OAK POINTE OF CARTHAGE, A VIVA SENIOR LIVING COMMUNITY.

PRINTED: 04/14/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30168 B. WING 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 W AIRPORT DRIVE CARTHAGE, MO 64836 (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 INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE | ! DEFICIENCY) OAK POINTE OF CARTHAGE A4724| 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Based on interview and record review, the facility staff failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered timely at hire for three of five sampled staff members (Caregiver A, Caregiver B, and Level One Medication Aide (LIMA) C. The facility census was 36. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, shows the following: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) | two-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three _ weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. Review of the facility's policy titled "Tuberculosis (TB) Testing," revised 12/20/21, showed the following: -For the protection of all residents, staff, and Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURI TITLE (X6) DATE a LY 105 STATE FORM eae QGHW11 If continuation sheet 1 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30168 PRINTED: 04/14/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING: B. WING COMPLETED Cc 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 W AIRPORT DRIVE CARTHAGE, MO 64836 OAK POINTE OF CARTHAGE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 guests, each facility will have a tuberculin skin testing protocol consistent with state regulations and corporate requirements; -A newly hired staff member will have evidence of TB screening completed within 10 days of hire and before occupational exposure. Communities will follow state regulations regarding TB testing for employees; -The Director of Nursing (DON) will ensure that all staff have evidence of TB screening completed within 10 days of hire and before occupational exposure; -The DON will ensure that all staff will have a documented baseline two-step tuberculin skin test (TST) or one blood assay for M.tuberculosis (BAMT) result; -The DON will maintain statistics regarding staff positive and latent TB screenings for assessment development. 1. Review of Caregiver A's personnel file showed the following: -A hire and start date of 01/28/25; -Staff did not document a two-step TB test was administered. 2. Review of Caregiver B's personnel file showed the following: -A hire and start date of 01/13/25; -Staff did not document a two-step TB test was administered. 3. Review of LIMA C's personnel file showed the following: -Hire date and start date of 01/28/25; -On 12/13/24, staff documented the first step of the two-part TB screening test was administered and read on 12/16/24 with a negative result; -Staff did not document the second TB step was administered. Missouri Department of Health and Senior Services STATE FORM 6899 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE QGHW11 DEFICIENCY) If continuation sheet 2 of 3 PRINTED: 04/14/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 30168 B. WING 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 W AIRPORT DRIVE CARTHAGE, MO 64836 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK POINTE OF CARTHAGE Continued From page 2 4. During an interview on 04/03/25, at 5:55 P.M., the DON said the following: -He/She began working at the facility about two weeks ago; -The facility had been without a DON for almost two months; -He/She was responsible for resident and staff TB testing. 5. During an interview on 04/03/25, at 5:55 P.M., the Executive Director said the following: -The facility had been without a DON for about two months; -A DON from another facility was filling in at the facility twice a week until a DON was hired; -The DON is responsible for TB testing for staff and residents; -Caregiver A, Caregiver B, and LIMA C began employment before the former DON left, but he/she could not locate TB testing for these employees. Missouri Department of Health and Senior Services STATE FORM Sa99 QGHW11 If continuation sheet 3 of 3 PLAN OF CORRECTION Oak Pointe Carthage Provider/Supplier Name: Street Address, City, Zip: Date of Survey: 300 W. Airport Road, Carthage, MO 64836 04/03/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION ID PREFIX TAG SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The facility shall screen residents and staff for tuberculosis as vidiliea required for long-term care facilities by 19 CSR 20-20.100 ialaiaats a No residents were affected by the deficient practice. 