CHAPTERS LIVING OF JOPLIN.

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: 14251C B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 207 SOUTH NORTHPARK LANE SPRING RIVER CHRISTIAN VILLAGE INC JOPLIN, MO 64801 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. 11 This regulation is not met as evidenced by: Based on interview and record review, the facility 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 completed prior to admission or one week after admission and failed to complete the second step of the TB screening test for two resident (Residents #1 and #2) of six sampled residents. The census was 66, General requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents tuberculosis using the Mantoux method purified protein derivative (PPD - skin test) five tuberculin unit test. Each facility shall be responsible for ensuring that all test results are completed and that dacumentation is maintained for all residents; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD two-step tuberculin test. If the Initial test is negative, zero to nine millimeters (0-9 mm), the second test, which can be given after admission, should be given one to three (1-3) weeks later. Review of the facility policy titled "Infection Prevention and Control Manual TB Screening Residents,” updated on 06/22/23, shawed the following: Missouri Department of Health and Senior Services LABORATORY DIRECTDR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM B1F111 DEFICIENCY) PRINTED: 08/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/14/2024 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X8) (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE PRINTED: 08/26/2024 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 C 14251C B. WING 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 201 SOUTH NORTHPARK LANE JOPLIN, MO 64801 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) SPRING RIVER CHRISTIAN VILLAGE INC Continued From page 1 -For all new admissions without documentation of a previous positive TST (Mantoux tuberculin skin test) or IGRA (TB blood test- interferon gamma release assay) or documentation of previous treatment for latent TB infection or TB disease, a tuberculin skin test will be done upon admission or within one week of admission; -If the first step is non-reactive, the second test will be administered seven to twenty-one days later. 1. Review of Resident #1's medical record showed the following: -Admission date of 02/29/24: -Staff documented the first step TB screening test administered on 04/23/24 (one month and three weeks after admission) with negative results read on 04/26/24; -Staff did not document a second step of the TB screening test administered. 2. Review of Resident #2's medical record showed the following: -Admission date of 06/19/24; -Staff documented the first step TB screening test administered on 08/08/24 (one month and three weeks after admission) with negative results read on 08/11/24; -Staff did not document a second step of the TB screening test administered. 3. During an interview on 08/14/24, at 4:46 P.M., Licensed Practical Nurse (LPN) A said the following: -Whoever admits a new resident, is the one who completes the two-step TB screening test; Missouri Department of Health and Senior Services STATE FORM 6899 B1F111 If continuation sheet 2 of 5 PRINTED: 08/26/2024 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 C 14251C i 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 201 SOUTH NORTHPARK LANE JOPLIN, MO 64801 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) SPRING RIVER CHRISTIAN VILLAGE INC Continued From page 2 -Staff usually give the new residents the TB test right after admission; -She was not sure why the new residents were not given the TB tests after admission to the facility. 19 CSR 30-88.020(14) Resident Fund Bond Requirements The bond required by section 198.096, RSMo, for operators holding personal funds of residents shall be in a form approved by the department and shall provide that residents who allege that they have been wrongfully deprived of moneys held in trust may bring an action for recovery directly against the surety. The bond shall be in an amount equal to at least one and one-half (1 1/2) times the average monthly balance of the residents ' personal funds, including residents ' petty cash, or the average total of the monthly balances for the preceding twelve (12) months. The average monthly balance(s) or the average total of the monthly balance(s) shall be rounded to the nearest one thousand dollars ($1,000). One (1) bond may be used to cover the residents " funds in more than one (1) facility operated by the same operator, if the facility is a multilicensed facility on the same premises. If not on the same premises, then one (1) bond may be used if the bond specifies the amount of coverage provided for each individual facility and the coverage for each facility is a minimum of one thousand dollars ($1,000). II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to secure a surety bond in an amount Missouri Department of Health and Senior Services STATE FORM 6899 B1F111 If continuation sheet 3 of 5 PRINTED: 08/26/2024 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 C 14251C B. WING 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 201 SOUTH NORTHPARK LANE JOPLIN, MO 64801 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) SPRING RIVER CHRISTIAN VILLAGE INC Continued From page 3 sufficient to cover at least one and one-half times the average monthly balance of the residents’ personal funds. The facility census was 65. Review showed the facility did not provide a policy regarding maintaining a surety bond. 1. Review of the facility's resident trust account bank statements, dated August 2023 to July 2024, showed the following: -August 2023 balance of $62,826.38: -September 2023 balance of $74,176.85 ; -October 2023 balance of $80,737.17; -November 2023 balance of $85,071.17; -December 2023 balance of $78,551.64; -January 2024 balance of $81,439.73; -February 2024 balance of $64,220.44; -March 2024 