluation should be performed at pre-admission, admission, and ongoing to | determine specific resident needs or conditions that require interventions through the care plan YW ANSTO VA dal WA2V11 If continuation sheet 1 of 6 ER/SUPPLIER REPRESENTATIVE'S wre TITLE 6899 PRINTED: 11/21/2024 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 C 23613D B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 1 process; -An individualized service plan/plan of care is designed to meet those needs identified that prevent the resident from maintaining the highest reasonable level of functioning; -Missouri Assisted Living Facilities (ALF) are required to complete Plan of Care/ISP on all residents within five days of admission and update every six months and when a change of condition is identified. Development and reviews must involve both resident and legal representative; -ISP should be updated within 24 hours on any resident who has had a hospitalization or Skilled Nursing Faciltiy (SNF) stay. -ISP should outline a resident's needs, preferences, services to be provided and goals expected by the resident or the resident's legal representative. ISP provides for or coordinates oversight for services to meet the needs, social and recreational preferences, and should be documented in a written contract signed by the resident or legal representative of the resident. 1. Review of Resident #1's face sheet showed the following: -Admission date of 07/09/24; -Diagnoses included neurocognitive disorder with lewy bodies (a progressive condition that causes a decline in thinking and motor skills), Parkinson's disease without dyskinesia with fluctuations (uncontrolled, involuntary movement that may occur with with Parkinson's), and chronic pain syndrome. Review of the resident's Community Based Assessment (CBA - documented basic information and analysis provided by appropriately trained and qualified individuals Missouri Department of Health and Senior Services STATE FORM 6899 WA2V11 If continuation sheet 2 of 6 PRINTED: 11/21/2024 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 C 23613D B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 2 describing an individual ' s abilities and needs in activities of daily living, instrumental activities of daily living, vision/hearing, nutrition, social participation and support, and cognitive functioning using an assessment tool approved by the Department of Health and Senior Services), dated 07/12/24, showed the following: -The resident was admitted from an independent living facility, where he/she was not taking his/her medication and was having some falls; -The resident required supervision for bathing/grooming and was independent for transfers and ambulation. Review of the resident's records showed staff did not document completion of an ISP. 2. Review of Resident #2's face sheet showed the following: -Admission date of 04/26/24: -Diagnoses included unspecified dementia, mild with mood disturbance (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), postconcussional syndrome, syncope (fainting) and collapse, and congestive heart failure. Review of the resident's CBA, dated 04/26/24, showed the following: -The resident was admitted from a hospital where he/she was for six weeks for observation and is not able to be home alone; -The resident required supervision for bathing/grooming and is independent for transfers and ambulation. Review of the resident's records showed staff did Missouri Department of Health and Senior Services STATE FORM 6899 WA2V11 If continuation sheet 3 of 6 PRINTED: 11/21/2024 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 C 23613D B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 3 not document completion of an ISP. 3. Review of Resident #3's face sheet showed the following: -Admission date of 05/31/24; -Diagnoses included dementia in other classified elsewhere mild with mood disturbance, anxiety disorder, insomnia (a sleep disorder that makes it difficult to fall asleep or stay asleep), and low vision right eye and left eye. Review of the resident's CBA, dated 06/04/24, showed the following: -The resident was admitted from home where his/her spouse had been his/her main caregiver; -The resident requires physical assistance for bathing/grooming and is independent for transfers and ambulation. Review of the resident's records showed staff did not document completion of an ISP. 4. Review of Resident #4's face sheet showed the following: -Admission date of 08/07/24; -Diagnosis included dementia in other classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, Alzheimer's disease with late onset, and osteoporosis (bone loss). Review of the resident's CBA, dated 08/09/24, showed the following: -The resident was admitted from another memory care unit; -The resident required physical assistance for Missouri Department of Health and Senior Services STATE FORM 6899 WA2V11 If continuation sheet 4 of 6 PRINTED: 11/21/2024 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 C 23613D B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 4 bathing/grooming and is independent for transfers and ambulation. Review of the resident's records showed staff did not document completion of an ISP. 5. Review of Resident #5's face sheet showed the following: -Admission