SPRINGHOUSE VILLAGE.

PRINTED: 03/17/2026 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 (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING: B. WING 03/12/2026 32469 STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGHOUSE VILLAGE SPRINGFIELD, MO 65802 NAME OF PROVIDER OR SUPPLIER (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(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to screen residents as required when staff failed to complete the required annual evaluation to rule out signs and symptoms of tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) for two residents (Resident #1 and #2) The facility census was 97. General requirements for Tuberculosis Testing for Employees and Residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents using the Mantoux method PPD five tuberculin unit test (TST - skin test). Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -If the initial test is negative, the second test should be given as soon as possible within three weeks; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Review of the facility policy titled "Tuberculosis: Residents," undated, showed the following: -The Community may screen residents at time of admission and readmission for information Missouri Department of Health and Senior Services (X6) DATE 23BE11 H continuation shéet 1 of 3 PRINTED: 03/17/2026 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 32469 B. WING 03/12/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 1 regarding exposure to or symptoms of TB; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD two step tuberculin test; -If the initial test is negative, zero to nine millimeters, the second test should be given one to three weeks later; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. 1. Review of Resident #1's medical record showed the following: -Admission date of 12/15/23; -Diagnoses included edema (the swelling of body tissues caused be excess fluid build up) and cerebrovascular disease (conditions affecting blood flow and vessels in the brain, such as stroke); -Staff last documented an annual TB screening on 12/31/24. 2. Review of Resident #2's medical record showed the following -Admission date of 10/03/23; -Diagnoses included chronic kidney disease (the long-term, progressive loss of kidney function), and high blood pressure; -Staff last documented an annual TB screening on 10/14/24. 3. During an interview on 03/12/26, at 4:50 P.M. the Director of Health and Wellness said the following: -A new company took over the facility several months ago and he/she was not sure what form they were using for resident annual TB screenings; -He/She knew the residents need an annual Missouri Department of Health and Senior Services STATE FORM 6899 23BE11 If continuation sheet 2 of 3 PRINTED: 03/17/2026 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 32469 B. WING 03/12/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 (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) SPRINGHOUSE VILLAGE Continued From page 2 evaluation to rule out signs and symptoms of TB; -He/She was responsible for resident TB testing. Missouri Department of Health and Senior Services STATE FORM 6899 23BE11 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: Springhouse Village Street Address, City, Zip: 3877 E Farm Rd 132, Springfield, Mo. 65802 Date of Survey: March 12, 2026 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) The facility shall screen residents and staff for tuberculosis as required for LTC facilities as evidenced by: 1. All resident charts will be reviewed for Tuberculosis screening by the Director of Health and Wellness and Memory Care Nurse 2. All residents who have not been screened for tuberculosis will be screened for tuberculosis A4724 utilizing the Resident TB Test Consent, Screening & Documentation form 3. Going forward, all annual Tuberculosis screens will be done when the resident’s annual assessment is due and completed 4. To be monitored by the Director of Health and Wellness and Executive Director through annual assessments and periodic chart reviews COMPLETION DATE March 31, 2026 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: 05/14/2025 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 Cc 32469 i 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 (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) SPRINGHOUSE VILLAGE 19 CSR 30-86.047(37) Appropriate Action & 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/II This regulation is not met as evidenced by: Class Il Based on observation, interview, and record review, the facility failed to take appropriate action after a change in condition when staff failed to failed to complete a full nursing assessment and complete ongoing monitoring, failed to address signs and symptoms of pain, failed to contact physician to obtain direction, and failed to notify the management and the resident's family of a continued decline in condition for one resident (Resident #1) who suffered an unwitnessed fall. The facility census was 94, Review of the facility's policy titled "Falls," undated, showed the following: -If a resident falls, care managers are instructed to summon immediate assistance from the Director of Health and Wellness, or certified medication technician (CMT)/level one medication aide (LIMA) on duty; -The Director of Health and Wellness or the CMT/LIMA will perform a brief overview and Missouri Department of Health and Senior Services ROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE (Karen Dobson. 20-2 6899 NTWH11 If continuation sheet 1 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 1 inspection for head injury, bleeding, or obvious deformities; -The Director of Health and Wellness or CMT/LIMA checks for range of motion ability; -The Director of Health and Wellness or care managers will call emergency medical services (EMS) if the resident has trauma resulting in deformity, exhibits any change in level of consciousness, or received obvious head or significant trauma; -The resident's physician is contacted immediately for further instructions, if the resident did not hit their head, denies pain or discomfort, and has usual range of motion. The physician communication form may be used; -The Director of Health and Wellness or designee will notify the resident's family and/or responsible party immediately, providing information about the Community's response to the resident's fall; -For 48 hours after the fall, the Director of Health and Wellness or designee on each shift will monitor the resident and make a brief narrative charting entry; -The Director of Health and Wellness or designee will document the fall and complete all required incident reports Review showed the facility did not provide a policy regarding pain management. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed an admission date of 01/13/25. Review of the resident's pre-screening and assessment for admission to assisted living facilities, completed on 01/13/25, showed the following: -Resident performed tasks independently, was ambulatory, could transfer to and from bed and to Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 2 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 2 and from chair, and could complete his/her own dental care, hair care. and shaving; -Resident needed some assistance for bathing (set up), -Resident was well oriented, followed instructions, and was sociable; -Resident was not socially inappropriate and did not have disruptive behavior; -Resident was not sad or anxious or diagnosed or treated for a mental illness or developmental disability. Review of the resident's Individualized Service Plan (ISP - planning document prepared by the facility 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), completed on 01/13/25, showed the following: -Independent with walking; -No history of falls; -Participates in activities and socializes; -Staff reminders for bathing; -May need assistance with gathering supplies and getting in/out of shower and occasional reminders or direction to participate in activities, supervision with ADLs; -Staff to administer medication. Review of resident's physician order sheet, dated 04/01/25, showed the following: -Diagnosis included dementia (decline in mental ability that interferes with daily life), cerebral atrophy (progressive loss of brain cells), and anxiety (feelings of worry, unease, or nervousness). (Staff did not have orders on file for any pain medications.) Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 3 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 3 Review of the resident's April 2025 Progress Notes showed the following: -On 04/22/25, at 7:30 P.M., staff found the resident in his/her room in his/her recliner saying help. The resident said he/she fell in the room in front of his/her bed. After LIMA A walked around the room, it appeared the resident had fallen in the bathroom where there was blood stains in the shower, near the toilet, and on the grab bars. The resident had skin tears to his/her left hand and left elbow. The resident complained of pain to right upper shoulder, but could move all four extremities. Resident was fully conscious at this time. Resident had nothing ordered to give for pain. Staff obtained vitals of blood pressure 156/97 millimeters of Mercy (mm/Hg) (normal range is lower than 120/80 mg/Hg), temperature 98.3 degrees Fahrenheit (F), pulse of 79 beats per minute (bpm), oxygen 96%, and respirations of 18 per minute. Staff notified family by voicemail and doctor notified by fax of the fall. Staff will continue to monitor. (Staff did not document actions taken to address resident pain, did not document an attempt to obtain an order for pain medication, did not document a full nursing assessment, did not document a physician phone call, and did not document notification of the Director of Wellness regarding the fall.) -On 04/22/25, at 10:00 P.M., CMT B completed vitals for 9:30 P.M. and noticed the resident had bleeding. Second shift said the resident had fallen. The resident could not walk straight, complained about his/her neck and his/her left side hurting. He/she wet the bed twice and wouldn't stop moving. The resident was up all night. The resident seemed confused and asked for multiple cups of water. Staff reported everything to the nurse. (Staff did not document actions taken to address the resident's pain, did not document an attempt to obtain an order for Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 4 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 4 pain medication, did not document a full nursing assessment, did not document a physician phone call regarding the resident's decline in condition, and did not document notification of the resident's family of the resident's decline in condition.) -On 04/23/25, at 5:43 A.M., the Health Care Coordinator noted upon entering resident room, he/she noted the resident was in bed on his/her left side. Upon touching the resident, he/she opened his/her eyes and then closed them. He/she checked the resident's vitals checked and found the resident's blood pressure was 176/88 mm/Hg, pulse was 80 bpm, respirations were 18 per minute, and temperature was 98 degrees F. The resident's pupils reacted to light. The resident noted to have a small brown emesis. Resident had left hand with kerlix wrap (a gauze wrap) and right forearm had purple bruising the length of his/her arm. The top of the resident's head, towards back in middle, had dry blood of a 2 cm X 1 cm area with no active bleeding. He/she asked resident if he/she was able to roll self onto his/her back so range of motion (ROM) could be checked. The resident then yelled out in pain and grabbed his/her neck. He/she directed the resident to remain still. Staff called the resident's family members to inform them of the assessment and told them the resident was being sent to the emergency room for evaluation. The family members agreed. Staff called 911 at 5:47 A.M. and they arrived at 6:05 A.M. to take resident to the hospital. Review of the resident's Neurological Flow sheet, beginning 04/22/25, showed the following: -Direction for vital signs and neuro checks to be completed every 15 minutes for one hour, every 30 minutes for one hour, every 1 hour for four hours and every 4 hours for twenty four hours; -Staff began vital signs on 04/22/25 at 7:30 P.M.; Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 5 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 5 -All vitals were checked every 15 minutes for one hour and every 30 minutes for one hour; -Beginning 04/22/25, at 9:30 P.M., through the time the resident was sent out on 04/23/25 the level of consciousness, staff did not document checks of movement, hand grasps, pupil size, pupil reaction, and speech were not documented as being checked. During interviews on 04/28/25, at 1:32 P.M., and on 04/29/25, at 9:05 A.M., LIMAA said the following: -When a resident had a fall, the med tech assessed the resident by checking all four extremities to see if they would bend at 90 degrees, looked for pain, completed vitals, and assessed back for injuries or skin tears; -If the Director of Wellness was not at the facility, the staff reached out to the emergency