CAPE ALBEON.

PRINTED: 03/18/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X71} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 22838C — 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION 0) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE i COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE { DATE i DEFICIENCY} i CAPE ALBEON Aarad 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. {I This reguiation is not met as evidenced by: . Based on interview and record review, the facility : failed to ensure the required two step tuberculosis ; (TB) screening test was completed prior to hire, | for three of four sampled employees and prior to : admission for four of six sampled residents | (Residents #6, #4, #3 and #5), The census was | 61. : General requirements for TB testing for staff and : residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shail screen their : residents and staff for tuberculosis. Each facility i shall be responsible for ensuring that all test | results are completed and that documentation is | maintained: . -Within one monih prior to or one week after : admission, all residents new to long-term care i are required to have the initial test of a two-step : TB test; -If the resident's initial test is negative, the second . test should be given one to three weeks later. : The CDC (Centers for Disease Control) states TB | tests should be read 48 to 72 hours after i administration; : -All long-term care facility residents shail have a | documented annual evaluation to rule out signs | and symptoms of TB disease; : -All positive findings shal! require a chest X-ray to rule out active pulmonary disease; -Individuais with a positive finding need not have | repeat annual chest X-rays. They shail have a ' documented annual evaluation to rule out signs Missouri Department of Health an¢Senlor Services ' LABORATORY DIRECTOR'S OR PROMID RISUPRLIER RE SENTATIVE'S SIGNATURE : TITLE (X6) DATE 2699 6VRZ11 if continuation sHeet 1 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22838C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 CAPE ALBEON (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 and symptoms of tuberculosis disease; -Within one month prior to starting employment, all new to long-term care employees are required to have the initial test of a two-step TB test; -All employees and volunteers are required to obtain Mantoux PPD (purified protein derivative) two-step TB test within one month prior to starting employment in the facility. If the initial test is Zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the initial test is negative, the second test should be given as soon as possible within one to three weeks after employment begins. The CDC states TB tests should be read 48 to 72 hours after administration; -Employees with an initial Zero to nine millimeters TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record. 1. Review of Resident #6's medical record, showed the following: -Admit date 12/20/21; -A one-step TB/PPD test administered on 11/30/21, with no documented read on date; -A two-step TB/PPD test administered on 12/7/21, with no documented read on date. 2. Review of Resident #4's medical record, showed the following: -Admit date 10/1/22: -A one-step TB/PPD test administered on 9/15/22, with no documented read on date; -A two-step TB/PPD test administered on 9/22/22, with no documented read on date. 3. Review of Resident #3's medical record, Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 PRINTED: 03/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 12 PRINTED: 03/18/2024 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 22838C — 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 (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) CAPE ALBEON Continued From page 2 showed the following: -Admit date 5/1/23; -A one-step TB/PPD test administered on 5/4/23, and a result of negative with no documented read date or induration; -A two-step TB/PPD test administered on 5/11/23, and result of negative with no documented read date or induration. 4. Review of Resident #5's medical record, showed the following: -Admit date 10/27/23; -A one-step TB/PPD test administered on 10/28/23, with no documented read on date; -A two-step TB/PPD test administered on 11/4/23, with no documented read on date; 5. Review of Employee F's personnel file, showed the following: -Start date 5/27/22: -A first-step TB/PPD test administered on 6/1/22, with a read on date of 6/4/22, and an induration of O mm; -No documented second-step TB/PPD test administered with in 1-3 weeks after the first-step. 6. Review of Employee B's personnel file, showed the following: -Start date 10/31/22: -A first-step TB/PPD test administered on 11/3/22, with no documented read on date and no induration in mm; -A second-step TB/PPD test administered on 11/8/22, with no documented read on date and no induration in mm. 7. Review of Employee A's personnel file, showed the following: -Hire date 1/2/24: -A one-step TB/PPD test administered on 9/6/23, Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 If continuation sheet 3 of 12 PRINTED: 03/18/2024 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 22838C — 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 (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) CAPE ALBEON Continued From page 3 and a read date of 9/8/23, with an induration of 0 mm, negative; -No documented second-step TB/PPD test administered within 1-3 weeks after the first-step. 8. During an interview on 2/22/24 at 3:00 P.M., the Resident Care Director (RCD) said the facility's online database did not have a way to document the TB/PPD test read on dates so no residents would have the documented read on date. The RCD said she was not aware some TB/PPD tests did not have the reaction of mm of induration documented and was not aware this was required. 