date of 09/20/24: -Diagnoses included Alzheimer's disease, insomnia, chronic pain syndrome, repeated falls, and adult failure to thrive. Review of the resident's CBA, dated 09/24/24, showed the following: -The resident was admitted from a Skilled Nursing Facility where he/she had been admitted for failure to thrive and falls; -The resident required physical assistance for bathing/grooming and supervision for transfers and ambulation. Review of the resident's records showed staff did not document completion of an ISP. 6. During an interview on 10/23/24, at 12:10 P.M., Level One Medication Aide (L1MA) B said the residents are supposed to have an ISP. He/she looks at the ISP to see if there is updates and to find out about new residents. The ISP helps him/her know more about the resident and what specific needs they may need. 7. During an interview on 10/23/24, at 12:15 P.M., L1MAC said the ISP is supposed to be available for staff to look at. It lets the staff know how much assistance the resident required. He/she was aware that some of the newer residents did not Missouri Department of Health and Senior Services STATE FORM 6899 WA2V11 If continuation sheet 5 of 6 PRINTED: 11/21/2024 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 C 23613D B. WING 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 5 have ISP's, but he/she thought the previous facility program manager was working on getting them caught up. 8. During an interview on 10/23/24, at 11:47 A.M., LPN A said the following: -She has been covering the nursing duties at the facility since last weeks. He/she was going to start looking at ISPs and making sure they were updated; -The ISP should be completed within five days of admission and every six months. It is generally completed by the nurse and the program manager; -He/she was not aware that some of the residents did not have a completed ISP. 9. During an interview on 10/23/24, at 11:34 A.M., the Administrator said the following: -The resident's ISP should be completed when a resident admits to the facility after the community-based assessment is completed -The program manager is generally responsible for completing the ISP. The facility's program director recently quit; -He/she was not aware that the some resident ISP's were not being completed upon admission. MO000244008 Missouri Department of Health and Senior Services STATE FORM 6899 WA2V11 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Name: Lakewood Assisted Living/The Arbors at Lakewood Street Address, City, Zip: 4685 S Robberson, Springfield, MO 65810 Date of Survey: 10/23/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE Immediate Action: A Plan of Care/ISP has been developed on residents #1, #2, #3, #4 & #5 as well as ail additional residents residing within the community. All Plan of Care/ISP where developed with input from both resident and legal representative. The Regional Nurse will review Policy and Procedure on Plan of Care/ISP with the Administrator and Director of Nursing on or before 12/6/2024. Ongoing Compliance: This facility will adhere to the policy of having all Plan of Care/ISP on all residents within 5 days of admission and update every six month and when a change of condition is identified. This process will include both resident and legal representative. All Plan of Care/ISP will be available to all staff at all times to aide in providing care fo resident and what specific needs they may need and that have been determined by the resident and legal representative. A4754 Director of Nursing will assure ongoing compliance through monthly review of all resident charts to assure Plan of Care/ISP are completed and appropriate to reflect the specific care and needs of the resident. Completion Date: 12/6/2024 12/6/2024 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: 12/26/2023 ; 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 Cc 12/11/2023 B. WING 23613D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE LAKEWOOD-ASSISTED LIV Y AM A d ons ae ie SPRINGFIELD, MO 65810 (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) A8030 19 CSR 30-88.010(29) Dignity/Privacy A8030 Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/IIl This regulation is not met as evidenced by: Based on record review and interview, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Medication Aide (CMA) A) became involvedina | verbal altercation with one resident (Resident #1) when the resident declined to take medication. The facility census was 46. | Review of the facility's policy titled "Exhibit F Resident Rights," revised 12/2018, showed the following: | -The resident has the right to privacy and respect | _ regarding accommodations, personal care, medical treatment, written and telephone communications, and visits with other individuals. | 4. Review of Resident #1's medical record | showed the following: -Admission date of 04/05/23; -Diagnoses included anxiety disorder, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood | , vessels that supply it), chronic obstructive pulmonary disease (COPD - a group of lung Missouri Department of Health and Senior Services lake ee R/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 22L411 If continuation sheet 1 of 7 PRINTED: 12/26/2023 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 