OAK POINTE OF KEARNEY, A VIVA SENIOR LIVING COMMUNITY.

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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG 19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change 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: C. Whenever a significant change has occurred in the resident's condition, which may require a change in services. Il This regulation is not met as evidenced by: Class II Based on interview, and record review the facility failed to ensure Community Based Assessments (CBA) were updated for all residents upon a significant change of condition for one of six sampled residents (Resident #2 ). The facility census was 50. The facility did not provide a policy regarding updating CBA's. 1. Review of Resident #2's face sheet showed: -Admit date was 11/20/24; -Diagnoses included Vascular Dementia. During an interview on 7/17/25 at 12:04 P.M., Level One Medication Aide (LIMA) A said: -Resident #2 urinated on another resident in the dining room; -It was not an episode of incontinence, but rather he/she unzipped his/her pants and urinated under Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE 6899 STATE FORM UOY511 PRINTED: 07/31/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/17/2025 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 TITLE (X6) DATE If continuation sheet 1 of 11 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 the table causing the urine to splatter on two other residents; -Administration had not addressed Resident #2's behaviors Review of the resident's progress notes showed: -On 2/23/25 the resident exited his/her room and pulled down his/her pants to use the restroom, staff redirected the resident and noted they would keep his/her door closed to help prevent it from happening again; -On 4/4/25 the resident was found in the hallway looking for his/her call pendent in a fake tree and had urinated on his/her walker; -On 4/27/25 the resident had a bowel movement on his/her living room floor; -On 5/26/25 the resident had a large bowel movement on his/her living room floor; -On 6/22/25 the resident had a bowel movement on the floor in his/her closet. -On 6/23/25 the resident was eating in the dining room and unzipped his/her pants and urinated on the floor under the table; -On 6/28/25 the resident pulled down his/her pants in the hallway to use the restroom. Staff redirected him/her to his/her room. During an interview on 7/17/25 at 1:30 P.M., Resident #2 said: -He/she did not remember urinating or defecating on the floor. Review of the resident's current CBA dated 6/26/25 showed: -The resident was well oriented to date, day, and place, did not wander or have confusion, and did not have any socially inappropriate or disruptive behaviors; -The resident did not have any issues with bladder or bowel control. Missouri Department of Health and Senior Services STATE FORM 6899 UOY511 PRINTED: 07/31/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 11 PRINTED: 07/31/2025 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 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 2 During an interview on 7/17/25 at 4:15 P.M., the Director of Nursing said: -Resident #2 only recently began having issues with urinating and having bowel movements on the floor; -Did not know why the CBA completed on 6/26/25 did not reflect the toileting issues; During an interview on 7/17/25 at 4:15 P.M., the Administrator said: -CBA's should be completed every six months and with any change of condition; -Resident #2's CBA should be reflective of his/her current toileting and behavioral needs. 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 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: Class II Based on interview and record review, the facility failed to ensure all 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 6899 U0Y511 If continuation sheet 3 of 11 PRINTED: 07/31/2025 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 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 3 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) were updated and documented services to be provided by staff and goals expected by the resident or the resident's legal representative for two of six (Resident #1 and #2) sampled residents. The facility census was 50. The facility did not provide a policy regarding updating ISP's. 1. Review of Resident #1's face sheet showed: -Admit date was 6/24/25; -Diagnoses included Myelodysplastic syndrome (a type of blood cancer), alcohol abuse, and weakness. Observation of the resident's room on 07/17/25 at 10:30 A. M. showed: -A Hoyer lift was present in the room. During an interview on 7/17/25 at 10:30 A.M., the resident said: -He/She had lived at the facility for about six weeks; -Prior to that he/she lived at home but