balance of $56,679.93; -April 2024 balance of $35,290.09; -May 2024 balance of $37,456.71; -June 2024 balance of $37,264.01; -July 2024 balance of $35,646.33. Review showed the total of the resident trust fund account balance from August 2023 through July 2024 was $729, 360.45, resulting in a monthly average of $60,780.03. The monthly balance rounded to the nearest thousand equaled $61,000.00. The monthly rounded balance and 1.5 showed a bond of $91,500.00 required. Review of the facility's approved surety bond, located on the Department of Health and Senior Services database, reviewed on 08/14/24, showed the home had a surety bond in the amount of $60,000. During interviews on 08/14/24, at 3:00 P.M. and 5:30 P.M., the Executive Director said the Missouri Department of Health and Senior Services STATE FORM 6899 B1F111 If continuation sheet 4 of 5 PRINTED: 08/26/2024 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 C 14251C B. WING 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 201 SOUTH NORTHPARK LANE JOPLIN, MO 64801 (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) SPRING RIVER CHRISTIAN VILLAGE INC Continued From page 4 following: -Their home office is responsible for changing the surety bond amount; -The Chief Financial Officer (CFO) that signed off on the bond amount is no longer with the company; -The bond amount was lowered when the skilled side of the facility was closed. *The higher classification is merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 B1F111 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: Spring River Christian Village Street Address, City, Zip: Date of Survey: 8/14/24 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 The facility will conduct timely screening of residents for the 201 S. North Park Lane, Joplin, MO 64804 A4724 required two-step tuberculosis (TB). 8/15/24 Pp Pp The residents identified (#1 and #2) have completed 2step TB a 8/25/24 and documentation is complete. The facility has determined that this had the potential to affect ; 8/15/24 residents. The Nurse Manager will determine if documentation is available/in order or if a two-step TST process needs to take 8/15/24 place when community has a new admission. If a TST needs to take place, the AL Nurse manager or Nurse designee will administer TST 18 step upon admission or within one week of admission. The results of the 1st TST will be read 48-72 hours later. If the first step is non-reactive, the second 8/15/24 test will be administered 7 to 21 days later. The results of the 2nd TST will be read 48-72 hours later. Documentation will be completed, The AL Nurse Manager or designee will monitor the process for accuracy and timeliness by tracking each resident screening. 8/15/24 Monitoring will be ongoing, and results will be reviewed monthly by the QAPI committee. PLAN OF CORRECTION Provider/Supplier Name: | Spring River Christian Village I Street Address, City, Zip: Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The facility will meet Resident Fund Bond Requirements. 8/15/24 The facility has determined that this had the potential to affect ; 8/15/24 residents. . The bond amount Is corrected and does not exceed the amount authorized surety bond amount. The Office Manager or designee will check the monthly balance and make sure that it is within the acceptable amount to be sécured by the surety amount sufficient to cover at least one and one-half times the average monthly balance of the residents personal funds. If the amount is above the allowed amount, the 8/15/24 Company Controller will be notified, and the surety bond amount will be increased to be in compliance. Monitoring will be ongoing, and results will be reviewed monthly by the QAPI committee. 201 S. North Park Lane, Joplin, MO 54804 8/14/24 ID PREFIX TAG A9023 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.

An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 06/12/2025 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 14251C B. WING 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 201 SOUTH NORTHPARK LANE JOPLIN, MO 64801 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) CHAPTERS LIVING OF JOPLIN 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II This regulation is not met as evidenced by: Class II Based on record review and interview during a fire safety inspection process, 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 sixty-five. This deficiency affects sixty-five of sixty-five residents. Record review reveled the annual fire alarm inspection had been performed 7 months late. The last semiannual was March 2023 with the next inspection being the annual in April 2024. Fire alarm testing must be completed every months alternating annual with semiannual testing. During the exit interview on May 22, 2024 at 1450, the maintenance man could not find the last semiannual and said he would email it to me. Follow up email on May 23, 2024 at 1130, the maintenance man sent the semiannual report which revealed the violation. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 5LR311 If continuation sheet 1 of 2 PRINTED: 06/12/2025 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 14251C B. WING 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 201 SOUTH NORTHPARK LANE JOPLIN, MO 64801 (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) CHAPTERS LIVING OF JOPLIN Continued From page 1 (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class III 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 sixty-five. This deficiency affects sixty-five of sixty-five residents. Observation revealed unapproved wastebaskets in use throughout the facility in over 50 of the 65 occupied rooms, as well as various offices and common areas thoughout the building. While maintenance did remove the wastebaskets at the time of discovery, due to the sheer number of deficiencies, a plan of correction is needed to address this situation going forward. During the exit interview on May 22, 2024 at 1500 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 STATE FORM 6899 5LR311 If continuation sheet 2 of 2