AMERICAN HOUSE WILDWOOD VILLAGE.

PRINTED: 07/30/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION (IDENTIFICATION NUMBER: (X2} MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 07/10/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 251 PLAZA DRIVE WILDWOOD, MO 63048 AMERICAN HOUSE WILDWOOD VILLAGE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x8) COMPLETE DATE (X4) 10 PREFIX TAG A4765) 19 CSR 30-86.047(30) Hospice Care Exception * A4765 The requirements of subsections (29)(D), (E) and (F) shall not apply to a resident receiving hospice care, provided the resident, his or her legally authorized representative or designee, or both, and the facility, physician and licensed hospice provider all agree that such program of care is appropriate for the resident. II This regulation is not met as evidenced by: Based on observation and interview, the facility did not provide nor have available hospice contracts with hospice providers the residents had elected to use, for one of three sampled residents. The census was 65. During an interview on 7/10/25 at 11:32 A.M., the hospice Registered Nurse said she visited multiple residents in the facility. The hospice residents received durable medical equipment as needed, wound care, and pain medications. The hospice company has a contract with the residents or the families. He/she said all hospice residents receive an individualized hospice care plan, The care plan reflected what responsibilities the hospice provider will reform for the resident. During an interview on 7/10/25 at 1:09 P.M., the Wellness Director said multiple residents in the facility received hospice services. The facility did not have any contracts between the various hospice providers and the facility. The residents who received hospice services are provided specific medical equipment, supplies, hospice staff visits and medications. During an interview on 7/10/25 at 8:42 A.M., the Administrator said the facility had five hospice companies who provide hospice care to facility residents. The hospice staff from the companies Missouri Depastment of Health and Senior Seqvices LABSRTOR DIRECYOR'S OR PROVIDER/SURPLIER REP. RESENTATIVE'S SIGNATURE STATE FORM 8699 6SWT11 — if continuation sheet 1 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER AMERICAN HOUSE WILDWOOD VILLAGE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 07/30/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED Cc 07/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4765 19 CSR 30-86.047(30) Hospice Care Exception The requirements of subsections (29)(D), (E) and (F) shall not apply to a resident receiving hospice care, provided the resident, his or her legally authorized representative or designee, or both, and the facility, physician and licensed hospice provider all agree that such program of care is appropriate for the resident. II This regulation is not met as evidenced by: Based on observation and interview, the facility did not provide nor have available hospice contracts with hospice providers the residents had elected to use, for one of three sampled residents. The census was 65. During an interview on 7/10/25 at 11:32 A.M., the hospice Registered Nurse said she visited multiple residents in the facility. The hospice residents received durable medical equipment as needed, wound care, and pain medications. The hospice company has a contract with the residents or the families. He/she said all hospice residents receive an individualized hospice care plan. The care plan reflected what responsibilities the hospice provider will reform for the resident. During an interview on 7/10/25 at 1:09 P.M., the Wellness Director said multiple residents in the facility received hospice services. The facility did not have any contracts between the various hospice providers and the facility. The residents who received hospice services are provided specific medical equipment, supplies, hospice staff visits and medications. During an interview on 7/10/25 at 8:42 A.M., the Administrator said the facility had five hospice companies who provide hospice care to facility residents. The hospice staff from the companies Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6SWT11 If continuation sheet 1 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER AMERICAN HOUSE WILDWOOD VILLAGE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 visit the residents several times a week. The hospice providers provide specialty care items and perform wound care. The facility did not have hospice contracts with the hospice providers. The hospice providers initiate a contract with the residents and their families. 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. IAI This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6SWT11 PRINTED: 07/30/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER AMERICAN HOUSE WILDWOOD VILLAGE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Based on observation and interview, the facility failed to ensure a safe medication storage system was in place. Observation of the medication cart on the third floor, showed 3 Ziploc bags which contained prefilled syringes. The syringes were not labeled with the resident's name, medication or physician orders, for the unidentifiable liquid. The census was 65. Review of the Medication Administration policy , revised 8/1/22, showed the following: -Policy: to appropriately administer medication as required by the physician order and in accordance with state regulation; -Purpose: ensure the safe dispensing of and prevention of errors in medication administration; -Procedure: -The facility does not allow pre-setting or pre-pouring of medications. Medications should be prepared at the time of delivery, administer and document; -Us the "6 rights": -Right resident; -Right drug; -Right dose; -Right route; -Right time; -Right documentation; -To prevent a medication error, it is important to read the medication labels. Compare medication with the medication administration record (MAR) or electronic medication administration record (eMAR). After opening medication, compare the label with the MAR/eMAR before administrating the medication; -Do not use medication which: -Has expired; -ls in unmarked containers or from containers whose labels are illegible; Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6SWT11 PRINTED: 07/30/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 9 PRINTED: 07/30/2025 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 07/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) AMERICAN HOUSE WILDWOOD VILLAGE Continued From page 3 -Staff should discard any medication which as been removed or tampered with from its container, do not return any of the medication to the container. Staff cannot give medications from an unmarked container or medication box; -Staff should only administer medications they had prepared. Staff should never give a resident medication which is unlabeled or prepared by someone else. During an observation and interview on 7/9/25 at 8:23 A.M., Level One Medication Aide (L1MA) A opened the top left drawer of the third floor medication cart, unlocked and opened the drawer. Inside the drawer, three separate large Ziploc bags. Black marker labeling noted to be smeared on the outside of the bags. The following was observed in the bags: -One bag: four pre-filled syringes, unlabeled with resident name, no labeling observed on the syringe; -One bag: 13 pre-filled syringes, the fluid was blue colored. No medication identifiers noted on the individual syringes; -One bag: three pre-filled syringes, the fluid was pink colored. No medication identifier noted on the individual syringes; L1MAA said he/she did not pre-fill the medication syringes. The medication in the syringes should be liquid morphine (a narcotic, used for severe pain) and ordered for residents on hospice services. The hospice providers pre-fill the ordered morphine for the residents. The syringes do not contain the individual resident names, the medication, the dosage, the order, or the time/date the medication was drawn into the syringe. The staff are not allowed to draw up insulin or liquid medications. One of the staff nurses or the hospice nurse filled the medication syringes. He/she had been educated it was the Missouri Department of Health and Senior Services STATE FORM 6899 6SWT11 If continuation sheet 4 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER AMERICAN HOUSE WILDWOOD VILLAGE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 practice of the facility to administer morphine in this manner. During an interview on 7/9/25 at 11:41 A.M., the hospice Care Manager Registered Nurse said she had been coming to the facility for several months to visit patients. She had not pre-filled any morphine syringes for the hospice patients she visits. The facility Nurse or the hospice Nurse would pre-fill the syringes. The facility would not allow the L1MAs to remove the liquid medication for the residents and for the resident to have access to the ordered morphine, the medication had to be pre-drawn up. The medication is placed in a Ziploc bag. The syringes are not labeled in any way. The resident's name and medication should be written on the bag. She said the practice was not a safe way to prepare, store or administer a medication. During an interview on 7/10/25 at 7:35 A.M., the Wellness Director said she had been instructed it was the facility policy to have either facility Nurses or the hospice Nurse pre-fill the morphine syringes. Corporate leadership had not provided the policy for her review upon request. The facility staff will notify a staff Nurse or the hospice Nurse when the resident needed additional morphine syringes. She had not pre-filled any syringes. The syringes do not contain the resident's name, physician orders, the route, the drug, or the date the medication was withdrawn from the original container. The Wellness Director said the practice was unsafe and staff were unable to verify the accuracy of medication administration. During an interview on 7/10/25 at 8:01 A.M., the Corporate Clinical Nurse said the corporation had a policy in which the pharmacy was allowed to pre-fill liquid narcotic medications syringes. She Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6SWT11 PRINTED: 07/30/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER AMERICAN HOUSE WILDWOOD VILLAGE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 had been unaware that the hospice provider or the staff Nurses pre-filled narcotic syringes. She was unaware the pre-filled syringes did not contain the resident name, dose, physician order, drug name, when the medication was dispensed into the syringe and expiration. The practice is not safe. All medications should be labeled with the resident name, physician order, route, drug name, pharmacy name and expiration date. She did not have access to the policy. M000254310 19 CSR 30-86.047(47)(A) Physicians Orders Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to ensure hospice wound care orders where transcribed into the facility physician order sheet. The failure resulted in delayed wound treatment applied to a chronic sacral (tailbone) wound when staff did not report an open wound to a nurse, but instead, cleaned the resident up and dressed the resident for the day, for one of three sampled residents (Resident #2). The census was 65. Review of the Medication Order Policy, revised 8/1/22, showed: -Policy: appropriately administer medications as Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6SWT11 PRINTED: 07/30/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER AMERICAN HOUSE WILDWOOD VILLAGE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 required by the physician orders; -Purpose: ensure safe dispensing and prevention of errors; -Procedures: -All physician orders must be in writing via fax or physical prescription; -In the event that a physician calls in an order or escribes to the pharmacy, request the pharmacy to fax the signed and dated order to the community for the resident's medical record. Review of Resident #2's medical record, showed the following: -Admit date 9/15/23; -Enrolled in hospice services; -No wound care orders noted in the facility record; -No Electronic Treatment Administration Record (eTAR), to show administered treatments. Review of the resident's hospice care plan dated 2/2/25, showed the following: -Treatments: -Coccyx: Cleanse skin with cleanser, apply skin prep to outer wound. Moisten packing strips with normal saline and apply crushed Flagyl (antibiotic) 500 milligram. Pack wound using cotton applicator, cover with foam dressing. Change daily. Review of the resident's individual service plan (ISP) dated 3/25/25, showed the following: -Need: Wound Treatment/prevention; -Goal: maintain or maximize current level of function; -Action: third party wound care, hospice to manage sacral wound. Staff to notify nurse with any changes or if the dressing is soiled or needed changing. Staff provide change in position. Staff observe the resident's skin for any changes such Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6SWT11 PRINTED: 07/30/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER AMERICAN HOUSE WILDWOOD VILLAGE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 as bruises, rashes, tears or open wounds. All changes should be reported to the nurse immediately. During an observation and interview on 7/9/25 at 9:12 A.M., showed Caregivers (CG) A and B entered the resident's room, greeted the resident and applied gloves. CG A and B said the resident had an open area to the tailbone. The resident is seen by hospice and the hospice staff will change the dressing. CG A and B assisted the resident onto his/her side and exposed the resident's buttocks. The resident had an open wound and no dressing in