05/09/25 | TB skin tests were administered to Caregiver A, Caregiver B, and L1MA C, and results were read by the Director of Nursing (DON). The second step of the two-step TB testing process will 05/09/2025 be completed within the required time frame following the initial | | po wy test. DON and/or ED will continue ongoing monitoring of new hire two-step TB to ensure compliance. The Director of Nursing (DON) has created a binder tracking each staff member's hire date and TB testing dates to ensure timely completion of annual TB tests. The DON and/or Executive Director will review the TB binder on the first of each month to verify all current employees remain compliant with the annual TB testing requirements. The Executive Director will notify the DON of all new hires to ensure each new employee receives their initial TB test within 10 days of hire, completes the two-step process as required, and is added to the ongoing monthly TB cam | =e Pp Pp | pliance monitoring. 05/09/2025 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 04/03/2025 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 S| 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 W AIRPORT DRIVE CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF CARTHAGE 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. WII This regulation is not met as evidenced by: Class II Based on record review and interview during the fire safety inspection process on April 1, 2025, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was 38. This deficiency affects 38 of 38 residents. Record review revealed that no semi-annual fire alarm testing and inspection report was available for 2024. During the exit interview on April 1, 2025 at 1530, the maintenance director stated he would contact Marmic for the report. Follow-up on April 2, 2025 at 1200 via email, the maintenance director has emailed a second annual fire alarm inspection report and a semi annual sprinkler inspection report. | contacted Marmic directly and found they only do an annual fire alarm inspection at the facility. Further record review showed the facility performed their own semi-annual fire alarm testing and inspection in 2023. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Warbene Whbame, CD 06/02/2025 STATE FORM aso DUYO11 lf continuation sheet 1 of 1 PLAN OF CORRECTION i Provider/Supplier Fai Oak Pointe Carthage Street Address, City, Zip: 300 W Airport Drive; Carthage, MO; 64836 Date of Survey: April 1, 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Oak Pointe of Carthage will test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. The annual fire inspection was conducted on March 20, 2025 and a semi-annual fire alarm testing and inspection will be completed in September 2025 and every 6 months between annual inspections thereafter. Testing has been put into TELS (scheduling/monitoring software program for facility maintenance) to ensure all necessary testing is completed timely. The Maintenance Director is responsible for ensuring that the semi-annual fire alarm testing and inspection is scheduled and completed timely. The Executive Director has testing months noted on the calendar as well. COMPLETION DATE 09/20/2025 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 05/24/2024 ; FORM APPROVED Missourt Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDERJSUPPLIERICLIA {X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30168 B.WING 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 300 W AIRPORT DRIVE CARTHAGE, MOQ 64836 (X4) IO SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING {NFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF CARTHAGE A2286; 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal, (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. This regulation is not met as evidenced by: Class lil Based on observation and interview during the fire safety inspection process, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being used for trash. The facility census was forty-four. This deficiency affects forty-four of forty-four residents. Observation revealed unapproved wastebaskets in use throughout the facility in over 30 of the 44 occupied rooms. While maintenance did remove the wastebaskets at the time of discovery, due to the sheer number of deficiencies, a pian of correction is needed to address this situation going forward. During the exit interview on May 15, 2024 at 1030 the maintenance man had already removed the wastebaskets from the rooms and stated he would remove them from the building. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE Da DATE STATE FORM eas9 75RUTI If continuation sheet 1 of 4 PLAN OF CORRECTION Provider/Supplier Name: Oak Pointe of Carthage Street Address, City, Zip: 300 West Airport Drive, Carthage, MO, 64836 Date of Survey: May 15, 2024 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 A2286 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM- 4,20 Requirements. Only metal or UL-or RM-fire resistant rated | ———ss|s wastebaskets shall be used for trash. On Ma th, 2024 the Maintenance Director removed the wa baskets from the affected rooms immediately and replaced with the proper Fire Resistant Rated wastebaskets. A walk through of all apartments was completed to make sure all waste baskets were only metal or UL- or FiV-fire resistant rated oF > om a iC? => a &: iO ~ = he 7) fad] 4 £- fox 5" 2] ) im &. av] ia [je] > tn o “—t O > oO. 3 {) (om—e oO fe! Fy > &. .@] eo 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.