had been in the hospital for two weeks after a fall; -He/She had become progressively weaker due to his cancer diagnosis; -He/She used a walker at home but due to his/her cancer diagnoses had become progressively weaker and now required the use of a Hoyer lift for transfers. During an interview on 7/17/25 at 12:04 P.M., Level One Medication Aide (LIMA) B said: -Resident #1 required two people to assist with Activities of Daily Living (ADL's), getting dressed, and using the Hoyer lift to transfer to his/her Missouri Department of Health and Senior Services STATE FORM 6899 U0Y511 If continuation sheet 4 of 11 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 wheelchair. Review of the Resident #1's ISP dated 6/23/25 showed: -He/She required assistance of one person with transfers; -The ISP did not indicate the resident required a Hoyer lift for transfers. 2. Review of Resident #2's face sheet showed: -Admit date was 11/20/24; -Diagnoses included Vascular Dementia. During an interview on 7/17/25 at 12:04 P.M., LIMA A said: -Resident #2 urinated on another resident in the dining room; -It was not an episode of incontinence, but rather he/she unzipped his/her pants and urinated under the table causing the urine to splatter on two other residents; -Administration had not addressed Resident #2's behaviors. Review of the resident's progress notes showed -On 2/23/25 the resident exited his room and pulled down his pants to use the restroom, staff redirected the resident and notes they would keep his/her door closed to help prevent it from happening again; -On 4/4/25 the resident was found in the hallway looking for his/her call pendent in a fake tree and had urinated on his/her walker; -On 4/27/25 the resident had a bowel movement on his/her living room floor; -On 5/26/25 the resident had a large bowel movement on his/her living room floor; -On 6/22/25 the resident had a bowel movement on the floor in his/her closet. -On 6/23/25 the resident was eating in the dining room and Missouri Department of Health and Senior Services STATE FORM 6899 UOY511 PRINTED: 07/31/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 11 PRINTED: 07/31/2025 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 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 5 unzipped his/her pants and urinated on the floor under the table; -On 6/28/25 the resident pulled down his/her pants in the hallway to use the restroom. Staff redirected him/him to his/her room. During an interview on 7/17/25 at 1:30 P.M., Resident #2 said: -He/She did not remember urinating or defecating on the floor. Review of the resident's current ISP dated 12/27/24 showed: -The resident did not exhibit any present or past behavioral issues; -The resident had intermittent episodes of incontinence; -The ISP did not address urinating and defecating on the floor. During an interview on 7/17/25 at 4:15 P.M., the Director of Nursing said: -Resident #1 required two staff to assist with transfers; -Resident #2 ISP should have been updated with intervention regarding urinating and defecating on the floor. During an interview on 7/17/25 at 4:15 P.M., the Administrator said: -Resident #1 required two staff to assist with transfers; -Resident #2 ISP should have been updated with intervention regarding urinating and defecating on the floor. 19 CSR 30-86.047(46) Safe & Effective Medication System Missouri Department of Health and Senior Services STATE FORM 6899 U0Y511 If continuation sheet 6 of 11 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 6 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. Il This regulation is not met as evidenced by: Class II Based on observation, interview, and record review, the facility failed to ensure all residents’ medications were administered in accordance with physicians’ instructions using acceptable nursing techniques when Certified Medication Technician (CMT) A and Level One Medication Aide (LIMA) A failed to properly sanitize and prime insulin pens (used for administering insulin) for two residents (Resident #4 and #6). The facility census was 50. Missouri Department of Health and Senior Services STATE FORM 6899 UOY511 PRINTED: 07/31/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/17/2025 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 7 of 11 PRINTED: 07/31/2025 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 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 7 The facility did not provide a policy regarding sanitization while administering medications. Review of the manufacturer's instructions for use of Aspart Insulin Flex Pen U-100 showed: -The insulin pens should have been primed before every use to ensure all air that may have collected had been removed. Review of LIMAA's personnel record showed: -A hire date of 01/20/22: -LIMAA obtained his/her insulin administration certification on 01/27/2022. Review of CMT A's personnel record showed: -A hire date of 7/5/24: -CMT A obtained his/her insulin administration certification on 04/23/2014. 