place. CG A and B provided personal care, applied a clean brief, the staff secured the brief in place and dressed the resident. CG A and B transferred the resident into his/her chair. CG A and B did not notify a facility Nurse the wound was untreated and got the resident up in his/her chair. During an interview on 7/9/25 at 11:32 A.M., the resident's hospice Case Manager said hospice obtained the wound care orders. Hospice orders are written on paper and provided to the facility Nurse. He/she does not have access to the facility electronic medical records to document orders. He/she did not see the resident today, since the resident was not scheduled to be seen. Facility staff did not report the sacral wound and did not have the treatment in place. The facility staff should provide wound care if the dressing needed to be replaced prior to the hospice visit. During an interview on 7/9/25 at 1:09 P.M., the facility Wellness Director said staff are expected to immediately report missing wound treatments. All orders should be reflected in the resident's medical record. All treatments should reflect on the facility TAR. Hospice providers do not have Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6SWT11 PRINTED: 07/30/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/10/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE AMERICAN HOUSE WILDWOOD VILLAGE WILDWOOD, MO 63040 PRINTED: 07/30/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/10/2025 (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 A4798 | Continued From page 8 access to document orders. Hospice orders are written on paper form and given to the facility Nurse. She was unaware the resident's treatment orders did not reflect in the facility's orders. *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM oeee 6SWT11 DEFICIENCY) If continuation sheet 9 of 9 PLAN OF CORRECTION Provider/Supplier American House at Wildwood Village Name: Street Address, . ‘ 251 Plaza Dr Wildwood Mo 63040 City, Zip: Date of Survey: 7/10/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Hospice Care Exception Description of violation: The requirements of subsections (29)(D), CE) and (F) shall not apply to a resident receiving hospice care, provided the resident, his or her legally authorized representative or designee, or both, and the facility, physician and licensed hospice provider all agree that such program of care is appropriate for the resident. Audit: An audit of all current residents on hospice has been done and the Hospice company noted. A review of 7/14/2025 contracts kept on file within the community for Hospice has been done. Responsible person(s)- Executive Director/designee, Director of Nursing /designee Rule # 19 CSR 30- ok ; . a. 86.047(30) Achieving Compliance moving forward: Upon any new hospice admission whether admitted from the community or admitted within, a contract will be obtained by the Wane A4765 and ongoing Executive Director/designee or Director of Nursing/designee. The hospice contract will be signed by the hospice company and the Executive Director on day of admission and held on file in a contract binder in Executive Directors office. A copy of the hospice contract will also be kept in the hospice binder kept in the resident's chart. Responsible person(s)- Executive Director or designee, Director of Nursing/designee Monitoring: No less than once per quarter for the purpose of ensuring facility compliance as it pertains to hospice contracts, the Executive Director /designee or the Director of Wellness/designee will audit all current residents on hospice and the company they are using to ensure there is an active, current and signed contract on file within the community. 7/14/2025 and ongoing Responsible person(s): Executive Director/designee, Director of Wellness/designee Rule # 19 CSR 30- 86.047(46) A4797 Safe and Effective Medication System Description of Violation: To appropriately administer medication as required by the physician order and in accordance with state regulation; -Purpose: ensure the safe dispensing of and prevention of errors in medication administration Audit: An audit of med carts has been completed and any resident that was being administered prefilled medications was identified. 7/17/2025 Person responsible: Director of Wellness/designee, Assistant Director of Wellness/designee An audit of current medications currently in Ziploc bags has been identified and dispensed per doctors’ orders. No 7117/2025 further medication will be prefilled or stored in Ziploc bags per state regulation. Person responsible: Director of Wellness /designee, Assistant Director of Wellness/designee Achieving Compliance/Systemic moving forward: The facility will not allow presetting or prefilling of medication and will appropriately administer medication as required 7/17/2025 by the physician order and in accordance with state and ongoing regulations. The facility will ensure that medications are prepared at the time of delivery, delivered, administered and documented using the 6 rights- Right resident Right drug Right dose Right route Right time Right documentation Clinical Specialist has provided education to the WD that 7130/2025 the facility does not allow presetting or prefilling of medication. An in service was given by the Wellness Director and 7/30/2025 pharmacy to all Med Techs on proper medicine dispensing. Monitoring compliance: No less than once per month for the next six months and the quarterly thereafter the 7/17/2025 Director of Wellness/designee will inspect all med carts to ensure that we do not have any prefilled medications and that all medications are given in accordance with physician orders and the 6 rights of medication administration. Responsible person(s)- Director of Wellness/designee, Assistant Director of Wellness/designee Rule # 10 CSR 30- 86.047 (47)(A) A4798 Physicians Orders Followed Description of violation: Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. Audit: A EMR chart audit and an in service with nursing was completed of all current hospice residents to identify where hospice orders, new 1118/2025 physician orders and wound care orders should be entered. An audit was done of all current hospice companies to contact and communicate the need for proper 7/18/2025 communication and documentation of all hospice visits with the Director of Nursing and/or Assistant Director of Nursing. Responsible person(s): Director of Nursing/designee, 7130/2025 Assistant Director of Nursing/designee Achieving compliance/systemic moving forward: For all current and future hospice residents all visits will be followed up with communication and orders given to the Director of Nursing or the Assistant Director of nursing to ensure all new hospice orders are entered into the EMR An in-service was completed by Wellness Director with all staff on skin and wounds and proper communication with nursing on untreated wounds and any new skin issues. Person(s) responsible: Director of Nursing/designee, Assistant Director of Nursing/designee 7/18/2025 Monitoring compliance: Upon hire and no less than once ‘ and ongoing per month staff will be in serviced on skin care and communication. No less than once per month for six months and then quarterly an EMR and service plan audit will be done on all hospice residents to ensure all new hospice and physician orders are documented correctly and up to date. Person(s) responsible: Director of Nursing/designee, Assistant Director of Nursing /designee 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: 07/19/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (x3) DATE SURVEY COMPLETED Cc 07/03/2024 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PLAZA AT WILDWOOD SENIOR LIVING THE SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X4) 1D PREFIX TAG (x5) COMPLETE DATE A2293) 19 CSR 30-86.022(16)(C) One Lock per Resident A2293 Request Standards for Designated Separated Areas. (C) The facility may allow resident room doors to be locked providing the residents request to lock their doors. Any lock on a resident room door shall not require the use of a key, fool, special knowledge, or effort to lock or unlock the door from inside the resident's room. Only one (1) lock shail be permitted on each door. The facility shail ensure that facility staff has the means or mechanisms necessary to open resident room doors in case of an emergency. I/il This regulation is not met as evidenced by: Class 4I* Based on observation and interview, the facility failed ensure facility staff had the means or mechanisms necessary to open resident room doors in case of an emergency. Staff were unable to access resident room 101 during an emergency in December of 2023 which caused them to call 911 and have the door broken into to reach the resident. This had the potential to affect all residents. The census was 67. During an interview on 4/2/24 at 8:21 A.M., Resident #7's family member said the facifity called him in December of 2023, and said the resident had passed away. When the family member arrived at the resident's room, he/she noticed his/her door was torn down, The family member questioned why the door was torn down. The staff informed the family member the Emergency Medical Technician (EMT) staff had to tear the door down once they arrived on the scene. Prior to EMT arriving, the resident had used hi/her call bu in her apartment to call for Missouri Departme tof HY h LABORATORY DIRECTOR'S: ‘ \; STATE FORM (RO TITLE (X6F DATE BRAM Ding 7129 2024 sera GXE011 {{ continuation sheet 4 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 1 so the staff eventually called "911" and when they took the door down, the staff went in to check on the resident, he/ she had already passed away. During an interview on 7/2/24 at 11:34 A.M., Maintenance Director K said the only time the key fobs do not work is if their batteries are dead. He said a 9 volt battery can be used if you hold it to the door with the key fob and the team was aware of this process when the incident happened in December. The system does not alert when a battery is running low but will flash red. The team is supposed to let him know or the front desk. He said he was aware of the incident in March and the lock not functioning appropriately. He put the battery in and then it worked fine. There is not an override or any type of code when the fob is not functioning correctly. During the month he said he tests doors as he's walking up and down the halls to confirm they are working. He said it would be smart to document those tests going forward. He said he used to pull a call light weekly before the new company took over the building but the new company has not required the report to be pulled. He said they only check the report if there is a concern that comes up. During an interview on 7/1/24 at 11:13 A.M., Medication Partner F said he/she asked specific residents in the past not to lock their door due to concerns of not being able to unlock it with the fob. He/she said he/she was told if there is an issue with the fob to talk to the Maintenance Director or to his/her supervisor. During an interview on 7/1/24 at 9:48 A.M., Care Coordinator B said he/she heard there can be problems with the key fobs. They switch out the fobs if there is an issue but they can sometimes Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 2 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 2 be temperamental. Observation on 7/1/24 between 9:39 A.M. and 3:32 P.M., and on 7/2/24 between 8:30 A.M. and 2:35 P.M., of the resident room 101 door, on the first floor of the facility, showed the door in disrepair. During an interview on 7/3/24 at 2:58 P.M., the Administrator said she was not aware the door was broken and she was not aware it had been in disrepair since December of 2023, as she was not the Administrator during that time. She said she expected the door to have been repaired, at the time of the incident. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to ensure the facility was substantially constructed and maintained in good repair. Staff failed to maintain the door for resident room 101 for two of two days of observation. The census was 67. Observation on 7/1/24 between 9:39 A.M. and 3:32 P.M., and on 7/2/24 between 8:30 A.M. and 2:35 P.M., of resident room 101, showed the door with three gouges, approximately two inches long and one inch wide on the side of the door near Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 3 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 the handle and lock, which exposed the wood underneath. Additionally, punctured holes, approximately four inches long, one to the right side of the door lock and one about a foot below the door handle, and five scratches running the full width of the door about 1 centimeter wide. During an interview on 7/2/24 at 11:34 A.M., Maintenance Director K said he was aware of the incident in December, where the key fob did not work and the paramedics had to tear the door down to get to a resident. He did not know why the door had not yet been replaced. During an interview on 7/3/24 at 2:58 P.M., the Administrator said that she was not aware the door was broken and she was not aware it had been in disrepair since December of 2023, as she was not the Administrator during that time. She said she expected the door to have been repaired after the incident. 