contact; -lf the fall was unwitnessed, or it can't be determined the resident hit their head, staff start neurochecks; -He/she was not sure how often the neurochecks were completed. He/she complete them based upon the neurological flow sheet; -He/she got off at 9:30 P.M., on 04/22/25; -He/she walked into the resident's room and the resident was sitting in the recliner; -He/she asked the resident if he/she was okay. He/she didn't see any signs of a fall in the resident's room, so he/she went into the bathroom, and found blood on the shower, toilet, and grab bars; -The shower was not wet, and the resident had on his/her shoes and had not taken a shower; -The resident had a skin tear on his/her left hand; -The resident was calm, but the resident said he/she had a crook in his/her neck; -LIMA completed an assessment and looked for other injuries. The resident was able to move Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 6 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 6 his/her arms up and he/she didn't see any other issues; -The resident continued to say his/her neck had a crook in it and did report pain in his/her right shoulder; -He/she took the resident's vitals which were fine. The only issues he/she saw were the skin tear on the hand and elbow. He/she completed first aide; -He/she called the Director of Health and Wellness. He/she told him/her the resident had a fall and had the skin tears to the hand and elbow, the vitals were fine, but the resident was having some pain in the shoulder. The resident reported a crook in his/her neck. He/she was told to administer the resident Tylenol; -He/she looked after hanging up the phone and the resident did not have orders for pain medication; -He/she did not call the Director of Wellness back to let him/her know there were no orders for pain medication; -The Resident didn't rate his/her pain levels, only said there was a crook in his/her neck and he/she had pain in the right shoulder; -He/she called the emergency contact and they did not answer so he/she left a voicemail. He/she didn't recall exactly what the voicemail said, only that the resident had fallen, and had skin tear; -He/she began the vitals on the resident and he/she had no complaints other than the crook in his/her neck and the shoulder pain. The resident had no changes in his/her behavior; -If there was no order for pain medications he/she had been directed in the past to wait or send the resident out if it's at night. He/she didn't feel like the resident needed to be sent to the hospital; -He/she had not been taught to complete fall assessments, only told what needs to be done like ROM, first aid and asking about pain. Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 7 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 7 During an interview on 04/29/25, at 2:52 P.M., Resident Assistant (RA) D said the following: -When he/she found a resident after a fall, he/she got the med techs; -The med techs completed an assessment before the resident was moved; -The med tech called the nurse, family, and the doctor; -He/she was familiar with the resident and worked until 9:30 on 04/22/25; -LIMAA called him/her to the resident's room when the LIMA found the resident had fallen; -When the RA arrived, the resident was sitting in his/her recliner; -He/she saw blood in several places in the bathroom and the shower wasn't wet. It looked like prints from the hand where the resident tried to get up; -LIMAA completed and assessment and he/she assisted. They only found the skin tear on the hand. They checked the head and did not see any redness, bumps, or open areas; -The resident complained of pain on his/her right side of the back and the lower part of the neck, about the hairline on the same side; -He/she stayed with the resident while the LIMA went to see if the resident had an order for pain medication. He/she didn't believe the resident did have an order, but he/she wasn't certain; -He/she knew LIMA A called various people. He/she was there for one call, but he/she wasn't sure who the call was too; -The resident was mostly independent. He/she went to the toilet on his/her own, dressed him/herself, and the staff do stay in the room when the resident showers to be there if there was a fall; -The resident had no problems walking. He/she would come out for afternoon coffee and walk down the hall. The resident liked to walk outside a Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 8 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 8 lot; -He/she did see the resident one other time before his/her shift ended and the resident continued to complain of pain and LIMAA was taking care of him; -He/she was leaving for the day and was told the resident was bleeding from his/her head; -He/she thought maybe the resident had the injury and was messing with it and caused it to open up. During an interview on 04/28/25, at 1:56 P.M., CMT B said the following: -When a resident falls, he/she will assess the resident and determine if it's okay to move the resident; -He/she asks the resident questions to determine what happened. Sometimes they are able to say and other times they are not; -He/she would call the Director of Wellness, the resident's family, and fax the physician; -If the fall was not witnessed, or if he/she was not able to tell whether the resident hit their head, neurochecks and vitals were completed as directed by the neurological flow sheet, every 15 minutes for and hour, every 30 minutes for an hour, every hour for four hours and every four hours for 24 hours; -On 04/22/25, he/she was supposed to work in the assisted living area, but got moved to the memory care unit; -He/she was not familiar with residents in the memory care unit; -He/she did not receive a full report from the off going staff in the unit. They gave that to another staff member; -He/she was told some information from the resident care aide that was working in the unit, that the resident had fallen; -He/she went into the resident's room around Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 9 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 9 9:30 to do the vitals and neurochecks; -The resident's head, towards the bottom in the back, was bleeding and had been bleeding as the pillow case had blood on it. He/she could see some skin peeled back on the resident's head. The resident was also complaining of pain at the back of his/her neck and the left side; -He/she was concerned so he/she got the staff that received report and that staff said he/she was not told the resident had a head injury; -The resident's temperature was also a little high so