1. Review of Resident #4's record showed: -Admitted to the facility on 10/21/24; -Diagnoses included Type II Diabetes (a chronic condition where the body doesn't use insulin properly). Review of the resident's current Physician's Order Sheet (POS) dated 7/1/25 showed: -11/26/2024 Insulin Aspart U-100 (insulin pen injection used for diabetes) to be administered three times daily, eight units at 8:00 A.M., eight units at 12:00 P.M., and eight units at 5:00 P.M. Observation of LIMAA on 07/17/2025 at 11:20 A.M. showed: -LIMAA did not sanitize the top of Resident #6's insulin pen prior to applying a new needle to the pen, -LIMAA did not prime two units from the resident's pen to ensure all air bubbles were out Missouri Department of Health and Senior Services STATE FORM 6899 U0Y511 If continuation sheet 8 of 11 PRINTED: 07/31/2025 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 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 8 of the pen prior to administration to the resident. 2. Review of Resident #6's record showed: -Admitted to the facility on 06/18/2025; -Diagnoses included: Type II Diabetes. Review of the resident's current POS dated 07/01/25 showed: -06/18/2025 Insulin Aspart U-100 seven units to be administered three times daily at 8:00 A.M., 12:30 P.M., and 5:00 P.M.. Observation of CMT A on 07/17/2025 at 11:36 P.M. showed: -CMT Adid not sanitize the top of Resident #6's insulin pen prior to applying a new needle to the pen, -CMT A did not prime two units from the resident's pen to ensure all air bubbles were out of the pen prior to administration to the resident. During an interview on 07/17/2025 at 12:05 P.M., CMT A said: -He/She was taught to sanitize the pen after every use; -He/She knew two units should be used to prime an insulin pen prior to every usage; -He/She forgot to sanitize and prime the insulin pen. During an interview on 07/17/2025 at 12:20 P.M., LIMA A said: -He/She was taught to sanitize the pen after every use; -He/She knew two units should be used to prime an insulin pen prior to every usage; -He/She forgot to sanitize and prime the insulin pen. During an interview on 07/17/2025 at 4:15 P.M., Missouri Department of Health and Senior Services STATE FORM 6899 U0Y511 If continuation sheet 9 of 11 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 the Director of Nursing (DON) said: -Staff were expected to sanitize and prime insulin pens prior to use. During an interview on 07/17/2025 at 4:15 P.M., the Administrator said: -Staff were expected to sanitize and prime insulin pens prior to use. 19 CSR 30-87.020(13) Carpeting Carpeting, if used as a floor covering, shall be of closely woven construction, properly installed, easily cleanable and maintained in good repair. Carpeting is prohibited in food-preparation, equipment-washing and utensil-washing areas where it would be exposed to large amounts of grease and water, in food-storage areas and toilet room areas where urinals or toilet fixtures are located. III This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to maintain carpeting in good condition. The facility census was 50. 1. Observation on 7/17/25 at 10:06 A.M. of the Memory Care (MC) Room H showed: -Several dark brown ring like stains on the carpet in front of the bed. 2. Observation on 7/17/25 at 11:17 A.M. of MC, Room L showed the carpet was dirty and discolored in front of the bed and around the bathroom entrance. 3. Observation on 7/17/25 at 1:31 P.M. showed Missouri Department of Health and Senior Services STATE FORM 6899 UOY511 PRINTED: 07/31/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 11 PRINTED: 07/31/2025 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 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 10 the carpet in the hallway between Rooms 112-114 was dirty with several dark brown/gray stains. During an interview on 7/21/23 at 2:30 P.M., the Administrator said he was aware the carpeting should be kept clean and in good condition. 19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean Walls and ceilings, including doors, windows and skylights, shall be clean and maintained in good repair. Ill This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure walls were kept clean and in good repair. The facility's census was 50. 1. Observation on 7/17/25 at 10:06 A.M. of Memory Care (MC) Room D showed: -The walls had several small sections where the drywall was scuffed/cracked/and dirty. 