23613D B. WING 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 1 diseases that block airflow and make it difficult to breathe), anemia (a condition in which the blood doesn't have enough healthy red blood cells), and depression. Review of the resident's Individualized Service Plan (ISP - planning document prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident ' s legal representative in partnership with the facility), dated 04/05/23, showed the following: -The resident had some memory lapse; -The resident had a sad or anxious mood; -The resident had no socially inappropriate or disruptive behaviors. Review of the resident's signed physician order showed an order, dated of 06/08/23, for Tramadol (a narcotic used to treat moderate to severe pain) 25 milligram (mg) every six hours as needed for pain. Review of a written statement from CMAA, dated 12/02/23, showed the following: -He/she went into the resident's room to see if he/she wanted to take his/her tramadol since he/she was awake; -The resident said yes; -When the CMA gave it to him/her, the resident held it in his/her hand, but would not take it; -When the CMA asked if the resident could take it real quick, the resident started yelling at the CMA to leave his/her room; -The CMA tried to explain to the resident that the CMA had to see him/her take it; -The resident began switching the medication Missouri Department of Health and Senior Services STATE FORM 6899 221411 If continuation sheet 2 of 7 PRINTED: 12/26/2023 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 23613D B. WING 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 2 between his/her hands and under the blanket; -The resident then acted like he/she took the pill by taking a sip of water, but the CMA did not see the pill; -The CMA asked the resident if the CMA could look around the bed for the pill. The resident sat up and the pill rolled out from under him/her; -The resident grabbed the pill before the CMA could get it; -The CMA decided he/she had to get the pill back; -The CMA tried to get the pill out of the resident's hand and the resident started to hit the CMA with his/her arms and other hand; -During this the CMA grabbed the tramadol from the resident. During an interview on 12/11/23, at 12:30 P.M., CMAA said the following: -He/she went to the resident's room about 6:00 A.M. on 12/02/23 and asked him/her if he/she wanted a pain pill (tramadol); -The resident said yes and he/she got the pill, popped it in a cup, and put it in the resident's hand; -The resident told the CMA he/she would not take it while the CMA was in the room; -He/she told the resident that the CMA has to see him/her take the pill; -The resident kept hiding the pill under his/her blanket, but eventually had it in his/her hand; -The CMA talked "sternly" to him/her about taking the pill, but the CMA did not yell at the resident or call him/her any names; -The resident yelled at the CMA, but the CMA could not recall what he/she said; -The CMA felt like he/she needed to take the pill back at this time, as the resident refused to take it; Missouri Department of Health and Senior Services STATE FORM 6899 221411 If continuation sheet 3 of 7 PRINTED: 12/26/2023 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 23613D B. WING 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 3 -The CMA tried to get the pill out of his/her hand. The CMA was not sure what hand the pill was in; -He/she did not pry his/her fingers open. He/she was fishing in the resident's hand; -The resident hit the CMA on the shoulder and kicked at him; -It is not the facility's policy to try and get medication out of a resident's hand; -Staff are supposed to communicate and ask for help if needed. Review of a text message from CMA D to the Program Director dated 12/02/23, at 10:00 A.M, showed the following: -He/she heard loud screaming from the resident's room around 6:00 A.M.; -CMAA was giving the resident medication and some kind of fight broke out for about 10 minutes; -The resident came out of his/her room a few minutes later looking scared and confused; -The resident said he/she got in a fight. Review of a written statement from CMA D, dated 12/04/23, showed the following: -He/She heard loud screaming from the resident's room; -CMAA was giving the resident his/her medications and some kind of fight broke out for about 10 minutes; -He/She was down the hall at the time; -The resident came out of his/her room later looking very scared, which is not like him/her; -The resident told him/her he/she got in a fight. During a phone interview on 12/11/23, at 3:25 P.M., CMA D said the following: -Around 6:00 A.M. on 12/02/23, he/she was Missouri Department of Health and Senior Services STATE FORM 6899 221411 If continuation sheet 4 of 7 PRINTED: 12/26/2023 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 23613D B. WING 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 4 across the hall (with the living room area in between) helping a resident to rise for the day; -The door to the room he/she was in was open, the door to the room CMAA was in was closed; -He/She heard the resident yelling at first. He/She yelled "get out, | don't want it."; -He/She heard CMAA yelling back at the resident, but could not make out what he/she