he/she called the Director of Wellness to let him/her know the resident's head was bleeding and the resident's temperature was higher than normal, and the resident was complaining of pain. The Director of Wellness said to clean the wound and if the temperature didn't go back down, to call him/her back. The CMT told the Director of Wellness the resident did not have a medication for pain and no further direction was provided; -He/she had not worked with the resident before, but other staff said the resident normally slept through the night and was able to do most things for him/herself. -The resident was up and down all night and was confused. The resident would be roaming around his/her room, came into the hall several times, as well as peed in his/her bed two times; -He/she called the nurse when there was a change in condition with a resident. That is why he/she called the on-call nurse; -He/she checked on residents every two hours. He/she saw the resident every couple of hours as he/she would only sleep 10 to 15 minutes at time; -He/she completed the neurochecks and documented them, however, if some were the same he/she didn't always document the top half of the sheet; -He/she told the on coming nurse as soon as he/she arrived and the Healthcare Coordinator Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 10 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 10 came, assessed the resident, and sent him/her out to the hospital. During an interview on 04/28/25, at 12:32 P.M., the Memory Care Unit Director said the following: -When a resident had a fall, the resident was not to be moved and vitals were obtained; -Staff were to call the nurse on-call if there was no nurse in the building. Staff should also call the physician and the family; -He/she wasn't sure what all was supposed to be done in relation to vitals as he/she was not a nurse. During an interview on 04/28/25, at 2:49 P.M., LIMA C said the following: -When a resident had a fall, they're not moved and the nurse assessed the resident. If the fall occurred after hours, the LIMA's assess the resident. The family was called and the physician was made aware of the fall; -The resident was assessed for ROM, knees and arms moving properly without pain, observations for injuries, and neurochecks and vitals were started; -The nurse directed staff on how often to do vitals and neurochecks; -If a resident's condition changes after a fall, staff should with their judgement and if needed follow=up with the family again. During an interview on 04/30/25, at 2:50 P.M., the physician said the following: -He/she followed the resident for his/her chronic disease management; -He/she was sent a notification on 04/22/25 that the resident had an unwitnessed fall, with a skin tear to the left hand and elbow; -If the resident hit his/her head, they would need to be assessed; Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 11 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 11 -The resident did not have orders in his/her chart for Tylenol; -If the resident was having pain, the facility should have called their on-call and since the on-call was not able to prescribe narcotics, and since they couldn't be seen at the clinic after hours, they would have ordered the facility to send the resident for an evaluation; -He/she did not receive any calls from the facility. During interviews on 04/28/25, at 11:45 A.M. and 12:40 P.M., the Healthcare Coordinator said the following: -When residents have a fall, either him/herself or the Director of Health and Wellness assess the resident; -The assessment included ROM to each limb, assessing for pain, any visible injuries, vitals, and neurochecks are started; -Neurochecks were completed every 15 minutes for an hour, every 30 minutes for four hours, and every 4 hours for three days; -If a nurse was not in the building, staff were to call the Director of Health and Wellness as he/she was on call all the time; -Staff notified hospice if the resident was on hospice and notified the physician by fax unless they suspected an injury. In that case staff would call the physician. Staff would also call the family; -He/she came in the morning of 04/23/25, at 5:30 A.M., and shortly after arriving the staff came to him/her and said the resident had fallen; -He/she went to the resident's room and the resident was laying on his/her left side, and there was coffee ground emesis coming out his/her mouth; -The resident was normally happy and will respond appropriately. The resident did not have his/her normal response and this was a red flag; -He/she checked the resident's vitals and when Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 12 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 12 he/she went to move the resident's arm, the resident screamed in pain; -He/she called one family member and had no answer so he/she called the other family member and he/she said to send the resident out so He/she called 911; -He/she was told the second shift heard the resident hollering for help, they went into the resident's room, and he/she was sitting in the recliner; -The LIMA noted blood on the resident's hand and asked the resident what happened. The Resident said he/she fell at the foot of the bed, but staff found blood in the bathroom; -He/she didn't know if anyone assessed the the resident as there was no nurses in the building. Staff called the Director of Health and Wellness, whose on call, and he/she gave direction; -The physician and family should be called as soon as the resident was stable. He/she was told one of the family members were called, but he/she didn't know if there was any follow up later in the night; -Since the resident complained of pain, and did not have an order for pain medication, the staff should have called 911 and sent the resident to the emergency room; -Staff were supposed to be rounding to check on resident every two hours; -After falls, the staff complete neurochecks per the directions, and the neurochecks include vitals, looking at pupils, and hand grip. During an interview on 04/28/25, at 12:05 P.M. and 1:49 P.M., the Director of Health and Wellness said the following: -When a resident falls, the staff were to summons a med tech or aide to the room to start an assessment; -The LIMA or CMT will complete ROM, look for Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 13 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 13 injury, begin first aide if necessary, ask the resident about pain and discomfort,complete vitals, and contact the doctor and family; -If a nurse was not in the building, the staff were to call the on-call