2. Observation on 7/17/25 at 10:10 A.M. of Memory Care (MC) Room D showed: -The walls had several small sections where the drywall was scuffed/cracked/and dirty. During an interview on 7/17/25 at 4:15 P.M., the facility Administrator said all walls should be kept clean and in good repair. Missouri Department of Health and Senior Services STATE FORM 6899 U0Y511 If continuation sheet 11 of 11 [ PLAN OF CORRECTION Brenetsen/=ippller Oak Pointe of Kearney Name: | rere: Street Address, | 500 Meadowbrook Dr, Kearney MO 64060 City, Zip: | _| Date of Survey: 07/17/2025 - | 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 Community Based Assessment - Significant Change DEFICIENCY: The facility failed to ensure Community Based Assessments (CBA) were updated after significant changes in condition for Resident #2. 1. Resident #2's CBA was updated to reflect recent A4751 - 19 aed A CSR 30- changes in condition and behavior. 2. Re-education provided to all care staff reporting 09/01/2025 86.047(28)( + changes of condition to the DON/ED upon F)(1)(C) ar significant change. 3. DON/designee will conduct random reviews of all progress notes to identify significant changes and verify timely CBA updates. a eee Individualized Service Plan - Develop DEFICIENCY: The facility failed to update Individualized Service Plans (ISPs) for Residents #1 and #2 to reflect current care needs and behavioral changes. scenaeen 1 1. ISPs for Residents #1 and #2 were revised to reflect CSR 30- . . 09/01/2025 accurate transfer assistance needs and behavioral 86.047(28)( G) support plans. 2. All care staff re-trained on ISP documentation protocols, including updates after condition or behavior changes reported to the DON/ED. 3. DON/designee will perform random reviews of ISPs for timely and complete updates. Cher at KoA, 8/116 Safe & Effective Medication System DEFICIENCY: Medication staff failed to sanitize and prime insulin pens prior to administration for Residents #4 and #6. A4797 - 19 1. LIMA A and CMT A along with all medication CSR 30- staff were re-educated on insulin administration 09/01/2025 86.047(46) competencies, insulin pen sanitation and priming were completed. 2. DON/designee will perform random observations of insulin administration for 90 days. Carpeting DEFICIENCY: The facility failed to maintain carpeting in good repair in Memory Care rooms and hallways. A6013 - 19 1. Carpets in Rooms H, L, and hallway were cleaned; CSR 30- replacement plans initiated. 87.020(13) 2. Maintenance schedule updated to include bi-weekly carpet inspections for the next 90 days then monthly. 09/01/2025 1— Walls/Ceilings/Doors/Windows Clean DEFICIENCY: Walls in Memory Care Room D were dirty and scuffed. 1. Dirty and damaged drywall in Room D was cleaned A6015 - 19 and repaired. CSR 30- 2. Maintenance and housekeeping staff re-educated on | 09/01/2025 87.020(15) keeping surfaces clean and in good repair. 3. Administrator to complete monthly environmental audits to include inspection of walls and surfaces. + — —4 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. Cup. aut RAL, A) 81145 PRINTED: 09/16/2025 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 R-C B. WING 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) | OAK POINTE OF KEARNEY /49CSR 30-86.047(41) Medication Storage/Accessibility 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. WAU This regulation is not met as evidenced by: Class III Based on observation, interview, and record review the facility failed to ensure all medications were kept in a secured facation behind at least one lock and were accessible to only persons authorized to administer medications. The facility census was 48 residents. Review of the facility's Medication Administration policy dated 10/22/24 showed: -All medications were to be in locked storage that was not accessible to persons other than staff qualified to perform medication administration; -Medication carts were to remained locked at all times. 1. Observation on 09/03/25 at 10:14 A.M. showed an unlocked medication cart parked in the | hallway outside room 102 and no staff around the ' cart. During an interview on 09/03/25 at 1:38 P.M. Level One Medication Aide (LIMA) A said: -He/She was the only staff in charge of all medication carts on the assisted living side of the facility, when the cart was found unlocked and unattended: -He/She knew medication carts were to be locked at all times when left unattended. Missouri Department of Health and Senior Services LABORATORY DIR R'§ OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6a99 UoYs12 If continuation sheet 1 of 5 PRINTED: 09/16/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY A4782 19 CSR 30-86.047(41) Medication Storage/Accessibility 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. I/II This regulation is not met as evidenced by: Class III Based on observation, interview, and record review the facility failed to ensure all medications were kept in a secured location behind at least one lock and were accessible to only persons authorized to administer medications. The facility census was 48 residents. Review of the facility's Medication Administration policy dated 10/22/24 showed: -All medications were to be in locked storage that was not accessible to persons other than staff qualified to perform medication administration; -Medication carts were to remained locked at all times. 