9. During an interview on 2/22/24 at 5:10 P.M., the Administrator said she was not aware the TB/PPD tests were not showing the reaction in mm of induration. She said the TB/PPD tests should have the reaction in mm of induration documented on the test. The Administrator said she was not aware some TB/PPD tests did not have a read on date but she said the tests should have a documented read on date. 19 CSR 30-86.047(28)(D) Complete a Premove-in Screening The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (D) Completes a premove-in screening conducted as required by section 198.073.4 (4), RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)). II This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 If continuation sheet 4 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22838C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 CAPE ALBEON (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Based on interview and record review, the facility failed to complete resident pre-move in screening assessments for admission for three of six sampled residents (Residents #2, #4 and #3). The census was 61. 1. Review of Resident #2's medical record, showed the following: -Admit date 5/20/19; -Diagnoses included Alzheimer's disease, anxiety, and major depressive disorder; -No documented pre-screening prior to admission. During an interview on 2/22/24 at 2:50 P.M., the Resident Care Director said she did not have the resident's pre-screening in the resident's medical record and she would have to log into the facility's old online database to retrieve the pre-screening. The RCD said the pre-screening should be accessible in the resident's medical record, in the current online database the facility used. 2. Review of Resident #4's medical record, showed the following: -Admit date 10/1/22; -Diagnoses included Alzheimer's disease, anxiety disorder, muscle weakness, difficulty walking, cognitive communication deficit and anxiety disorder; -No documented pre-screening prior to admission. 3. Review of Resident #3's medical record, showed the following: -Admit date 5/1/23; -Diagnoses included heart failure, kidney disease stage 3, localized edema (water retention), diabetes, dementia, major depressive disorder; -No documented pre-screening prior to Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 PRINTED: 03/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22838C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 CAPE ALBEON (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 admission. 4. During an interview on 2/22/24 at 4:15 P.M., the Administrator said she is aware that a pre-screening is required and thought they were being completed. 19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr In addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer ' s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer 's disease and related dementias as follows: (A) For employees providing direct care to such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer 's disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues; and I/II This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to ensure all staff who provide direct care to residents, who had a diagnoses of dementia or Alzheimer's disease, had the required three hour Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 PRINTED: 03/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22838C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 CAPE ALBEON (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 training to care for residents with a diagnoses of Alzheimer's disease, or dementia for two of four sampled employees. The census was 61. 1. Review of Caregiver A's personnel file, showed the following: -Start date: 1/2/24: -No documented training for Alzheimer's disease and dementia training. 2. Review of Certified Nursing Assistant (CNA) B's personnel file, showed the following: -Start date 10/31/22; -A dementia training certification completed 10/31/22, with no documented length of training; -An in-service dated 1/2024, with a topic of "Communicating with dementia residents and coworkers" with no documented length of training. 3. During an interview on 2/22/24 at 5:25 P.M., the Administrator said she was not aware some employees did not have Alzheimer's training documentation in their personnel file and she was not aware the training in CNA B's personnel file, did not show the actual hours of training completed by CNA B. The Administrator said the training hours should be documented in the employee's personnel file. 19 CSR 30-87.020(5) Toxic Material Storage Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 PRINTED: 03/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22838C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 CAPE ALBEON (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents for one of one day of observation. This had the potential to affect all residents. The census was 61. 1. Observation on 2/22/24 between 6:47 A.M. and 3:00 P.M., of the unlocked storage closet on the west hall, across from the fish tank, showed the following: -One 11 ounce (0z) spray can of Blaster White Lithium Grease High Performance. The precautionary statement read, "Danger: Extremely flammable. Harmful or fatal if swallowed, vapor harmful. Contact may irritate eyes. Contents Under Pressure."; -Three 12 oz spray cans of Armstrong Ceiling Stains Away. The precautionary statement read, "KEEP OUT OF REACH OF CHILDREN. DANGER: Extremely flammable liquid and vapors may cause flash fire. Harmful or fatal if swallowed. Contents under pressure."; -Fourteen 5-gallon buckets of Sherwin Williams paint. The precautionary statement read, "Caution: Highly flammable liquid and vapor. Causes serious eye irritation. May cause drowsiness or dizziness. Wear eye or face protection. Keep away from heat, hot surfaces, sparks, open flames and other ignition sources. No smoking. Avoid breathing vapor. IF INHALED: Call a POISON CENTER or doctor if you