19 CSR 30-86.032(3)(A) Additional Businesses-Requires DHSS Approval Only activities necessary to the administration of the facility shall be contained in any building used as a long-term care facility except as follows: (A) Related activities may be conducted in buildings subject to prior written approval of these activities by the Department of Health and Senior Services (hereinafter-the department). Examples of these activities are Home Health Agencies, physician ' s office, pharmacy, ambulance service, child day care and food service for the elderly in the community; II/III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 4 Class II* Based on observation, interview and record review, the facility failed to obtain approval from the Department of Health and Senior Services (DHSS) to have a second business on the facility property, for two of two days of observation. The census was 67. A review of the Department of Health and Senior Services Second business log on 7/2/24, showed no approved second business for the facility. During an interview on 7/3/24 at 2:00 P.M., the Administrator said the facility has a salon and therapy which is currently in operation for residents. The Administrator said she had not seen any letters from DHSS regarding the operation of the salon and therapy, but she got a call yesterday saying they will send her the information and she needs to resubmit information back to them. The Administrator said she was aware DHSS rescinded the approval to operate the second businesses and it was explained to her that she needed to resubmit the information to DHSS. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident "s needs and preferences, services to be Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 5 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 5 provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to develop individualized service plans (ISP, the planning documented prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) which included resident needs, services to be provided by staff and goals expected by the resident or the resident's legal representative for four of six sampled residents (Resident #6, #5, #4 and #1). The census was 67. 1. Review of Resident #6's medical record, showed the facility admitted the resident on 7/10/23, with diagnoses which included dementia, psychotic disturbance, mood disturbance, depression and high blood pressure. Review of the resident's progress notes, showed the following: -On 12/29/23 at 9:30 P.M., the resident pressed his/her call button and when the care aide went into the resident's room, he/she found the resident on the floor. The resident tried to put him/herself to bed. The Director of Nurses (DON) was called and assessed the resident. A message was left to the resident's family member and the resident's physician was made aware; -On 1/3/24 at 3:14 P.M., the resident was found on the floor in his/her kitchen area. The resident said he/she fell out of the bed and scooted into the kitchen and pushed his/her call light. The DON completed an assessment. There were no Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 6 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 signs of injury noted and the resident was assisted back up from the floor and into his/her bed; -On 1/19/24 at 4:14 P.M., the resident was found on the floor in the bathroom sitting on his/her buttocks with his/her arms on his/her knees. The resident was unable to report how the fall occurred. The resident denied hitting his/her head. The resident's wheelchair was not present. The DON completed an assessment, and the resident was negative for injury. The intervention was to encourage and remind the resident to use his/her wheelchair; -On 2/14/24 at 3:35 P.M., a Medication Partner (MP) was called to the resident's room by a Care Partner (CP). The resident was observed sitting on the floor, in the bathroom, with his/her back against the toilet. The DON was called, assessment completed over the phone. No injuries noted. The resident denied pain. The resident was assisted up to his/her feet and on the toilet; -On 2/28/24 at 6:33 P.M., the Nurse was alerted the resident was found sitting on the floor. The Nurse went to the resident's room and found the resident sitting on his/her bottom with his/her knees tucked to his/her chest and his/her arms around his/her knees. The Nurse asked the resident what happened, and the resident said he/she was getting out of his/her recliner to transfer to the wheelchair when he/she slid off the recliner. The resident was able to move all extremities without any limitations. The resident denied any pain/discomfort. The denied hitting his/her head. The Nurse completed a head-to-toe assessment. No injuries or bruising noted. The resident's vitals were within normal limits. The resident was assisted off the floor with an assist of two and escorted down to dinner per his/her request. The resident was placed on 72 hour Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 7 monitoring. The resident's family member was notified; -On 3/20/24 at 11:00 A.M., at 9:20 A.M., aCP found the resident on the floor. The resident was lying on his/her right side by the bed with a pillow under his/her head. The staff notified the Nurse. The Nurse assessed the resident. The resident's range of motion was within normal limits. The resident denied pain and denied hitting his/her head. The resident did not have injuries noted. The Nurse notified the resident's family member, the DON and the resident's physician. The Nurse spoke with the resident's family member who inquired if the resident used his/her call light. The resident had used his/her call light. The family member was glad because the resident did not normally use the call light. The DON will educate staff when the resident uses his/her call light; he/she needed action quickly due to the resident not using the call light for minor things because he/she did not like to ask for assistance; -On 4/14/24 at 9:40 P.M., the staff answered a call light and found the resident on the bathroom floor with his/her wheelchair beside him/her. The resident denied hitting his/her head, denied pain and his/her range of motion was in normal limits. The staff notified the DON. The resident's vitals were taken, and the Nurse notified and assessed the resident over the phone. The staff said they had just gotten the resident back to bed after toileting him/her then he/she was on the light. The staff notified the resident's physician, family and the Administrator. Review of the resident's fall risk assessments, showed the following: -Scoring: The score and category will appear in the header of the assessment. Morse Fall Scoring: High risk 45 and higher. Moderate risk: 25-44 and Low Risk: 0-24; Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 8 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 8 -On 4/23/24 at 4:08 P.M., the resident's fall risk assessment scored a 75; -On 5/14/24 at 3:36 A.M., the resident's fall risk assessment scored a 75. Review of the resident's progress notes, showed the following: -On 5/14/24 at 3:26 A.M., the facility's system alerted the staff of a fall. The staff went into the resident's room and found him/her sitting on the floor. The nurse was notified. The nurse assessed the resident. The resident denied hitting his/her head, denied pain and no injuries were noted. The resident's range of motion was within normal limits. The resident's family member was called, he/she said the resident tried to transfer him/herself from the bed to the wheelchair, but the wheelchair moved when doing so; -On 6/4/24 at 2:16 P.M., the resident was found on the floor in front of his/her chair and the wheelchair to his/her side. The resident said he/she did not hurt him/herself or hit his/her head. The DON completed range of motion to all extremities. The resident did not complaint of pain. The CP and DON assisted the resident up and vitals were taken. No injuries were noted; -On 6/6/24 at 8:01 A.M., the facility's system alerted the staff of a fall. The resident was found sitting on the floor beside his/her bed. The resident said he/she rolled out of bed. The DON assessed the resident. The resident's range of motion was within normal limits. The resident denied pain and denied hitting his/her head. No injuries were noted. Review of the resident's fall risk assessments, showed the following: -On 6/7/24 at 7:56 A.M., the resident's fall risk assessment scored a 75. Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 9 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 9 During an interview on 7/1/24 at 1:10 P.M., MPL said the resident had not fallen lately but he/she had tried to get out of the bed on his/her own before and the resident was not supposed to do so. MP L said the resident had tried to use the restroom by him/herself as well and he/she was not supposed to do so. MP L said the resident needed assistance with all of his/her activities of daily living (ADLs). MP L said the resident required full assistance with dressing, top and bottom. MP L said the resident required full assistance with showering, which included washing the resident, drying the resident and applying lotion. MP L said the resident required full assistance with toileting as well which included assistance getting on and off the commode as well as clean up. During an interview on 7/1/24 at 1:40 P.M., CP | said the resident required assistance with all of his/her ADLs. CP | said for dressing, the resident's family member set out clothes for the week for the resident. CP | said the resident required top to bottom assistance for dressing. CP | said the resident required full assistance with toileting which included assisting the resident on and off the commode as well as peri-care. CP | said he/she was not aware the resident was a high fall risk and had several falls since December of 2023. CP | said had he/she known this about the resident, he/she would have rounded on the resident every 30 minutes. CP | said someone in the facility should have told him/her this about the resident. CP | said he/she did not know if he/she had access to the resident's ISP but he/she thought there was a binder with this information but he/she did not know how updated the binder was. Review of the resident's ISP dated 4/25/24, Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 10 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 showed the following: -Need: Continence: The resident required assistance with continence needs; -Need: Grooming: The resident will be groomed appropriately; -Need: Bathing: The resident required assistance with bathing; -Need: Dressing/Undressing: The resident will be dressed appropriately; -Fall Risk: The resident will have interventions and strategies to increase safety and prevent falls. On 1/19/24, the resident had a fall, and the intervention was to encourage and remind the resident to use their wheelchair. On 2/11/24, the resident had a fall without injury. The resident was to be encouraged to press his/her call light button for assistance. On 3/20/24, the resident had a fall. The intervention was to have staff respond quickly when the resident's call light was pressed and if the staff was not able to, they should call for other staff to assist the resident. The resident did not like to call for assistance. On 5/14/24, the resident had a fall, and the intervention was to make sure the resident's wheelchair wheels were locked when the resident is out of the wheelchair. On 6/4/24, the resident had a fall. The intervention was to have the resident use his/her pendant and call for assistance before self-transferring. The resident required status checks and staff were to continue frequent checks. The staff were required to check on the resident every two hours; -Need: Transfer Ability/Mobility: The resident required assistance with transferring/mobility; -Need: Status checks: Continue frequent checks. The CP will check on resident every two hours; -The ISP did not specify what kind of assistance the resident required for any of the needs; -The ISP did not address the resident's need of toileting; Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 11 -The ISP did not address all of the resident's falls; -The ISP did not address a new intervention for each fall: -The ISP did not address preferences of the resident for each need. During an interview on 7/2/24 at 11:19 A.M., MP F said he/she did not know where the ISPs are kept, and he/she had not seen one. MP F said the staff gave a verbal report at shift change. MP F said it would be helpful to have instructions on how to care for the residents, referring to the ISPs. During an interview on 7/2/24 at 9:42 A.M., the Assistant Director of Nursing (ADON) said new interventions for preventing falls are passed down to the staff through shift change report. The ADON said these interventions should also be documented on the resident's ISP. The ADON said all CPs have access to the ISPs in the binder at the nurse's station, which should have the most updated version of each resident's ISP. The ADON was not aware not all CPs were aware where the ISPs were and if they had the most updated version. The ADON was aware the resident slid out of his/her chair a lot. The ADON said the resident usually tried to transfer him/herself at night. The ADON said the staff usually check on the resident twice during the night and more frequently during the day. The ADON said it would be best to check on the resident at least every two hours with the resident's extensive fall history. The ADON said it would be ideal to check on the resident more frequently than every two hours, but she was not sure that was possible, and she was not sure why she thought it was not possible. They ADON said due to the resident's fall history, he/she should not be ambulating about on his/her own. The Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 12 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 12 ADON said when staff go by the resident's room, they usually peek their head in to check on the resident and see if he/she needed anything. The ADON said the staff members should know the resident's fall history because they worked with the resident before. The ADON was not aware some staff members did not know