1. Observation on 09/03/25 at 10:14 A.M. showed an unlocked medication cart parked in the hallway outside room 102 and no staff around the cart. During an interview on 09/03/25 at 1:38 P.M. Level One Medication Aide (LIMA) A said: -He/She was the only staff in charge of all medication carts on the assisted living side of the facility, when the cart was found unlocked and unattended; -He/She knew medication carts were to be locked at all times when left unattended. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 UO0Y512 If continuation sheet 1 of 5 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 PRINTED: 09/16/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R-C 09/03/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 OAK POINTE OF KEARNEY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 During an interview on 09/03/25 at 2:44 P.M. the Administrator said he/she expected medication carts to be locked at all times when not in use. {A6013}, 19 CSR 30-87.020(13) Carpeting Carpeting, if used as a floor covering, shall be of closely woven construction, properly installed, easily cleanable and maintained in good repair. Carpeting is prohibited in food-preparation, equipment-washing and utensil-washing areas where it would be exposed to large amounts of grease and water, in food-storage areas and toilet room areas where urinals or toilet fixtures are located. III This regulation is not met as evidenced by: Class III *This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/17/25. Based on observation and interview, the facility failed to maintain carpeting in good condition. The facility census was 48. 1. Observation on 09/03/25 at 1:47 P.M. of the facility's hallways showed: -A dark stain approximately one foot in diameter on the floor just outside the theater; -A dark stain approximately six inches in diameter on the floor outside room 116; -A dark stain approximately one foot in diameter on the floor outside room 102 and 101. 2. Observation on 09/03/25 at 1:50 P.M. of Memory Care (MC) Room A showed a tan floor Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A6013} If continuation sheet 2 of 5 oe UOY512 PRINTED: 09/16/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY {A6013}| Continued From page 2 {A6013} with a one foot dark stain at the end of the bed, and a larger two foot circular dark colored stain in the middle of the room. 3. Observation on 09/03/25 at 1:52 P.M. of MC Room L showed a tan floor with a dark stain between the bed and recliner. 4. Observation on 09/03/25 at 1:55 P.M. of MC Room H showed: -A tan floor with a dark one foot stain just inside the door; -A small red stain outside the bathroom entrance; -A large dark stain at the end of the bed; -Several small spill stains in front of the recliner and in front of the window. 5. Observation on 09/03/25 at 2:00 P.M. of room 107 showed tan carpet with dark staining in the high traffic areas. 6. Observation on 09/03/25 at 2:05 P.M. of room 120 showed a dark one foot stain in front of the kitchen sink. During an interview on 09/03/25 at 2:44 P.M., the Administrator said: -He/She was aware the carpeting should be kept clean and in good condition; -He/She expected all staff to assist in keeping the floor clean, but there was only so much cleaning they could do with the carpet being original from when the facility was built. 19 CSR 30-88.010(28) Med Record Confidential, A8029 Written Consent All information contained in a resident's medical, personal or financial record and information Missouri Department of Health and Senior Services STATE FORM 6899 U0Y512 If continuation sheet 3 of 5 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 concerning source of payment shall be held confidential. Facility personnel shall not discuss aspects of the resident's record or care in front of persons not involved in the resident's care or in front of other residents. Written consent of the resident or his or her legally authorized representative shall be required for the release of information to persons not otherwise authorized by law to receive it. II/III This regulation is not met as evidenced by: Class II* *Higher class merited due to extent of violation. Based on observation, interview, and record review the facility failed to ensure all aspects of residents’ records were kept confidential when Resident #1 and #2's information was left visible on an unattended computer. The facility census was 468 residents. Review of the facility's New Employee Training policy dated 10/23/24 showed: -Health Insurance Portability and Accountability Act (HIPPA) and privacy were reviewed with all new employees. 