feel unwell. IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 PRINTED: 03/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22838C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 CAPE ALBEON (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 present and easy to do. Continue rinsing. If eye irritation persists: Get medical advice or attention."; During an interview on 2/22/24 at 3:52 P.M., the Maintenance person said the storage closet should be locked when not in use. The Maintenance person said he was not aware the door was not locked. He said sometimes the housekeepers will go into the closet to get light bulbs and forget to lock it. 2. Observation on 2/22/24 between 7:19 A.M. and 1:00 P.M., of the memory care resident use bathroom, under the sink, showed a full container of Clorox wipes. The precautionary statement read, "Hazards to humans and domestic animals. Caution: may cause eye irritation. Avoid contact with eyes or clothing. Keep out of reach of children" 3. Observation on 2/22/24 between 10:50 A.M. and 12:30 P.M., of resident room 149, on the kitchen counter, showed a full container of Clorox wipes. 4. During an interview on 2/22/24 at 4:25 P.M., the Administrator said she was not aware the door was not locked. The Administrator said the storage room door should be locked at all times. The Administrator said she was not aware there were chemicals in the memory care bathroom, under the sink or that there were chemicals in resident rooms. The Administrator said all chemicals should be locked up and no chemicals should be in resident rooms. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 PRINTED: 03/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22838C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 CAPE ALBEON (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. II/III This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to ensure staff washed their hands and/or changed gloves between tasks while preparing and serving resident meals for one of one observed prepared and served meal. This had the potential to affect all residents. The census was 61. Observation on 2/22/24 between 7:05 A.M. and 7:25 A.M., showed Cook A donned a pair of gloves. -He/she walked to the preparation station and took out a storage container and placed paper in the bottom of the pan; -Wearing the same gloves, he/she removed the fryer basket and used his/her gloved left hand and removed hashbrowns and placed them into a container. He/she walked over to the warmer, and used same gloved hand to open the door and placed the container in the warmer; -With the same gloves on, he/she grabbed another container, utilized gloved hands and placed additional hashbrowns with his/her left hand into the container, walked to steam table and put the container into the steam well. -With the same gloves, he/she began to prepare resident plates using his/her gloved right hand to place an orange slice onto the plate, and gloved Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 PRINTED: 03/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 12 PRINTED: 03/18/2024 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 22838C — 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 (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) CAPE ALBEON Continued From page 10 left hand to place the bacon on the plate. He/she placed the plate into the window for the server to take to the resident; -With the same gloves on, he/she walked to the upright and grabbed the handle with his/her right hand and opened the door. He/she walked back over to the steam table, grabbed another plate, with the same gloved left hand, placed an orange slice onto the plate, a scoop of eggs and then tongs to place the bacon; -At 7:12 A.M., with the same gloved right hand, he/she cracked two eggs into a skillet and picked up two plates with his/her gloved left thumb on top of plate surface; -At 7:15 A.M., wearing the same gloves, he/she grabbed another plate with his/her right hand, placed an orange slice on the plate, walked over to the stove top and cracked two more eggs into the skillet. He/she walked over to the cold table preparation area and closed the lid and touched the handle with the same gloved right hands; -At 7:20 A.M., he/she moved to clean a warming container, placed a towel with his/her left hand into cleaning solution and wiped out the container. After he/she cleaned the container, he/she removed gloves and threw them into a trash container. He/she then donned a new pair of gloves without sanitizing or washing his/her hands. During an interview on 2/22/24 at 10:11 A.M., the Dining Director said the cook should have changed gloves throughout the meal preparation and plating process. During an interview on 2/22/24 at 1:20 P.M., the Administrator said the cook should be changing gloves when prepping, preparing and serving food. Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 If continuation sheet 11 of 12 PRINTED: 03/18/2024 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 22838C — 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3300 LAKE BEND DRIVE VALLEY PARK, MO 63088 (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) CAPE ALBEON A7002 Continued From page 11 *The higher classification merited due to the extent of the violation Missouri Department of Health and Senior Services STATE FORM 6899 6VRZ11 If continuation sheet 12 of 12 PLAN OF CORRECTION Provider/Supplier Name: Cape Albeon Gaetip 3300 Lake Bend Drive, Valley Park, MO 63088 Date of Survey: 02/22/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER Piease accept this Plan of Correction as Credible Allegation of Compliance. Submission of this Response and Plan of Correction is not a legal admission that a deficiency was correctly cited and is also not to be construed as admission against interest by Cape Albeon Administration or any employee, agents or other individuals who may draft or