nurse. Either he/she or the Healthcare Coordinator were the on-call nurses; -lf the staff become aware of a fall, and the resident had already moved themselves, staff should ask the resident what happened and continue with the assessment and contacts; -When a resident falls and they are not able to tell you if they hit their head, or if it's unwitnessed, staff were to complete neurochecks per the neurological flowsheet; -On 04/22/25, he/she received a call between 7:30 P.M. and 8:00 P.M. from staff; -He/she was told the LIMA checked the resident for injuries, completed ROM and all extremities were able to moved, and no pain reported. The resident did have a skin tear to the hand and first aide was applied; -Staff faxed the doctor and notified the responsible party; -When there was a fall, the physician was always faxed to inform him/her of the fall or when the resident was sent out; -The staff did not tell him/her when they called the resident was having pain. If he/she would have been told the resident was having pain, he/she would have told staff to send the resident to the emergency room; -Staff did notify the resident's family but they did not answer so a voicemail was left with them;. -Staff don't usually call the family again. -He/she trains the LIMA's when hired on how to assess a resident after a fall and they're taught to never move the resident until they're assessed and it's safe to move the resident; -The vitals were to be completed as directed on the neurological flow sheet; Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 14 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE Continued From page 14 -He/she looked at the neuro sheet for the resident from 04/22/25. The sheet showed the staff last completed the level of consciousness, movement, hand grasps, pupil size, pupil reaction and speech at 9:00 P.M. Staff continued checking vitals (blood pressure, temperature, respirations) until the resident was sent to the hospital at 5:30 A.M.; -All vitals were to be completed per the flow sheet or until the resident is sent out; -He/she was not told the resident had pain and had no orders for pain medication; -If the had pain, and it's after normal hours with no orders for pain meds, the resident should be sent to the emergency room.; -The resident should have been sent to the emergency room since he/she was having pain; -If the resident's condition declined after a fall, staff should contact the famiy and make them aware of the change in condition. During an interview on 04/28/25, at 3:00 P.M., the Director of Health and Wellness and the Executive Director said the following: -When a resident falls, the LIMA was called to assess the resident and this would include ROM, pain levels, discomfort, asking the resident if they had pain, and looking for injuries. The staff were to call the on-call nurse if the nurse was not in the facility; -The on-call nurse would determine if the resident needed to be sent to the hospital; -If the resident's condition declined, or changed, the staff should call the on-call nurse and the family to update them on the changes; -If the resident was in pain, and had no pain medications ordered, the resident should be sent to the hospital; -LIMAs were trained to complete assessments and the neuro flow sheet, They expected staff to Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 15 of 16 PRINTED: 05/14/2025 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 32469 B. WING 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 (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) SPRINGHOUSE VILLAGE Continued From page 15 complete an assessment and the neurochecks as directed. M000253200 Missouri Department of Health and Senior Services STATE FORM 6899 NTWH11 If continuation sheet 16 of 16 PLAN OF CORRECTION Name: Provider/Supplier Springhouse Village Street Address, City, Zip: 3877 E Farm Rd 132, Springfield, Mo. Date of Survey: April 28, 2025 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A4T78B The facility will take appropriate action to ensure that after a change of condition, staff will assess, monitor, and address signs and symptoms of pain, and follow protocol to ensure the resident's family and physician are notified timely as evidenced by: May 23, 2025 1. The Director of Health and Wellness provided training for all CMA’s and CMT’s regarding change of condition and notification of physician and family on April 27-29. The physician communication form was reviewed as part of the training, for non injury incidents. The CMA’s and CMT’s understand the importance of following through with ensuring that if a resident does not have pain medication and is in pain, they will call the physician and the nurse on call for direction. April 29, 2025 2. The Director of Health and Wellness provided training for ail CMA’s and CMT’s regarding why they should call the DHW and family/physician on all falls on April 27-29. If the resident family member does not answer, a message will be left and the staff will be expected to call every few minutes until a family member is reached. If the family member does not answer, the staff was trained to call the on-call nurse back after 15 minutes and make them aware that they were not able to reach a family member. April 29, 2025 3. The Director of Health and Wellness provided training for all CMA’s and CMT’s regarding assessing a resident following a fall/reported fall on April 27-29, and what constitutes a no injury incident. This training included the Arvum falls policy. April 29, 2025 4. The Director of Health and Wellness provided training to ensure that the CMA’s and CMT's understand what needs to be charted following an incident on April 27-29, not only in the nurses notes, but also on the neurocheck form, ie: Head Injury Monitoring Log and how to utilize the form. April 29, 2025 5. The Director of Health and Wellness provided training to ensure that the CMA’s and CMT’s understand the incident reporting process, not only on the incident April 29, 2025 report form, but providing information shift to shift. | 6. The resident noted on the resident list involved in the cited deficiency is no longer in the community. 7. The residents who are a fall risk are identified through the evaluation process, which includes assessment and Morse fall scale, and monthly assessments. The ADHW reviewed the previous month of falls, and ensured that all had a fall assessment. The MC nurse reviewed all medication records, and requested prn pain meds from the residents physician, if the resident did not have a prn med order on their chart. All new residents will have their meds reviewed by the DHW, ADHW or MC nurse on admission, and a request for prn pain meds will be sent to the physician, if they do not have an order. CMA’s and CMT’s reviewed a paper program regarding the follow through on pain medication requests. 