1. Observation on 09/03/25 at 10:00 A.M. showed the screen to the computer on the medication cart parked near Memory Care (MC) room A, left on with resident information on it, and no staff around. 2. Observation of in the Memory Care on 09/03/25 at 11:40 A.M. showed: -Certified Medication Technician (CMT) A prepared medications for Resident #1, and then walked away from the medication cart to deliver the medication to Resident #1; Missouri Department of Health and Senior Services STATE FORM 6899 UOY512 PRINTED: 09/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 09/03/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 5 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 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 OAK POINTE OF KEARNEY PRINTED: 09/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 09/03/2025 (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 Continued From page 4 -CMT A left the computer screen turned on with Resident #1's information visible; -CMT A prepared insulin (medication used for diabetes) for Resident #2, and then walked away from the cart to administer the insulin to Resident #2 in his/her room; -CMT A computer screen was left turned on with Resident #2's information visible; -The medication cart was parked outside MC room A, near the dining room tables; -Multiple residents were at the dining room tables partaking in an activity; -Family members of other residents were coming in and out of the memory care unit walking past the computer left on with resident information visible. During an interview on 09/03/25 at 1:38 P.M. CMT A said: -He/She did leave the computer screens on when he/she walked away from it; -He/She knew computer screens with resident information were to be hidden at all times when left unattended. During an interview on 09/03/25 at 2:44 P.M. the Administrator said he/she expected computer screens containing resident information to be turned off at all times when not in use. Missouri Department of Health and Senior Services STATE FORM oeee UOY512 DEFICIENCY) If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: Oak Pointe of Kearney Street Address, City, Zip: 200 Meadowbrook Dr, Kearney MO 64060 Date of Survey: 9/3/25 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A4782-19 CSR 30- 86.047(41) Medication Storage/Accessibility DEFICIENCY: Residents in Rms 101-110 were identified as being affected by this deficient practice. Upon being made aware of the deficient practice, the Executive Director educated LIMA A of the deficient practice and it was corrected at that time. No other residents were affected by the deficient practice but all residents have the potential to have been affected 1. LIMA A along with all medication staff were re- educated on proper storage of medications in a secured location behind at least 1 locked door or cabinet by the ED/DON. 2. DON/designee will perform random cart checks for 90 days. 10/10/25 A6013-19 CSR 30- 87.020(13) Carpeting DEFICIENCY: Residents in AL Hallways/Rooms 101-102, 107, 116, 120 and Residents in MS Rooms A, H, and L were identified as being affected by this deficient practice. Upon being made aware of the deficient practice, the Executive Director educated Maintenance Director of the deficient practice and the carpet cleaning company was contacted and the bid for replacing of the flooring was submitted for approval. No other residents were affected by the deficient practice but all residents have the potential to have been affected 1. Flooring in Room H was replaced on 9/26/25, Flooring in Room L was replaced on 10/1/25. 10/10/25 2. Stain(s) noted in hallways outside theater, room 102-101, 116 were professionally cleaned on 9/29/25. 3. Stain(s) noted in room A, 107, 120 were professionally cleaned on 9/29/25. 4. Maintenance schedule updated to include bi-weekly carpet inspections for next 90 days then monthly Medical Record Confidential, Written Consent DEFICIENCY: Residents in MS Rms #1 and #2 were identified as being affected by this deficient practice. Upon being made aware of the deficient practice, the Executive Director educated CMT A of the deficient practice and it was corrected at that time. No other residents were affected by the deficient practice but all residents have the potential A8029-19 to have been affected CSR 30- 10/10/25 99.010(28) 1. CMT A along with all medication staff were re- educated on Health Insurance Portability and Accountability Act (HIPPA) and privacy by the ED/DON. 2. DON/designee will perform random cart checks for 90 