the resident had a fall history. The ADON was not aware some staff members did not know where the ISPs were located. The ADON said the resident could be on a toileting schedule to prevent falls in the bathroom and there was no reason why the resident was not already on a toileting schedule. The ADON was not sure what time the resident usually went to bed. The ADON was aware all falls were required to be listed on the resident's ISP and she was not aware the resident's falls were not documented on the resident's ISP. The ADON was aware there should be a new intervention for each fall documented on the ISP and she did not realize this was not documented on the resident's ISP. The ADON expected staff to peek their head in the resident's door each time they pass the resident's room due to the resident's fall history. The ADON said after review of the resident's current ISP, staff would not be able to provide adequate care for the resident. She said based off the current ISP, it did not have what kind of assistance the resident required, especially with transferring and what time the resident usually went to bed to prevent the resident from self-transferring. The ADON did not ask the resident what time he/she went to bed at night because she thought this was already addressed. Some of the resident's falls could probably have been prevented if more details were on the resident's ISPs. The ADON said the resident was a one person assist with dressing/undressing, showering and toileting. The ADON said the resident's ISP should have more Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 13 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 251 PLAZA DRIVE PLAZA AT WILDWOOD SENIOR LIVING THE WILDWOOD, MO 63040 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 13 details than what it did. 2. Review of Resident #5's medical record showed the facility admitted the resident on 3/26/21, with diagnoses which included high blood pressure, hypothyroidism, gastro-esophageal reflux disease, vitamin B deficiency. Review of the resident's ISP dated 5/14/24, showed the following: -Focus: Speech/communication. | will receive assistance with facilitation of communication needs. No interventions for how to assist with communication. -Focus: Continence. | will receive assistance with continence needs. No interventions for how to assist with care. -Focus: Grooming. | will be groomed appropriately. No interventions for how to assist with grooming. -Focus: Bathing. | will receive assistance with bathing. No interventions for how to assist with bathing. -Focus: Dressing and undressing. | will be dressed appropriately. No interventions for how to be assisted with dressing. -Focus: Escorting. | will receive assistance with escorting. No interventions for how to be assisted with escorting. -Focus: Expression/mood problems. | will receive assistance with expression or mood impairment. No interventions on how to be assisted with expression or mood impairment. -Focus: Wander Management. | will utilize a wander management system for safety. No interventions for what a wander management system is or how to use it to assist for safety. -Focus: A.M. Routine. | will arise in a timely manner per normal routine. No interventions to Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 14 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 251 PLAZA DRIVE PLAZA AT WILDWOOD SENIOR LIVING THE WILDWOOD, MO 63040 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 14 address what a normal morning routine looks like or how to assist. -Focus: P.M. Routine. | will go to bed in a timely manner per normal routine. No interventions to address resident preference but bedtime routine or how to assist the resident with normal routines. 3. Review of Resident #4's medical record showed the facility admitted the resident on 3/31/2023, with a diagnoses that included dementia, bipolar disorder, bradycardia, high blood pressure, and vitamin B deficiency. Review of the resident's ISP dated 6/18/24 showed the following: -Focus: Speech/communication. | will receive assistance with facilitation of communication needs. No interventions for how to assist resident with speech or communication needs. -Focus: Continence. | will receive assistance with continence needs. No interventions on how to assist with continence care. -Focus: Grooming. | will be groomed appropriately. No interventions for how to assist with grooming. -Focus: Bathing. | will receive assistance with bathing. No interventions for how to assist with bathing. -Focus: Dressing/undressing. | will be dressed appropriately. No interventions for how to be assisted with dressing. -Focus: Escorting. | will receive escorting. No interventions on how to assist with escorting. -Focus: Expression/mood problems. | will receive assistance with expression or mood impairment. No interventions on how to assist with expression or mood problems. -Focus: A.M. Routine. | will arise in a timely manner per normal routine. No interventions for resident preference for normal routines or how to Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 15 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 251 PLAZA DRIVE WILDWOOD, MO 63040 PLAZA AT WILDWOOD SENIOR LIVING THE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 15 assist the resident with normal routines. -Focus: P.M. Routine. | will go to bed in a timely manner per normal routine. No interventions for resident preference for normal routines or how to assist the resident with normal routines. 4. Review of Resident #1's medical record showed the facility admitted the resident on 11/11/23, with a diagnoses that included hyperlipidemia, dementia and aneurysm of the heart. Review of the resident's ISP dated 6/18/24 showed the following: -Focus: Speech/communication. | will receive assistance with facilitation of communication needs. No interventions for how to assist resident with speech or communication needs. -Focus: Continence. | will receive assistance with continence needs. No interventions on how to assist with continence care. -Focus: Grooming. | will be groomed appropriately. No interventions for how to assist with grooming. -Focus: Bathing. | will receive assistance with bathing. No interventions for how to assist with bathing. -Focus: Dressing/undressing. | will be dressed appropriately. No interventions for how to be assisted with dressing. -Focus: Escorting. | will receive escorting. No interventions on how to assist with escorting. -Focus: Wander Management. | will utilize a wander management system for safety. No interventions for what a wander management system is or how to use it to assist for safety. 5. During an interview on 7/3/24 at 1:00 P.M., the Administrator said she expected information on how to transfer the resident to be documented in Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 16 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 16 the resident's ISP. She said all instruction on how to transfer the resident, which included to indicate a clear path and instructions for the transfer itself. The Administrator said all falls should be documented in the resident's ISP. The Administrator said all interventions for falls should be included in the ISP. The Administrator expected details for how to dress and/or undress a resident be identified on the ISP. The Administrator expected details on how to assist a resident with toileting to be included in the resident's ISP. The Administrator said any and all information regarding the resident's activities of daily living, anything to do with their care necessities and anything to do with behaviors and moods should be detailed in the resident's ISP. The Administrator was not aware those details were not included in the resident's ISP. The Administrator said she had mentioned it is a resident right to choose when they want to go to bed and the ADON should have carried the information over to the team. M0O00237982 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. I/II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to provide proper care for residents, as defined in their individualized service plans (ISP, the planning documented prepared by an assisted living facility which outlines a resident's Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 17 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 17 needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility), for one of six sampled residents (Resident #6) who required assistance with transfers, his/her call light to be answered with a quick response and routine checks every two hours. The census was 67. Review of Resident #6's medical record, showed the facility admitted the resident on 7/10/23, with a diagnoses which included dementia, psychotic disturbance, mood disturbance, depression and high blood pressure. Review of the resident's progress notes, showed the following: -On 12/29/23 at 9:30 P.M., the resident pressed his/her call button and when the care aide went into the resident's room, he/she found the resident on the floor. The resident tried to put him/herself to bed. The Director of Nurses (DON) was called and assessed the resident. A message was left to the resident's family member and the resident's physician was made aware; -On 1/3/24 at 3:14 P.M., the resident was found on the floor in his/her kitchen area. The resident said he/she fell out of the bed and scooted into the kitchen and pushed his/her call light. The DON completed an assessment. There were no signs of injury noted and the resident was assisted back up from the floor and into his/her bed; -On 1/19/24 at 4:14 P.M., the resident was found on the floor in the bathroom sitting on his/her buttocks with his/her arms on his/her knees. The resident was unable to report how the fall occurred. The resident denied hitting his/her head. The resident's wheelchair was not present. The DON completed an assessment, and the Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 18 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 18 resident was negative for injury. The intervention was to encourage and remind the resident to use his/her wheelchair; -On 2/14/24 at 3:35 P.M., a Medication Partner (MP) was called to the resident's room by a Care Partner (CP). The resident was observed sitting on the floor, in the bathroom, with his/her back against the toilet. The DON was called, assessment completed over the phone. No injuries noted. The resident denied pain. The resident was assisted up to his/her feet and on the toilet; -On 2/28/24 at 6:33 P.M., the Nurse was alerted the resident was found sitting on the floor. The Nurse went to the resident's room and found the resident sitting on his/her bottom with his/her knees tucked to his/her chest and his/her arms around his/her knees. The Nurse asked the resident what happened, and the resident said he/she was getting out of his/her recliner to transfer to the wheelchair when he/she slid off the recliner. The resident was able to move all extremities without any limitations. The resident denied any pain/discomfort. He/she denied hitting his/her head. The Nurse completed a head-to-toe assessment. No injuries or bruising noted. The resident's vitals were within normal limits. The resident was assisted off the floor with an assist of two and escorted down to dinner per his/her request. The resident was placed on 72 hour monitoring. The resident's family member was notified; -On 3/20/24 at 11:00 A.M., at 9:20 A.M., a CP found the resident on the floor. The resident was lying on his/her right side by the bed with a pillow under his/her head. The staff notified the Nurse. The Nurse assessed the resident. The resident's range of motion was within normal limits. The resident denied pain and denied hitting his/her head. The resident did not have injuries noted. Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 19 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 19 The Nurse notified the resident's family member, the DON and the resident's physician. The Nurse spoke with the resident's family member who inquired if the resident used his/her call light. The resident had used his/her call light. The family member was glad because the resident did not normally use the call light. The DON will educate staff when the resident uses his/her call light; he/she needed action quickly due to the resident not using the call light for minor things because he/she did not like to ask for assistance; -On 4/14/24 at 9:40 P.M., the staff answered a call light and found the resident on the bathroom floor with his/her wheelchair beside him/her. The resident denied hitting his/her head, denied pain and his/her range of motion was in normal limits. The staff notified the DON. The resident's vitals were taken, and the nurse notified and assessed the resident over the phone. The staff said they had just gotten the resident back to bed after toileting him/her then he/she was on the light. The staff notified the resident's physician, family and the Administrator. Review of the resident's ISP dated 4/25/24, showed the following: -Need: Transfer Ability/Mobility: The resident required assistance with transferring/mobility; -Need: Status checks: The resident required frequent checks. The CP will check on the resident every two hours; -Need: Fall Risk: The resident required the staff to respond quickly when the resident pressed his/her call light and call other staff to answer the call light if they were not able to answer the call light quickly. Review of the resident's progress notes, showed the following: -On 5/14/24 at 3:26 A.M., the facility's system Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 20 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 20 alerted the staff of a fall. The staff went into the resident's room and found him/her sitting on the floor. The Nurse was notified. The Nurse assessed the resident. The resident denied hitting his/her head, denied pain and no injuries were noted. The resident's range of motion was within normal limits. The resident's family member was called, he/she said the resident tried to transfer him/herself from the bed to the wheelchair, but the wheelchair moved when doing so. Review of the facility's call light log, showed the following: -On 6/2/24 at 5:46 P.M., the resident pressed his/her call light, an escalation was triggered at 5:51 P.M. and another escalation was triggered at 5:56 P.M. The response time was 25 minutes; -On 6/3/24 at 6:36 P.M., the resident pressed his/her call light, an escalation was triggered at 6:41 P.M., another escalation was triggered at 6:46 P.M., and a final escalation was triggered at 6:51 P.M. The response time was 17 minutes and 52 seconds. Review of the resident's progress notes, showed the following: -On 6/4/24 at 2:16 P.M., the resident was found on the floor in front of his/her chair and the wheelchair to his/her side. The resident said he/she did not hurt him/herself or hit his/her head. The DON completed range of motion to all extremities. The resident did not complain of pain. The CP and DON assisted the resident up and vitals were taken. No injuries were noted; -On 6/6/24 at 8:01 A.M., the facility's system alerted the staff of a fall. The resident was found sitting on the floor beside his/her bed. The resident said he/she rolled out of bed. The DON assessed the resident. The resident's range of motion was within normal limits. The resident Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 21 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 21 denied pain and denied hitting his/her head. No injuries were noted. Review of the facility's call light log, showed the following: -On 6/10/24 at 11:04 A.M., the resident pressed his/her call light, an escalation was triggered at 11:09 A.M., and another escalation was triggered at 11:14 A.M. The response time was 25 minutes; -On 6/12/24 at 6:24 P.., the resident pressed his/her call light, an escalation was triggered at 6:29 P.M., another escalation was triggered at 6:34 P.M., and another escalation was triggered at 6:39 P.M. The response time was 16 minutes and 39 seconds; -On 6/13/24 at 6:16 P.M., the resident pressed his/her call light, an escalation was triggered at 6:21 P.M., another escalation was triggered at 6:26 P.M., and another escalation was triggered at 6:31 P.M. The response time was 16 minutes and 39 seconds; -On 6/14/24 at 11:34 A.M., the resident pressed his/her call light, an escalation was triggered at 11:39 A.M., another escalation was triggered 11:44 A.M., another escalation was triggered at 11:49 A.M., and another escalation was triggered at 11:54 A.M. The response time was 25 minutes; -On 6/15/24 at 1:16 P.M., the resident pressed his/her call light, an escalation was triggered at 1:21 P.M., another escalation was triggered 1:26 P.M., another escalation was triggered at 1:31 P.M., and a final escalation was triggered at 1:36 P.M. The response time was 25 minutes; -On 6/16/24 at 6:41 P.M., the resident pressed his/her call light, an escalation was triggered at 6:46 P.M., another escalation was triggered at 6:51 P.M., and a final escalation was triggered 7:01 P.M. The response time was 25 minutes; -On 6/17/24 at 6:21 P.M., the resident pressed his/her call light, an escalation was triggered at Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 22 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 22 6:26 P.M., another escalation was pressed at 6:31 P.M., another escalation was triggered at 6:36 P.M., and a final escalation was triggered at 6:41 P.M. The response time was 25 minutes; -On 6/21/24 at 2:46 P.M., the resident pressed his/her call light, an escalation was triggered at 2:51 P.M., another escalation was triggered at 2:56 P.M., and a final escalation was triggered at 3:01 P.M. The response time was 25 minutes; -On 6/22/24 at 11:09 A.M., the resident pressed his/her call light, an escalation was triggered at 11:14 A.M., another escalation was triggered at 11:19 A.M., and a final escalation was triggered at 11:24 A.M. The response time was 17 and 30 minutes; -On 6/24/24 at 6:02 P.M., the resident pressed his/her call light, an escalation was triggered at 6:07 P.M., another escalation was triggered at 6:12 P.M., another escalation was triggered at 6:17 P.M., and a final escalation was triggered at 6:22 P.M. The response time was 25 minutes. Review of the resident's apartment's camera footage, showed the following: -On 6/24/24 at 6:38 P.M., CP | checked on the resident and took the resident's trash out. -On 6/24/24 at 9:42 P.M., the resident self-transferred from his/her wheelchair to his/her bed with no assistance from staff; -On 6/25/24 at 9:53 A.M., a CP came in to get the resident out of bed an into the bathroom; -The resident was not checked on from 6/24/24 at 6:38 P.M., until 6/25/24 at 9:53 A.M. Review of the facility's call light log, showed the following: -On 6/28/24 at 6:03 P.M., the resident pressed his/her call light, an escalation was triggered at 6:08 P.M., another escalation was triggered at 6:13 P.M., and a final escalation was triggered at Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 23 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 23 6:18 P.M. The response time was 18 minutes and 14 seconds; -On 6/29/24 at 6:21 P.M., the resident pressed his/her call light, an escalation was triggered at 6:26 P.M., another escalation was triggered at 6:31 P.M., another escalation was triggered at 6:36 P.M., a final escalation was triggered at 6:41 P.M. The response time was 25 minutes. During an interview on 7/1/24 at 1:10 P.M., MPL said staff do not log their rounds on the residents unless it is a task for the resident. He/she said some residents have tasks to check on them more frequently, especially if the resident is a fall risk. MP L said if the resident did not have any triggers, then they would not be listed on the tasks and would receive a normal amount of rounds, which was every two hours. MP L said he/she peeked his/her head in the resident's apartment each time he/she passed the apartment just to check on him/her but other than that, MP L said he/she saw the resident twice a day for the resident's morning and evening medication. MP L said the resident did not have a fall lately and he/she was not aware of the resident's extensive fall history. During an interview on 7/1/24 at 1:40 P.M., CP | said the resident required assistance with all of his/her activities of daily living (ADLs). CP | said staff are not required to log the check-ins on the residents unless it is a task for the CP to complete. Only certain residents have certain tasks. CP | said things like falls trigger a task for the CP to complete. CP | said he/she was not aware the resident was a high fall risk and had several falls since December of 2023. CP | said had he/she known this about the resident, he/she would have rounded on the resident every 30 minutes. CP | said someone in the facility should Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 24 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 24 have told him/her this about the resident. CP | did not know if he/she had access to the resident's ISP but he/she thought there was a binder with this information, but he/she did not know how updated the binder was. CP | said no one told him/her to answer the resident's call light right away or call another CP to answer the light if he/she could not answer the call light at the moment. During an interview on 7/2/24 at 10:35 A.M., CP G said he/she was not aware of the resident's extensive fall history and was not aware the resident required frequent checks. CP G said the resident was a two hour check like most residents at the facility. CP G said he/she was aware the resident had a camera in his/her room and the resident's family checked on the resident frequently. CP G said the family usually alerted the facility if something happened to the resident that would have been seen on the camera. CP G was aware it was the staff's responsibility to check on the resident, not the family's responsibility. CP G said had he/she known the resident had such an extensive fall history, he/she would have checked on the resident every time he/she passed the resident's room. CP G said some CPs have told him/her to check on the resident every time he/she passes the resident's room. CP G said it depended on the day on whether or not he/she checked on the resident each time he/she passed the resident's room. CP G said the ISPs are in a binder, but he/she did not know where the binder was located. CP G said the resident's ISP should be more detailed in how often the resident required checks. CP G said the ISP would not help new CPs if they had not had a verbal report from old (people who have been there longer) CPs. Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 25 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 25 During an interview on 7/2/24 at 11:19 A.M., MP F said he/she did not know where the ISPs are kept, and he/she had not seen one. MP F said staff give a verbal report at shift change. MP F said it would be helpful to have instructions on how to care for the residents, referring to the ISPs. During an interview on 7/3/24 at 1:50 P.M., the Regional Director of Wellness (RDOW) said the residents are checked on depending on what the resident's ISP indicates. The RDOW said with a resident who had a history of falls like this, the resident should be checked on every two hours. The RDOW said she saw the resident transfer him/herself from the wheelchair to the bed and the resident should not have transferred him/herself alone like that. The RDOW said sometimes residents lose their sense of safety awareness. The RDOW said she was able to review the facility's footage which showed the resident was last checked on around 6:30 A.M., on 6/24/24 and was not checked on until the next morning around 9:56 A.M. The RDOW said this was not acceptable. The RDOW was not aware the resident had so many falls and the staff should have been looking at certain times the resident had fallen and try to prevent any future falls by using a toileting schedule, checking on the resident every two hours and making sure the resident did not self-transfer. During an interview on 7/2/24 at 9:55 A.M., the Assistant Director of Nursing (ADON) said the response time on call lights should be around 5 minutes for a resident with an extensive fall history. She said a resident with an extensive fall history should be checked on quickly if the resident pressed their call light. The ADON said the resident's call light log of response times was Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 26 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 26 unacceptable. The ADON said Maintenance pulled the call light log once a week and the log goes to the Administrator to review. The ADON said the log should be reviewed with the wellness team as well. The ADON was aware the resident tried to self-transfer at night when going to bed. The ADON said staff usually check on the resident two times during the night. The ADON said for a resident with an extensive fall history, it would be better to check on the resident more frequently than every two hours, but she thought that might not be possible and she did not know why it would be impossible. The ADON said she was not aware some staff members were not aware of the resident's extensive fall history, and she was not aware some staff members were not aware to check on the resident more often than every two hours. The ADON said some of the resident's falls could have been prevented if the expectations of the staff were more detailed on the resident's ISP, if the resident had a toileting schedule and if the resident was checked on at night before self-transferring to bed. During an interview on 7/1/24 at 1:50 P.M., the Administrator said she expected staff to document their rounds they completed on residents. The Administrator thought this was possible using the facility's online database. The resident's family member sent her an email on 6/30/24 at 10:28 A.M., regarding some concerns of the resident not being checked on. The Administrator was aware the resident had a camera in his/her room and the family member had mentioned to the Administrator concerns about care fees and how the care was not being completed. The Administrator said the family member mentioned to her the staff not checking on the resident every two hours one night. The Administrator was able to review the facility's Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 27 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 27 footage which showed the resident brought to his/her room around 6:38 P.M., and the resident was not checked on again until the next morning around 9:54 A.M. The Administrator said she was very surprised no staff member checked on the resident by the 10 hour mark. The Administrator expected staff to check on the resident every two hours. The Administrator said she had mentioned it is a resident right to choose when they want to go to bed and the ADON should have carried the information over to the team. The Administrator expected the ADON to find the time the resident went to bed and then predict when the resident goes to bed and then have the staff members check on the resident at that time to prevent the resident from self-transferring. The Administrator did not think of using a sign in/out sheet and was not aware this was being done prior but had stopped. The Administrator expected the resident to be on a toileting scheduling and she was not aware the resident was not on one. Had these expectations been met, the resident probably would not have fallen so many times. M000237982 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 28 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE PLAZA AT WILDWOOD SENIOR LIVING THE WILDWOOD, MO 63040 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 (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 Continued From page 28 medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. II This regulation is not met as evidenced by: *Class Il Based on observation, interview and record review, the facility failed to ensure a safe and effective medication system for one of six residents. The facility staff failed to confirm resident medication was provided to the resident and document administration of resident's medications. (Resident #5). The census was 67. Review of Resident #5's medical record showed the facility admitted the resident on 3/26/21 with diagnoses including hypothyroidism, high blood pressure, gastro-esophageal reflux disease and vitamin B deficiency. Review of the resident's Physician's Order Sheet (POS) dated 7/1/24, showed the following: -Levothyroxine 50 micrograms (MCG) tablet (1000 ea) Tab, take (1) tablet by mouth daily before breakfast. Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 DEFICIENCY) If continuation sheet 29 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 29 Review of the resident's Medication Administration Record (MAR) dated 6/1/24-6/30/24, showed no documentation for resident receiving her Levothyroxine on 6/5, 6/7, 6/8, 6/9, 6/11, 6/12, 6/13, 6/17, 6/18, 6/22, 6/25, and 6/30/24. Review of the resident's progress notes for the month of June 2023, showed the following: -6/24/24 at 6:53 A.M. Drug refused. No documentation of notifying the physican or family; -6/26/24 at 6:33 A.M. Refused. No documentation of notifying the physican or family; -6/29/24 at 6:41 A.M. Refused. No documentation of notifying the physican or family. During an interview on 7/1/24 at 1:15 P.M., the resident's family member said the resident's medications have been a "mess." He/she said the medications are not being given and he/she has taken approximately 30 packages of medications back from the facility of medications that were not administered. He/she said staff at the facility will say the resident refused his/her medications but he/she feels if the resident is refusing his/her medications, it's due to the approach that is used during administration. During an interview on 7/2/24 at 9:33 A.M., Care Coordinator B said he/she is aware the resident has refused his/her medications. If the resident is refusing to take his/her medications, staff is supposed to call the family member for assistance. During an interview on 7/2/24 at 11:02 A.M., Medication Partner F said if the resident refuses his/her medications, he/she will put them back into the cart and attempt three times. If he/she continues to refuse the medications, he/she is Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 30 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 30 supposed to contact the other Medication Partners or his/her supervisor. During an interview on 7/2/24 at 2:35 P.M., Medication Partner D said the resident refuses his/her medications a lot. He/she said she will get another Medication Partner to try to assist. If the resident refuses, he/she reports it to the nurse. During an interview on 7/3/24 at 2:58 P.M., the Administrator said if a resident refused their medications, she expected the physican and family to be notified and the resident documents to show the resident refused the medication. She was not aware the resident's record did not show the resident refused medications or that the physican wasn't notified. 19 CSR 30-86.047(65)(A) Safe Transfers Training Requirements Requirements for training related to safely transferring residents. (A) The facility shall ensure that all staff responsible for transferring residents are appropriately trained to transfer residents safely. Individuals authorized to provide this training include a licensed nurse, a physical therapist, a physical therapy assistant, an occupational therapist or a certified occupational therapy assistant. The individual who provides the transfer training shall observe the caregiver's skills when checking competency in completing safe transfers, shall document the date(s) of training and competency and shall sign and maintain training documentation. Initial training shall include a minimum of two (2) classroom instruction hours in addition to the on-the-job Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 31 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 31 training related to safely transferring residents who need assistance with transfers. II/III This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to develop a system to ensure all staff were properly trained in transferring residents, for one of six sampled residents (Resident #6). The census was 67. Review of Resident #6's medical record, showed the facility admitted the resident on 7/10/23, with a diagnoses which included dementia, psychotic disturbance, mood disturbance, depression and high blood pressure. Review of the camera footage in the resident's room, dated 6/24/24 at 6:17 P.M., showed Care Partner (CP) | entered the resident's room with the resident in his/her wheelchair being pushed by CP |. CP | pushed the resident's wheelchair up to the resident's recliner. CP | helped the resident put a piece of paper on the resident's end table and then CP | transferred the resident from the wheelchair to the recliner by placing one arm over the resident's shoulder with his/her hand in the resident's armpit and the other arm around the back of the resident and pivoted the resident towards the recliner. CP | did not use a gait belt. Observation on 7/1/24 at 9:15 A.M., showed CP | came into the resident's room to transfer the resident from his/her wheelchair to his/her recliner. CP | looked for a gait belt but could not find one in the resident's room. CP | walked out of the resident's room to retrieve a gait belt. Shortly after, CP | returned with a gait belt and transferred the resident from the wheelchair to Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 32 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 32 the recliner properly using the gait belt secured around the resident. During an interview on 7/1/24 at 1:30 P.M., CP | said he/she had not gotten a lot of training. CP | said he/she was trained on how to move a broda chair and some dementia training. CP | said he/she had not received specific training on how to transfer a resident. CP | said he/she used a gait belt when he/she transferred the resident because he/she saw other employees use a gait belt with the resident. During an interview on 7/2/24 at 9:23 A.M., CP J said he/she had not received any training on transferring. CP J said during his/her first couple days of employment at the facility, he/she had trained the other CPs on transferring. CP J said there were two other CPs who had trained him/her on transferring, but no nurse had trained CP J on transferring. CP J said one of the CPs who trained him/her on transferring was CP G. During an interview on 7/2/24 at 10:35 A.M., CP G said he/she watched a video on transfer training but had no transfer training from a nurse. CP G said there are times when residents do not have gait belts and when that happens, the CP will put their arms underneath the resident's arms. CP G said no one had told him/her to never transfer a resident without a gait belt. During an interview on 7/3/24 at 9:08 A.M., CP H said he/she had not been trained on transferring by a nurse. CP H said there was a physical therapist who taught him/her how to transfer a specific resident and the training was about 15 minutes long. During an interview on 7/2/24 at 1:30 P.M., Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 33 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 33 Physical Therapist (PT) L said on 3/8/24, the facility had a mass transfer training meeting which lasted about 20 minutes. PT L said the meeting had a staff volunteer act as a resident and he/she performed the transfer in front of the employees. PT L went over body mechanics, mid-assist, mod-assist, how to use a gait belt, and how to approach a resident. PT L said when he/she is asked to train the employees, he/she does one on one training with them which usually lasts about ten to 20 minutes. During an interview on 7/3/24 at 1:30 P.M., the Administrator said the transfer training was done by therapy in the past, but there is also a video on transferring which some staff watch. The Administrator said she did not know how long the training video was. The Administrator said she was aware the staff who were performing transfers were required to have two hours of training during orientation and one hour annually. The Administrator was not aware CPs were training other CPs on how to transfer residents. The Administrator was not aware some staff did not receive the required two hour transfer training. M0O00237982 19 CSR 30-88.010(29) Dignity/Privacy Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 34 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 34 excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. 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 treated residents with consideration, respect, and full recognition of their dignity and individuality, when staff members attempted to assist a resident to get up in the morning and administer her medications when she was saying "no" and "leave me alone" for one of six sampled residents (Resident #5). The census was 67. Review of Resident #5's medical record showed the facility admitted the resident on 3/26/21 with diagnoses including hypothyroidism, high blood pressure, gastro-esophageal reflux disease and vitamin B deficiency. Observation of a video obtained from an electronic monitoring device located in the resident's room from 6/24/24 at 6:41 A.M., showed Medication Partners D and F entered the room with an agency staff member. Medication Partner D walked over to the resident and placed his/her hand on the resident's back and asked if he/she would like to get up. The resident did not move or answer the question. Medication Partner D proceeded to turn the resident and sit him/her up and place him/her in a standing position next to the bed. The resident began saying "no" and "leave me alone." Medication Partner D then pulled the resident's brief off which left the resident exposed from the waist down. Medication Partner F voiced to the resident that everything was okay. The resident continued to Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 35 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 35 request for care not to be provided. Medication Partner D and F continued to provide care. The resident walked toward his/her doorway, half dressed, in an attempt to get away from the Medication Partners. The agency staff member attempted to administer the resident's medications and the resident threw the medication back at the staff member. During an interview on 7/2/24 at 9:07 A.M., the Administrator said she was aware of the family member's concerns and had reviewed the videos provided to her. She shared those videos with the Care Coordinator and communicated that the resident doesn't like to get up early. She said the communication on the third floor is not very good and the family member is an advocate for the resident and has valid concerns. She had given direction three or four times to the Care Coordinator. When she looked at the videos, she saw the staff were being nice to there resident and trying to talk to her. She said they have planned on initiated memory care training but have not yet been able to initiate the education. During an interview on 7/2/23 at 9:33 A.M., the Care Coordinator said she was aware of the concerns. She said she had not seen any of the videos except for one where the resident had a fall. She is aware the family member does not expect the resident to get up that early. Some days, the resident will refuse to get up and they have to go back later to assist him/her. She said the family member will also come up to help at times. With the medications, they should attempt at least three times before saying the resident refused his/her medications. During an interview on 7/2/24 at 11:01 A.M., Medication Partner F said he/she noticed a recent Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 36 of 38 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 36 change in the resident's behavior. The resident will yell out "no" or "I don't want to." The resident might be wet at the time and they don't want to leave him/her soiled so he/she will usually rub the resident's back and if the resident is really wet, he/she will take the resident's hand and assist the resident to see that he/she is wet and needs to be changed. Sometimes the resident will ignore them. Medication Partner F is aware there are cameras in the room. He/she said it is unacceptable to continue care when a resident is refusing. They need to come back later and try again. He/she said she can understand why the resident would feel uncomfortable with his/her brief being removed when she's saying "no." During an interview on 7/2/24 at 2:35 P.M., Medication Partner D said he/she felt the resident needs to be in a skilled facility because he/she refused care a lot. He/she is aware there are cameras in the room and will talk loudly so the family member is able to hear him/her speak to the resident. He/she has not had any training on how to assist residents with dementia or residents having behaviors. They take two people in the room so there are witnesses to what is going on. There is no reason to have three people in the room. He/she said the regular workers should know how to work with the resident and they verbally tell others how to assist. During an interview on 7/3/24 at 2:58 P.M., the Administrator said she expected the care team to have access to instructions on how to care for the residents and was not aware they didn't have instructions. She is aware of the family member's concerns about the resident's care and she expected the care team to assist him/her appropriately. She said they are in the process of initiating training for the care staff specifically for Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE011 PRINTED: 07/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 37 of 38 PRINTED: 07/19/2024 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 Cc 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE A8030 | Continued From page 37 assisting residents with dementia. *The higher classification is merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 GXE011 If continuation sheet 38 of 38 PLAN OF CORRECTION Provider/Supplier The Plaza at Wildwood Senior Living Name: Street Address, 251 Plaza Drive City, Zip: Wildwood, MO 63040 Date of Survey: 07/03/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 31049 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. Correction of Cited Deficiency: 19 CSR 30-86.022 (16) One Lock per Resident Request A2293 7/24/2024 The door and lock have been replaced. Installation occurred on 7/22/2024. Assessment to Identify other Residents that may be affected: The Executive Director and Plant Operations Team have . ; ; ; , . 