was yelling; -This yelling went back and forth between the resident and CMAA for about 10 minutes, making him/her uncomfortable; -CMAA never asked him/her for assistance; -The resident told him/her he/she was in a fight; -He/She texted the Program Manager later that morning about the incident; -Staff is trained to walk away, ask for help, or try to give the medication again a bit later. Review of a written statement from CMA C, dated 12/02/23, showed the following: -On 12/02/23, he/she entered the resident's room at 7:55 A.M. to get the resident up for the day; -The resident's whole demeanor was different and he/she looked upset. During an interview on 12/11/23, at 10:37 A.M., CMA C said the following: -He/She began work at 7:30 A.M. on 12/02/23 to relieve CMAA; -CMAA did not say anything to him/her about any incidents overnight; -He/She helped the resident to get up and ready for the day, per usual: -The resident was not acting normal; -He/She called the Program Director right away; -Staff are trained to walk away from a situation in which they are becoming frustrated, try a different Missouri Department of Health and Senior Services STATE FORM 6899 221411 If continuation sheet 5 of 7 PRINTED: 12/26/2023 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 23613D B. WING 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 5 approach, or get a team member to help. Review of the written statement from the Program Director, dated 12/02/23, showed the following: -He/She saw a text from CMAA around 8:00 A.M. on 12/02/23, time stamp of 6:42 A.M.; -The resident and CMAA had an altercation; -At 8:08 A.M. CMAC phoned him/her and stated the resident had a different demeanor than normal. During an interview on 12/11/23, at 10:05 A.M., the Program Director said the following: -He/She received a text from CMAA from about 6:00 A.M., on 12/02/23 but he/she did not see the text until about 8:00 A.M.; -It is not appropriate for a staff member to try and get a pill out of a resident's hand; -If staff are having problems getting a resident to take medication, they are supposed to ask for help from another staff member, walk away from the situation, or try to give the medication a bit later; -A resident has a right to refuse medication; -CMAA told him/her that the resident refused to take the medication after asking for it. During an interview on 12/11/23, at 9:37 A.M. the Administrator said the following: -He/She was contacted by the memory care Program Director the morning of 12/02/23 about an incident involving CMAA and the resident. Review of the written statement from the Administrator, dated 12/02/23, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 221411 If continuation sheet 6 of 7 PRINTED: 12/26/2023 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 23613D B. WING 12/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4685 ROBBERSON AVENUE SPRINGFIELD, MO 65810 (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) LAKEWOOD-ASSISTED LIVING BY AMERICAR Continued From page 6 -He/She was contacted at 8:50 A.M., on 12/02/23, by the Program Director of the Arbors (memory care unit) regarding an alleged staff to resident incident. Review of written statement from the Administrator, dated 12/06/23, showed the following: -It was the facility's conclusion the resident was upset about taking a medication and the employee did not show good judgement in redirecting the resident. M000228230 Missouri Department of Health and Senior Services STATE FORM 6899 221411 If continuation sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier The Arbors at Lakewood Name: Street Address, City, Zip: 4681 S Robberson, Springfield, MO 65810 Date of Survey: 42/11/2023 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 A8030 The filing of this plan of correction does not constitute any | 01/09/2024 admission by the facility regarding the alleged violation stated in the summary Statement of Deficiencies dated 12/11/2023 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. Immediate Action: The Arbors at Lakewood will treat each resident with consideration, respect and full recognition of his/her dignity and individuality thru the following training. All staff have attended were inservice on 1/2/2024 regarding Dignity & Respect, Resident Rights review and appropriate training methods. Inservicing included: e Notification of Leadership and Communication e Outlined Dignity & Respect using scenarios and examples e Resident Rights Review CMA A will be required to attend one on one training with Program Manager and Administrator regarding appropriate managing of resident behaviors and on deescalating behaviors. Initial training started on 12/6/2023 and additional training was completed 1/2/2024 and will continue for the next 90 days. CMA A was Assigned additional Relias Course training on the following courses: e Teepa Snow Challenging Behaviors e Essentials of Resident Rights e Teepa Snow Its all in Your Approach e Communication and People with Dementia Ongoing Compliance: Administrator will assure ongoing compliance through providing monthly inservicing to include education to all staff on Resident Rights and Managing residents with behaviors. Completion Date: 01/09/2024 | 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. ree ‘fyleu