who may be discussed in the Response and Plan of Correction. In addition, preparation and submission of this Plan of Correction does not constitute any admission or agreement of any kind by Cape Albeon of the truth of any facts alleged or correctness of any conclusion set forth in this allegation by the Survey Agency. ID PREFIX TAG COMPLETION DATE A4724 19 CSR 30-86.047(19) TB Screen Residents & Staff 04/30/2024 This facility will screen residents for tuberculosis as required for long-term care facilities in accordance with 19 CSR 20-20.100. Documentation has been updated to include a read on date and an area to include the induration in millimeters for the one-step, two-step and annual screenings for the TB/PPD tests for employees. Resident read-on dates will be documented on the Medication Administration records & under immunizations records. Additional in-servicing has been provided for the licensed nursing staff on reading & documenting TB results Resident #6’s medical record has been updated to show the read-on dates for the one-step and two-step TB/PPD tests. Resident #4’s medical record has been updated to show the 3/14/2024 read-on dates for the one-step and two-step TB/PPD tests. Resident #3’s medical record has been updated to show the read-on dates on the one-step and two-step negative TB/PPD with 0.00 mm induration. Resident #5’s medical record has been updated to show the read-on dates for the one-step and two-step TB/PPD tests. The Resident Care Director will manage the recordings for required documentation for the TB/PPD tests and annual screenings for the residents and will receive assistance from the Administrative Assistant to maintain documentation for employees. The Administrator will monitor the required documentation being used. Employee F is no longer employed at the facility. Employee B file has been updated to show the read-on dates on the one step & second step negative TB /PPD test with 0.0mm induration. Employee A file has been updated to show one step & second step TB /PPD test have been completed. A4?a? 19 CSR 30-86.047(28)(D) Complete a Pre-move-in Screening 04/30/2024 This facility will complete a pre-move-in screening assessment for each resident admission. The Resident Care Director and/or the Resident Care Managers will complete a documented pre-screening assessment prior toa resident move-in. The Administrator will review the screening documentation as part of the move-in process. Resident #2’s medical record shows documentation for a completed pre-screening and assessment. Resident #4’s medical record shows documentation for a completed pre-screening and assessment. Resident #3’s medical record shows documentation for a completed pre-screening and assessment. 19 CSR 30-86.047(63)(A) Alzheimer’s/Dementia Training- A4856 A&6005 Direct Care Staff, 3 hours. For employees providing direct care fo residents having Alzheimer’s disease or related dementia, the orientation training will include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer’s disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues. The Memory Care Director will provide at least three (3) hours of Alzheimer’s/Dementia training, through video presentations and/or with classroom sessions, to direct care staff who work with residents having Alzheimer's disease or related dementia. This education will be provided as part of the orientation process for newly hired staff. The Administrative Assistant will help to manage the training documentation indicating the time allocated for each employee's training. The Administrator will review monthly the documentation required for employees’ training. Caregiver A’s file will snow at least three (3) hours of Alzheimer’s/Dementia training. Certified Nursing Assistant B’s file will show at least three (3) hours of Alzheimer’s/Dementia training. 19 CSR 30-87.020(5) Toxic Material Storage This facility will ensure poisonous or toxic materials are kept locked up or stored in a place not accessible to residents. Facility staff have been in-serviced, during an All Staff meeting on March 1, on the importance of helping to ensure all poisonous or toxic materials are kept locked and stored inaccessible to residents. Each Department Director/Manager will monitor their areas for unsecured poisonous or toxic materials. The Administrator will monitor the accessibility to poisonous or toxic materials during walk thru of the facility. The storage closet on the west hall will be kept closed and locked after each use. The maintenance and housekeeping staff will ensure it is locked after each use. The Maintenance Director will monitor the operation of the use of the closet. The Resident Care Director will help to monitor the security of the door. The Administrator will monitor the security of this closet during the walk thru of the facility. The Clorox wipes have been removed from under the resident use bathroom sink and on the kitchen counter in apt. 149. The wipes have been secured in a locked cabinet. All resident rooms were checked for chemicals & removed if 04/30/2024 04/30/2024 present. The Memory Care Director will monitor the accessibility of any poisonous or toxic material to the residents in the Memory Care Household. The Administrator will monitor the security of the poisonous or toxic materials during walk thrus of the facility. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean fingernails Employees will properly use single-use gloves to serve, cook, and produce food. Changing in-between tasks, washing hands, and donning new gloves to prevent cross contamination resulting in safe food practices. A7002 04/30/2024 Dining Leadership will train all staff on proper glove use, personal hygiene, and cross contamination. Dining leadership will monitor the practice of proper glove use, and personal hygiene efforts to prevent any incidence of cross contamination to food. 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.