7/24/2024 inspected each resident door to identify areas not in good repair or not in compliance with the construction and fire safety rules. 9-2-2024 This inspection has been completed as of July 24, 2024. Procedure to ensure on-going compliance: Ongoing inspections will be performed quarterly by The Executive Director, Plant Operations Director and /or designee. Non-compliant findings will be documented in the TELS system for immediate attention. 7/24/2024 Monitoring for on-going compliance: Ongoing inspections will be performed quarterly by The Executive Director, Plant Operations Director and /or designee. Non-compliant findings will be documented in the TELS system for immediate attention. 7/24/2024 A3201 Correction of Cited Deficiency: 19 CSR 30-86.032 (2) Substantially Constructed and Maintained The door and lock have been replaced. Installation occurred on 7/22/2024. 1122/2024 Assessment to Identify other Residents that may be affected: The Executive Director and Plant Operations Director conducted a comprehensive inspection of each resident door to identify areas that are not in good repair or do not comply with the construction and fire safety rules. This inspection was completed by July 24, 2024. All inspections will be completed quarterly and on going. 712412024 Procedure to ensure on-going compliance: Ongoing inspections will be performed quarterly by The Executive Director, Plant Operations Director and /or designee. Non-compliant findings will be documented in the TELS system for immediate attention. 7/24/2024 Monitoring for on-going compliance: Door inspections will be monitored by both The Executive Director and Plant Operations Director. Any deficient findings will be reported in the TELS System for immediate attention. Door inspections will occur ongoing quarterly. 7/24/2024 A3202 Correction of Cited Deficiency: 19 CSR 30-36-032 (3) Additional Business Requires DHSS Approval The Second Business license application was filed in November 2023. The community’s representatives have been in ongoing communication with the state on all the information needed for the Second Business License, including up to and through July 3, 2024, when the State revoked the license without notice. The Community understands it has provided the State with all 7/3/2024 information needed and is just waiting for final approval of the license Assessment to Identify other Residents that may be 7/3/24 affected: All residents would be impacted by this. Residents and family members were made aware of the temporary license suspension. Residents and family members were assured that the situation. Procedure to ensure on-going compliance: 8/15/2024 A compliance calendar will be developed by August 15, 2024, that will include critical dates related to licensing and regulatory approvals. The calendar will include a reminder that the application and all required documents must be submitted for the second business license annually in June to receive by July. The calendar will be reviewed monthly and on-goi Monitoring for on-going compliance: 8/15/2024 The compliance calendar will be reviewed monthly to ensure the community is following all licensing and regulatory approvals. A4754 Correction of Cited Deficiency: 19 CSR 30-86.047 (28) Individual Service Plan Dev. 7/23/2024 Resident #6 Director of Wellness or designee updated resident community-based assessment and individualized service plan. Resident #5 Director of Wellness or designee updated resident community-based assessment and individualized service plan. Resident #4 No longer lives at Community. Resident #1 Director of Wellness or designee updated resident community-based assessment and individualized service plan. Assessment to Identify other Residents that may be 1/23/2024 affected: Director of Wellness or designee conducted a review of all individualized service plans and updated as needed to ensure resident needs, preferences, services to be provided, and goals expected of resident or legal representative are documented in their service plan. Procedure to ensure on-going compliance: Director of 7/23/2024 Wellness or designee will complete the community-based assessment and individualized service plan at move-in, semiannually and with any significant change in condition. Director of Wellness or designee will do random audit of community-based assessment and individualized service plan monthly to ensure they are accurate and up to date. Monitoring for on-going compliance: Director of Wellness or 7/23/2024 designee will do scheduled audits biweekly for the next 60 days ensuring the community-based assessments and individualized service plans are being completed timely, then monthly audits thereafter. A4777 Correction of Cited Deficiency: 19 CSR 86.047 Proper Care Per Individual Service Plan. Resident #6 — Director or Wellness or designees updated 7/5/2024 residents individual service plan to ensure up to date. Resident has had Medication and documentation audit completed by Director of Wellness designee. All medication will be given according to physician orders and reviewed daily. Assessment to Identify other Residents that may be 1/23/2024 affected: Director of Wellness or designee reviewed and updated, if needed all individual service plans and physician orders to ensure accuracy, compliance, and thorough documentation. Procedure to ensure on-going compliance: Director of Wellness or Designee conducted training for all nurses and medication partners on following physician orders and providing proper documentation of medication administration on 6/18/2024 completion of training will be on 8/2/2024. The Director of Wellness and designee will educate ongoing upon onboarding of new nurses and medication partners. Monitoring for ongoing compliance: Director of Wellness or designee is to conduct weekly medication cart and point click care audit to ensure proper administration. Director of Wellness or designee will conduct monthly audits of medication carts and point click care audits. Any deficient practice will be educated on to remain in compliance. These audits will continue monthly over the next 4 months. Any deficient practice will be educated on immediately to remain in compliance. Weekly audits will be conducted in PCC by Director of Wellness and designee. Any deficient practice will be educated on to remain in compliance. Review of compliance will be monitored monthly ongoing. 8/2/2024 8/2/2024 A4797 Correction of Cited Deficiency: 19 CSR 30-86-047 Safe and Effective Medication System 19 CSR 30-86.047(46) Safe & Effective Medication System Resident #5 — Director of Wellness or designee conducted an audit of medication administration and updated individual service plan as needed. Assessment to Identify other Residents that may be affected: Director of Wellness or designee conducted a medication cart audit and reviewed all physician orders to ensure accuracy, compliance, administration, and thorough documentation. Procedure to ensure on-going compliance: Director of Wellness or Designee conducted training for all nurses and medication partners on following physician orders and providing proper documentation of medication administration began on 6/18/2024 completion of training will be on 8/2/2024. The Director of Wellness and designee will educate ongoing upon onboarding of new nurses and medication partners this will be ongoing and monitored monthly by Director of Wellness and designee. Monitoring for on-going compliance: Director of Wellness or designee is to conduct a weekly medication cart audit, verification of orders and ensure MARS in PCC are in agreement. Training will commence during on boarding of new staff members and will be ongoing audits will occur weekly for 8/2/2024 7/15/2024 8/2/2024 7-11-2024 the next 4 months. Any deficient findings will result in immediate education to remain in compliance. A4860 Correction of Cited Deficiency: 19 CSR 30-86.047 (65) Safe Transfers Training Requirements 7/11/2024 All community staff received transfer training at Community town hall on July 11, 2024. Any staff not present at town were trained on a subsequent date. Review will occur monthly and ongoing. Assessment to Identify other Residents that may be 7/11/2024 affected: All community staff received transfer training at Community town hall on July 11, 2024. Any staff not present at townhall were trained on a subsequent date. Review will occur monthly and ongoing Procedure to ensure on-going compliance: Executive 7/11/2024 Director or designee will conduct safe transfer training upon hire, every six months and as needed. Review will occur monthly and ongoing Monitoring for on-going compliance: 7/11/2024 Executive Director or designee will conduct safe transfer training upon hire, every six months and as needed. Executive Director, Director of Wellness or their designee will conduct an audit of all training once a month for four months to confirm the training has been completed and is current for all staff. Review will occur monthly and ongoing A8030 Correction of Cited Deficiency: 19 CSR 30-88.010 (29) Dignity/Privacy 7/29/2024 All staff have received in-service on resident rights including resident refusal. Review will occur monthly and ongoing Assessment to Identify other Residents that may be 7/29/2024 affected: All staff have received in-service on resident rights including resident refusal. Procedure to ensure on-going compliance: 7/3/2024 Executive Director or designee will conduct resident right training upon hire, every six months and as needed, and then annually thereafter. Review will occur monthly and ongoing Monitoring for on-going compliance: 7/3/2024 Executive Director or designee will conduct resident right training upon hire, every six months and as needed, and then annually thereafter. Executive Director, Director of Wellness or their designee will conduct an audit of all training once a month for four months to confirm the training has been completed and is current for all staff. Review will occur monthly and ongoing. Submitted By: Lisa Anderson, Executive Director, The Plaza at Wildwood, Wildwood, MO = 7/29/2024 — 24 Lisa reudersou 7/29/2024 PRINTED: 10/16/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 {X4) 1D 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 INFORMATIGN) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A4754}, 19 CSR 30-86.047(28){G) Individual Service Plan {A4754} ~ Develop 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: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident *s needs and preferences, services to be provided, and goals expected by the resident or the resident's legal representative in partnership with the facility; H This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 7/3/24. Based on interview and record review, the facility failed to develop individualized service plans which included resident Care Partner (CP) instructions on what to do if a the resident's pressure sore dressing became soiled or dislodged, for one of one sampled resident (Resident #8) resulting in the resident's dressing becoming solied and coming off and not being replaced in a timely manner by a licensed nurse. ~ | The census was 65. Review of Resident #8's medical record, showed the facility admitted the resident on 9/15/23, with diagnoses which included high blood pressure and high cholesterol. Review of the resident's ISP dated 7/19/24 showed the following: -Focus: Skin and wound care- Resident has a stage "2+" (the sore has broken through the top Missouri Department of Heaith and Senior Services [0-d.a4 PLAZA AT WILDWOOD SENIOR LIVING THE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) OATE STATE FORM GXE012 if continuation sheat 1 of 8 PRINTED: 10/16/2024 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 R-C 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE {44754} Continued From page 1 {A4754} layer of the skin and part of the layer below) pressure area or venous/arterial ulcer located at the center of his/her coccyx. Hospice and community staff will work together to complete the daily treatment orders; -No instructions for CP should the dressing become soiled or dislodged; -Focus: Transfer ability/mobility- two person physical assist with a mechanical lift. Review of the resident's progress notes, showed the following: -On 9/12/24 at 2:39 P.M., pressure sacrum wound measured 2.0 cm