Inspection Results
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Facility failed to meet the following Requirement(s):Corrected DateLevel of HarmResidents Affected
Trash and Rubbish Disposal. (B) Trash shall be removed from the premises as often as necessary to prevent fire hazards and public health nuisance. II 7/11/2023   
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 11/8/2023   
The operator shall be responsible to assure compliance with all applicable laws and regulations. The administrator shall be fully authorized and empowered to make decisions regarding the operation of the facility and shall be held responsible for the actions of all employees. The administrator ' s responsibilities shall include oversight of residents to assure that they receive care as defined in the individualized service plan. II/III 7/11/2023   
The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II 11/8/2023   
The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (D) Completes a premove-in screening conducted as required by section 198.073.4 (4), RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)). II 7/11/2023   
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: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; II 4/23/2024   
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; II   
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: (H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident ' s condition which may require a change in services; II   
The facility shall not admit or continue to care for a resident who: (A) Has exhibited behaviors that present a reasonable likelihood of serious harm to himself or herself or others; I/II 7/11/2023   
In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the person listed in the resident ' s record as the legally authorized representative, designee or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medical examiner immediately upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home. I/II 7/11/2023   
All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. II/III 7/11/2023   
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 I medication aide. I/II 7/11/2023   
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 7/11/2023   
Staffing Requirements. (E) There shall be a licensed nurse employed by the facility to work at least eight (8) hours per week at the facility for every thirty (30) residents or additional major fraction of thirty (30). The nurse ' s duties shall include, but shall not be limited to, review of residents ' charts, medications, and special diets or other orders, review of each resident ' s adjustment to the facility, and observation of each individual resident ' s general physical and mental condition. The nurse shall inform the administrator of any problems noted, and these shall be brought to the attention of the resident ' s physician. II/III   
In addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer ' s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer ' s disease and related dementias as follows: (A) For employees providing direct care to such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer ' s disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues; and II/III 7/11/2023   
Each resident shall be served food prepared and served under safe, sanitary conditions that is prepared consistent with the preferences of the resident and in accordance with attending physician ' s orders. The nutritional needs of the residents shall be met. Balanced nutritious meals using a variety of foods shall be served. Consideration shall be given to the food habits, preferences, medical needs and physical abilities of the residents. II/III 7/11/2023   
Menus shall be planned in advance and shall be readily available for personnel involved in food purchase and preparation. Food shall be served as planned although substitutes of equal nutritional value and complementary to the remainder of the meal can be made if recorded. III 4/23/2024   
Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II 7/11/2023   
The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III 11/8/2023   
Tableware shall be washed, rinsed and sanitized after each use. II 7/11/2023   
Prior to or upon admission and at least annually after that, each resident or his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding provision of emergency and life-sustaining care, of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents' next of kin, legally authorized representatives or designees shall be informed, upon request, regarding state laws related to advance directives for health-care decision making as well as the facility's policies regarding the provision of emergency or life-sustaining medical care or treatment. If a resident has a written advance health-care directive, a copy shall be placed in the resident's medical record and reviewed annually with the resident unless, in the interval, he or she has been determined incapacitated, in accordance with section 475.075 or 404.825, RSMo. Residents' next of kin, legally authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. II/III   
The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III 7/11/2023   
Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III 11/8/2023   
Each resident shall be permitted to retain and use personal clothing and possessions as space permits. Personal possessions may include furniture and decorations in accordance with the facility's policies and shall not create a fire hazard. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to the resident during his or her stay in the facility, which are to be returned to the resident or responsible party upon discharge, transfer, or death. II/III 7/11/2023