8. To be monitored by the Director of Health and Wellness, or her designee by review of incident reports, nurses notes, and follow of up of fails/incidents the next morning following injuries after business hours. April 23, 2025 May 23, 2025 April 30, 2025 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: 01/11/2024 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 B.WING 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 (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) SPRINGHOUSE VILLAGE EAST LLC A2286) 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview on January 4, 2024, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. The facility census on January 4, 2022, was 96. This deficiency potentially affects 96 of 96 residents. Observation of the following resident rooms showed a non-compliant wastebasket(s) being used for trash: ~ 101 ~ 121 (2 non-compliant wastebaskets) ~ 126 ~ 201 ~ 204 ~ 207 ~214 ~218 ~219 ~ 222 ~ 225 ~ 228 ~ 230 (3 non-compliant wastebaskets) Observation of the Memory Care Activity office showed a non-compliant wastebasket being used for trash. During an interview on January 4, 2024, at 12:20 P.M., the Administrator said he/she did not know there were so many non-compliant wastebaskets Missoug. ealth and Senior Services R PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE eutw’, (X68) DATE Ko Buactr | STATE FO 6a99 MTIH11 If continuation sheet 1 of 2 PRINTED: 01/11/2024 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 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 (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) SPRINGHOUSE VILLAGE EAST LLC 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. Il This regulation is not met as evidenced by: Class II Based on observation and interview on January 4, 2024, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. The facility census on January 4, 2022, was 96. This deficiency potentially affects 96 of 96 residents. Observation of the following resident rooms showed a non-compliant wastebasket(s) being used for trash: ~ 101 ~ 121 (2 non-compliant wastebaskets) ~ 126 1201 ~ 204 ~ 207 ~ 214 ~ 218 ~ 219 e222 225 ~ 228 ~ 230 (3 non-compliant wastebaskets) Observation of the Memory Care Activity office showed a non-compliant wastebasket being used for trash. During an interview on January 4, 2024, at 12:20 P.M., the Administrator said he/she did not know there were so many non-compliant wastebaskets Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MTIH11 If continuation sheet 1 of 2 PRINTED: 01/11/2024 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 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 (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) SPRINGHOUSE VILLAGE EAST LLC A2286 | Continued From page 1 in the facility, but will remove them all immediately. Missouri Department of Health and Senior Services STATE FORM 6899 MTIH11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier ; ; Narnia: Springhouse Village Street Address, City, Zip: 3877 E Farm Rd. 132, Springfield, Mo. 6802 Date of Survey: January 4, 2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | ID PREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The community will ensure that only metal or UL listed fire resistant rated wastebaskets will be used for trash as evidenced by: *All non-compliant trash cans were removed from resident rooms by maintenance personnel per Fire Marshal list. *A letter was sent to family members by the Executive Director to make them aware that illegal trash cans in resident rooms would be removed and will need to be picked up within 2 weeks. *A letter was given to all residents by the Executive Director regarding the illegal trash cans, to ensure they knew the trash cans would be removed from their rooms and why. *A memo was sent to staff by the Executive Director to ensure they are aware of the fire safety regulation and so they can assist in keeping unsafe items out of resident rooms. *An additional safety round was completed by maintenance to ensure no other unsafe items were found in resident rooms. “To be monitored by maintenance on daily rounds and when repairs are made in resident rooms, and monthly rounds by the Executive Director through the QA process to ensure mpliance of 19CSR 30-86,022 (15 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.

1-Dec-2023 86:15 14176956298 14177683483 p.2 12/01/2023 10:25 (FAs) P,O02/005 PR ORLA: 11/17/2023 Missouri Department of Health and Senior Services. APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFIGATION NUMBER: (<3) DATE SURVEY COMPLETED (M2) MULTIPLE CONSTRUCTION A. BUILDING: B, WING 32469 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 BAST FARM ROAD 132 SPRINGHOUSE VILLAGE EAST LLC SPRINGFIELD, MO 65802 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE GROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFIGIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} A4749| 19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day The facility may admit or retain an individual for residency In an assisted living facility only if the individual doés not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined In section (4) of this rule: 1. Time frame requirements for assessment shall be: A. Within five (5) calendar days of admission; II This regulation is not mat as evidenced by: Based on record review and interview, the facllity failed to completa community based assessments (CBA- a state mandated assessment instrument required to ba completed by a certifled facillty staff) with five calendar days of admission for five out of nine sampled residents (Resident #1, #3, 44,45, and #7). The facility cansus was 95, Review showed the facility did not provide a policy related to completion of CBAs, 1. Review of Resident #1's medical record showed the following: -Admission date of 09/01/23; -Diagnoses Included diabetes mellitus I! (metabolic disorder that Increases blood sugar dua to the bodies Inability to produce insulin): -No CBA in chart. 2. Review of Resident #3's medical racord showed the following: RIHUPPLIER REPRESEN Missoun De i LABORATORY DIREC TORS F eo ATIVE'S SIGNATURE ; wach’, - (X8) DATE STATE FORM a, a ETT} BHTZ11 lFeontinuation sheet 1 of & foalt dSenior Services State of Missouri 4178956290 12/01/2023 10:16AM Pg 02/05 PRINTED: 11/17/2023 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 32469 B. WING 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE EAST LLC Continued From page 1 -Admission date of 08/24/22: -Diagnoses included hypertension (high blood presses); -No CBA in chart. 