by 2.5 cm by 0.3 cm, undermining 1.0 cm. The area around the wound looks good, pink in color, edges are smooth. Resident had slight discomfort with wound treatment. Overall tolerated well. Cleansed with wound cleanser, crushed meteronidazole and calcium alginate, applied Medihoney, applied skin prep to peri wound, then applied foam bandage daily and as needed if soiled or becomes dislodged; -On 9/14/24 at 2:36 P.M., pressure coccyx wound pink, moist, appropriate for ethnicity. Minor discomfort, resident tolerated well: -On 9/18/24 at 6:49 P.M., pressure sacrum wound pink, dry, intact. Minimal discomfort noted during dressing change. Resident tolerated well; -On 9/23/24 at 6:15 P.M., pressure sacrum wound pink, dry, intact. Minimal discomfort noted during dressing changed. Resident tolerated well. During an interview on 10/10/24 at 9:00 A.M., the Manager on Duty (MOD) said on 9/22/24 around 10:45 A.M., a CP called her and asked her to come to the resident's room to look at a dressing. When the MOD arrived, the two CPS had removed the resident's soiled brief and put a clean brief on him/her. The dressing was just Missouri Department of Health and Senior Services STATE FORM 6899 GXE012 If continuation sheet 2 of 8 PRINTED: 10/16/2024 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 R-C 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE {A4754}| Continued From page 2 {A4754} laying on top of the resident's wound, it was falling off because it would not stick to the resident because it was soiled. The dressing was "very soiled, as if it had not been changed from maybe the evening shift or the night shift". The MOD called the Director of Nursing (DON) and she said to take the soiled dressing off and place a clean piece of gauze over the wound and a nurse would assess the wound that night (night shift) and do the full dressing. The MOD said the CPS put a gauze barrier on the wound to protect it until the nurse came in. During an interview on 9/24/24 at 2:24 P.M., CP P said hospice assists with the bandage changes, however CP P had not been instructed on what to do if the bandage becomes soiled or dislodged. He/she said it would be helpful if the information was on the resident's ISP and if they had access to the resident's ISP. He/she said if it would become soiled or dislodged he/she would call a nurse for help. During an interview on 9/24/24 at 3:09 P.M., CP M said it would help if they were given direction on how to assist the resident if the bandage would become soiled or dislodged. He/she said the only direction they are provided is on the assignment sheets and it doesn't tell them what to do if something happens to the bandage. During an interview on 9/24/24 at 3:14 P.M., CP O said he/she knew not to touch the bandage and to call for a nurse or medication technician (med tech). If something were to happen to the dressing, he/she would leave it open to air until a nurse or med tech could come look at it. He/she was not aware of any written instructions on how to assist the resident. Missouri Department of Health and Senior Services STATE FORM 6899 GXE012 If continuation sheet 3 of 8 PRINTED: 10/16/2024 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 R-C 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE {44754} Continued From page 3 {A4754} During an interview on 9/24/24 at 9:45 A.M., the DON said the nurse in the building has access to the ISPs, as do the CPs, but the CPs use their credentials as an excuse to not being able to log in. She said it would be important for the CPs to have access to the ISPs and directions on how to care for the resident's wound or bandage, if it became soiled or dislodged. She said instructions on how to care for the pressure sore should be written on the ISP. During interviews on 9/25/24 at 3:24 P.M. and on 10/10/24 at 9:10 A.M., the Administrator said CP T called her on 9/22/24, "venting" because the resident had been incontinent and the dressing on his/her wound fell off and the CP did not know what to do. The Administrator said he/she expected skin conditions to be on the ISP. The ISP should have instructions for the CPs on what to do with the treatments. She said she was not aware it was not included on the ISP. She said the front line team should have direction to stop and call the nurse when they find a dressing or bandage has been dislodged or is soiled and needs to be changed, so the nurse can give them directions on what to do to protect the wound. M0O00242457 19 CSR 30-86.047(47)(A) Physicians Orders Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 GXE012 If continuation sheet 4 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Class II* Based on interview and record review, the facility failed to follow a physician's order for one of one sampled resident (Resident #8) for treatment of the resident's wound. The census was 65. Review of Resident #8's physician orders on 09/24/24, showed an order written on 7/12/24 for a sacral wound (a triangular bone that sits at the base of the spine and corner of the lower back to the tailbone): -Cleanse with wound cleanser; -Crush metronidazole (an antibiotic used to treat specific infections) and apply to wound; -Apply Medihoney (supports the removal of necrotic tissue and aids in wound healing) -Apply a calcium alginate dressing (a highly absorbent dressing) over the wound; -Apply skin prep to peri wound; -Apply a foam bandage daily and as needed if the dressing becomes soiled or becomes dislodged. Review of the resident's ISP dated 7/19/24, showed the following: -Focus: Skin and wound care- Resident has a stage "2+" (the sore has broken through the top layer of the skin and part of the layer below) pressure area or venous/arterial ulcer located at the center of his/her coccyx. Hospice and community staff will work together to complete the daily treatment orders; -No instructions for CP should the dressing become soiled or dislodged; -Focus: Transfer ability/mobility- two person physical assist with a mechanical lift. Review of the resident's medication administration/treatment administration record dated 7/12/24, showed the following: Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE012 PRINTED: 10/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 09/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 8 PRINTED: 10/16/2024 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 R-C 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 (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) PLAZA AT WILDWOOD SENIOR LIVING THE Continued From page 5 -A treatment ordered on 7/12/24 for a sacral (the triangular bone that sits at the base of the spine and corner of the lower back to the tailbone) wound: -Cleanse with wound cleanser; -Crush metronidazole (an antibiotic used to treat specific infections) and apply to wound; -Apply Medihoney (supports the removal of necrotic tissue and aids in wound healing) -Apply a calcium alginate dressing (a highly absorbent dressing) over the wound; -Apply skin prep to peri wound; -Apply a foam bandage daily and as needed if the dressing becomes soiled or becomes dislodged; -The treatment was not completed, 7/23, 7/25, and 7/29/24. Review of the resident's MAR/TAR dated August 2024, showed the treatment not completed on 8/22, 8/25, and 8/29/24. Review of the resident's physician's order sheet dated 9/24/24, showed the following: -An order dated 7/12/24, for sacral wound: -Cleanse with wound cleanser; -Crush metronidazole (an antibiotic used to treat specific infections) and apply to wound; -Apply Medihoney (supports the removal of necrotic tissue and aids in wound healing) -Apply a calcium alginate dressing (a highly absorbent dressing) over the wound; -Apply skin prep to peri wound; -Apply a foam bandage daily and as needed if the dressing becomes soiled or becomes dislodged; -The treatment was not completed on 9/2, 9/5 and 9/13/24. Observation of resident's wound on 9/25/24 at 9:25 A.M., showed the following: -Wound measured 8 centimeters (cm) x 5 cm X Missouri Department of Health and Senior Services STATE FORM 6899 GXE012 If continuation sheet 6 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 1.5 cm; -Perimeter healed; -Medi honey and bandage not dated; -Green slough (dead tissue separating from living tissue), approximately 1 cm depth, did not determine undermining or tunneling. Large amount of green/yellow discharge; -Odor present. During an interview on 9/25/24 at 9:25 A.M., the Memory Care Director (MCD) said the facility is responsible for changing the bandage. During an interview on 10/11/24 at 10:43 A.M., Hospice Nurse S said she works with the resident. She will do a dressing change if needed but the facility is primarily responsible for the dressing changes. Once a week she comes in to do an assessment and get measurements but that doesn't always mean that a dressing is being changed. She said there has been times when she comes to do an assessment and the dressing hasn't been changed for multiple days. She said she has "frequently" come in where the dressing has either not been changed or a dressing is not in place. She has brought this to the attention of the interim Director of Nursing (DON/regional nurse) in the past as well as the prior DON. She said they do not routinely change the dressing unless it's needed during their visit. During an interview on 9/25/24 9:57 A.M., the interim DON/regional nurse said hospice and the facility nurse change the dressing and the last time she had seen the wound was the previous week and there was no odor, drainage or slough. She said she would expect a different order if the wound was undermining or tunneling. She said the wound has been there for a while. She said the schedule for measuring the wound is every Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE012 PRINTED: 10/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 09/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PLAZA AT WILDWOOD SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 three days. She said she expects whoever does the dressing change to document the date it was changed on the dressing. She said she was not aware of the slough on the wound. She said the measurements should be documented in the progress notes. She said she expected the nurse to follow the physician's orders. She said the order was a daily order and she was not aware the order was not being followed each day. During an interview on 9/25/24 at 3:24 P.M., the Administrator said she expected all medications and treatments to be documented. If it was not documented, she would assume it just did not happen. She expected for staff to report if a medication or treatment was missed. She said she was not aware the MARs showed treatments were missed and she expected all treatments to have been completed as ordered. MO00242457 *The higher classification merited due to the extent of the citation and the citation's effect on the resident. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 GXE012 PRINTED: 10/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 09/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 251 PLAZA DRIVE WILDWOOD, MO 63040 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 8 PLAN OF CORRECTION Provider/Supplier Name: The Plaza at Wildwood Senior Living Street Address, 251 Plaza Drive City, Zip: Wildwood, MO 63040 Date of Survey: 09/25/24 31049 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. A4754 Correction of Cited Deficiency: 19 CSR 30-86.047 (28) Individual Service Plan Dev. 10-18-24 The Community will develop a personalized Individual Service Plan that will outline all residents' needs and preferences and services to be provided. Resident #8 Director of Wellness updated resident community- based assessment and individualized service plan. Assessment to Identify other Residents that may be 40-31-24 affected: Director of Wellness or designee will review all individualized service plans to ensure resident needs, preferences, services to be provided, and goals expected of resident or legal representative are documented in their service plan. 40-31-24 Procedure to ensure on-going compliance: Director of Wellness or designee will complete the community- based assessment and individualized service plan at move-in, semiannually and with any significant change. Director of Wellness or designee will do random audit of community-based assessment and individualized service plan monthly to ensure they are accurate and up to date. The Director of Wellness or designee will provide Point Click Care service plan reeducation to all care staff. Monitoring for on-going compliance: Director of Wellness or | Biweekly and designee will do scheduled audits biweekly for the next 60 days monthly ensuring the community-based assessments and individualized ongoing service plans are being completed timely, then monthly audits thereafter. Correction of Cited Deficiency: 19 CSR 30-86-047 Physician orders followed 40-18-24 19 CSR 30-86.047(47) (A) No medication, treatment or diet shail be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. The Wellness Director or designee will ensure resident #8 physician orders are reviewed for accuracy, compliance and thorough documentation. Assessment to Identify other Residents that may be 10-31-24 affected. The Director of Wellness or designee will review all physician orders to ensure accuracy, compliance, and thorough documentation. Procedure to ensure on-going compliance: 10-31-24 Director of Wellness or Designee will educate all nurses and medication partners on following physician orders and providing proper documentation in a designated skills training day. Monitoring for on-going compliance: Weekly Director of Wellness or designee is to conduct weekly ongoing medication cart audit, verify orders and MARS are in agreement. Chnstty Kay LPN, RWdD lo-aa.ad