3. Review of Resident #4's medical record showed the following: -Admission date of 06/27/22. -Diagnoses included hypertension; -No CBA in chart. 4. Review of Resident #5's medical record showed the following: -Admission date of 08/12/22. -Diagnoses included hypertension; -No CBA in chart. 5. Review of Resident #7's medical record showed the following: -Admission date of 09/07/22: -Diagnoses included atrial fibrillation (irregular or fast heat beat). -A blank CBA in the resident's chart. 6. During an interview on 11/07/23, at 5:20 P.M., the facility's Wellness Director/Licensed Practical Nurse (LPN) said he/she was not aware the CBA's were not done, he/she thought that they were up to date. He/she stated completion of CBAs was his/her responsibility. 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually The facility may admit or retain an individual for residency in an assisted living facility only if the Missouri Department of Health and Senior Services STATE FORM 6899 8HTZ11 If continuation sheet 2 of 8 PRINTED: 11/17/2023 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 32469 B. WING 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE EAST LLC Continued From page 2 individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; II This regulation is not met as evidenced by: Based on record review and interview, the facility failed to complete community based assessments (CBA - a state mandated assessment instrument required to be completed by a certified facility staff) at least semiannually for eight out of nine sampled residents (Resident #2, #3, #4,#5,46,#7,#8, & #9). The facility census was 95. Review showed the facility did not provide a policy related to completion of CBAs. 1. Review of Resident #2's medical record showed the following: -Admission date of 09/17/21. -Diagnoses included acute kidney injury (decrease in kidney function);. -Staff last completed a CBA for the resident on 03/08/23 (eight months prior). 2. Review of Resident #3's medical record showed the following: -Admission date of 08/24/22: -Diagnoses included hypertension (high blood presses): -No CBA in chart. Missouri Department of Health and Senior Services STATE FORM 6899 8HTZ11 If continuation sheet 3 of 8 PRINTED: 11/17/2023 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 32469 B. WING 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE EAST LLC Continued From page 3 3. Review of Resident #4's medical record showed the following: -Admission date of 06/27/22. -Diagnoses included hypertension; -No CBA in chart. 4. Review of Resident #5's medical record showed the following: -Admission date of 08/12/22. -Diagnoses included hypertension; -No CBA in chart. 5. Review of Resident #6's medical record showed the following: - Admission date of 09/27/21; -Diagnoses included hypertension; -The facility staff last completed a CBA on 03/08/23 (eight months prior). 6. Review of Resident #7's medical record showed the following: -Admission date of 09/07/22: -Diagnoses included atrial fibrillation (irregular or fast heat beat). -A blank CBA in the resident's chart. 7. Review of Resident #8's medical record showed the following: -Admission date of 04/03/21; -Diagnoses included chronic kidney disease (gradual loss of kidney function that can lead to kidney failure); -The facility staff last completed a CBA on 05/03/21 (over two year prior). Missouri Department of Health and Senior Services STATE FORM 6899 8HTZ11 If continuation sheet 4 of 8 PRINTED: 11/17/2023 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 32469 B. WING 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE EAST LLC Continued From page 4 8. Review of Resident #9's medical record showed the following: -Admission date of 05/14/21; -Diagnoses included fraility (overall decline in health, increased likelihood of falls and decreased immunity); -The facility staff last completed a CBA on 11/09/22 (one year prior). 9. During an interview on 11/07/23, at 5:20 P.M., the facility's Wellness Director/Licensed Practical Nurse (LPN) said he/she was not aware the CBA's were not done, he/she thought that they were up to date. He/she stated completion of CBAs was his/her responsibility. 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 Missouri Department of Health and Senior Services STATE FORM 6899 8HTZ11 If continuation sheet 5 of 8 PRINTED: 11/17/2023 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 32469 B. WING 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE EAST LLC Continued From page 5 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. WAIT This regulation is not met as evidenced by: Class II|* Based on record review and interview, the facility failed to annually review advance directives with each resident or his/her next of kin, legally authorized representatives or designees for seven out of nine sampled residents (Resident #2, #4, #5, #6,#7,#8 and #9). This had the potential to affect care of at least these seven residents in the case of an emergency situation. The facility census was 95. Review showed the facility did not provide a policy related to the review of advance directives. 1. Review of Resident #2's medical record showed the following: -Admission date of 09/17/21; -Diagnoses included acute kidney injury (decrease in overall kidney function); -Staff did not document reviewing advance directive information with the resident or his/her next of kin, legally authorized representatives or designees, annually since admission. 2. Review of Resident #4's medical record showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 8HTZ11 If continuation sheet 6 of 8 PRINTED: 11/17/2023 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 32469 B. WING 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE EAST LLC Continued From page 6 -Admission date of 06/27/22: -Diagnoses included hypertension (high blood pressure); -Staff did not document reviewing advance directive information with the resident or his/her next of kin, legally authorized representatives or designees, annually since admission. 3. Review of Resident #5's medical record showed the following: -Admission date of 08/12/22; -Diagnoses included hypertension; -Staff did not document reviewing advance directive information with the resident or his/her next of kin, legally authorized representatives or designees, annually since admission. 4. Review of Resident #6's medical record showed the following: -Admission date of 09/27/21; -Diagnoses included hypertension; -Staff did not document reviewing advance directive information with the resident or his/her next of kin, legally authorized representatives or designees, annually since admission. 5. Review of Resident #7's medical record showed the following: -Admission date of 09/07/22; -Diagnoses included atrial fibrillation (irregular or fast heartbeat); -Staff did not document reviewing advance directive information with the resident or his/her next of kin, legally authorized representatives or designees, annually since admission. Missouri Department of Health and Senior Services STATE FORM 6899 8HTZ11 If continuation sheet 7 of 8 PRINTED: 11/17/2023 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 32469 B. WING 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3877 EAST FARM ROAD 132 SPRINGFIELD, MO 65802 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) SPRINGHOUSE VILLAGE EAST LLC Continued From page 7 6. Record review of Resident #8's medical record showed the following: -Admission date of 04/23/21; -Diagnoses included chronic kidney disease (gradual loss of kidney function which can lead to kidney failure); -Staff did not document reviewing advance directive information with the resident or his/her next of kin, legally authorized representatives or designees, annually since admission. 7. Review of Resident #9's medical record showed the following: -Admission date of 05/14/21:;. -Diagnoses included fraility (overall decline in health, increased likelihood of falls and decreased immunity); -Staff did not document reviewing advance directive information with the resident or his/her next of kin, legally authorized representatives or designees, annually since admission. 8. During an interview on 11/07/09, at 5:06 P.M., the Well Director/Licensed Practical Nurse (LPN) said he/she was unaware the advance directives needed to be reviewed and updated annually. He/She stated she thought they were just done upon admission. He/she was in charge is responsible for updating all advance directives. Missouri Department of Health and Senior Services STATE FORM 6899 8HTZ11 If continuation sheet 8 of 8 1-Dec-2023 86:15 14176956298 14177683483 p.3 12/01/2023 10; 24 (FAs) P,003/005 PLAN OF CORRECTION Provider/Supplier Name; Streat Addre 8 Cy, Zip: | 3877 E Farm Rd 132, Springfield, Mo. 65802 Springhouse Village November 7, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER Co ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The community will ensure a CBA (Community Based Assessment) will be completed by a qualified individual within the time frame in the guidelines put forth by DHSS, as evidenced by: The Director of Health and Wellness conducted an audit of all resident charts for completion of pre-admission CBA. The Director of Health and Wellness shall be responsible for completing the CBA or will delegate the completion of the CBA on admission to ensure they are completed within the time frames put forth by DHSS, per their guidelines. The Memory Care nurse (LPN) will complete the approved training to do the CBA on admissions. The community devised an audit form to ensure CBA forms are done on a timely basis and there is a tracking system; to be completed by the Diractor of Health and Wellness. The Director of Health and Wellness, and a designee will complete any past due CBA assessments necessary to ensure all residents have an CBA on file. The Executive Director will ensure that there is a policy in place that énsures the procedure for doing 4 CBA is in place on admission per DHSS guidelines. To be monitored by the Director of Health and Wellness and the Executive Director. Date of Survey: Vezlary t2/ai/23 N/2¢/23 (/ 24/27, The community will ensure a CBA semi-annual audit will be completed by a qualified individual within the time frame in the guidelines put forth by DHSS, as evidenced by: The Director of Health and Wellness conducted an audit of resident charts for completion of semi-annual CBA. The Director of Health and Wellness shall be responsible for completing the semi-annual CBA or will delegate the completion of the semi-annual CBA to ensure they are completed within the time frames put forth by DHSS, per their guidelines. The Memory Care nurse (LPN) will complete the approved training to do the semi-annual CBA’s. The community devised an audit form to ensure semi-annual CBA’s are done on a timely basis and there is a tracking system; to be completed by the Director of Health and Wellness. (2f $/4 23 Af 294238 “/24/23 State of Missouri 4178956290 12/01/2023 10:16AM Pg 03/05 1-Dec-28023 86:16 14176956298 14177683483 p.4 12/01/2023 10; 24 (FAs) P,.O04/005 The Director of Health and Wellness and a designee will be tZ/3) {23 complete the past due semi-annual CBA assessments to ensure all residents have a semi-annual CBA on file as required. The Executive Director will ensure there is a policy in place that ensures the procedure for doing tha semi-annual GBA is in place per DHSS guidelines. To be monitored by the Director of Health and Wellness and Executive Director. The community will ensure that annually, Advanced Directives are reviewed with each resident to ensure all residents have the right to make treatment decisions for themselves, as evidenced by: The facility will ensure that they have a policy that outlines the guidelines for ensuring that each resident's Advanced Directives are charted/documented on admission and reviewed/documented annually, A meeting will be conducted on Wednesday, November 29, with residents (or family will be contacted on those residents who are incapacitated to ensure their understanding and accessibility of facility policies regarding emergency and life sustaining care. The residents/responsible party will have an opportunity to change (or leave in placa) Advanced Directives currently on file. information from meeting/family contact will be documented in resident file by 12/12/2023 by the Director of Health and Wellness or a designes. Updates will be lagged on the audit tool prepared for this information (and CBA on admission and semi annual assessments) to ensure follow through and discussion of Advanced Directives will ba conducted annually and documented on the ISP. State of Missouri 4178956290 12/01/2023 10:16AM Pg O4W/05 1-Dec-28023 86:16 14176956298 14177683483 p.o 12/01/2023 10:25 (FAs) P,O05/005 The Administrator signing and dating the first page of the CMS-2567/State Form ts indicating their approval of the plan of correction being submitted on this form. State of Missouri 4178956290 12/01/2023 10:16AM Pg 05/05