days 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: 11/06/2024 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 iC B.WING 10/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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} OAK POINTE OF KEARNEY 19 CSR 30-88.010(23) Develop/Implement A/N Policies 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 repart 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/IIl This regulation is not met as evidenced by: Class Il “Higher classification merited due to the effect on the resident. Based on interview and record review the facility failed to implement their abuse, neglect, and misappropriation policy when six of six sampled residents (Resident #1, #2, #3, #4, #5, and #6) reported money or items missing and the facility did not interview all possible witnesses, (staff). The facility census was 48. Review of the facility's Abuse Prevention Program policy dated 05/23/23 showed: -The facility prohibited the misappropriation of residents’ property; -The community executive director was to thoroughly investigation all alleged violations; -Investigation should have included interviews with employees who work on a specific floor where the residents resided. Review of the facility's investigation dated 10/18/24 showed: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENJATIVE'S SIGNATURE (X6) DATE STATE FORM e699 L8zo11 If continuation sheet 1 of 6 PRINTED: 11/06/2024 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 10/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 1 -The Community Manager summarized the reports he/she received from Resident's #2, #3, #4, #5, and #6; -No summarization of the report from Resident #1 on 10/15/24 was included; -He/She received reports of missing money from Resident #2 and #3 on 10/18/24, reports of missing money from Resident #4 and #5 on 10/19/24, and a report of missing jewelry on 10/24/24; -No interviews with facility staff were documented. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 08/29/24: -Diagnoses included Type II Diabetes Mellitus (a chronic disease that occurs when the body doesn't produce enough insulin or doesn't use it properly), hypertension (high blood pressure), hyperlipidemia (high level of fats in the blood), and heart disease. During an interview on 10/28/24 at 1:50 P.M. Resident #1 said: -He/She had three or four envelopes of cash in them totaling $2,500 from selling a few personal items recently; -He/She could not recall the last time he/she saw the money; -He/She reported this to the Director of Sales who reported it to administration immediately; -He/She had a camera in his/her room that caught Level One Medication Aide (LIMA) A taking the envelopes; -He/She would be more upset about the situation if he/she did not get the money back. Review of a video camera recording from Resident #1's room, dated 10/11/24 showed LIMA Acame out of the resident's bedroom, into the living room, with envelopes and he/she folded up Missouri Department of Health and Senior Services STATE FORM 6899 L8Z011 If continuation sheet 2 of 6 PRINTED: 11/06/2024 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 10/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 2 the envelopes and put them into his/her pockets. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 07/31/21; -Diagnoses included hypertension, Type II Diabetes Mellitus, hyperlipidemia, anxiety, and kidney disease. During an interview on 10/28/24 at 1:31 P.M. Resident #2 said: -He/She was missing between $300-400 that was last seen on 09/20/24: -He/She reported this to the Community Manager directly; -He/She felt very violated as all his/her belongings had to have been gone through to find the money; -He/She would like his/her money back or rent decreased due to the suspect being a staff member. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 12/29/22; -Diagnoses included Type II Diabetes Mellitus, hyperlipidemia, hypertension, and atrial fibrillation (irregular heartbeat). During an interview on 10/28/24 at 2:20 PM Resident #3 said: -He/She was missing some money, and reported it to the facility; -He/She was unsure of the last time he/she saw the money other than when his/her daughter gave the envelope of money to him/her around the beginning of October; -He/She reported this to the Community Manager directly. 4. Review of Resident #4's record showed: -He/She was admitted to the facility on 04/08/22: Missouri Department of Health and Senior Services STATE FORM 6899 L8Z011 If continuation sheet 3 of 6 PRINTED: 11/06/2024 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 10/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 3 -Diagnoses included hypertension, cerebral infarction (stroke), and abnormalities in mobility. During an interview on 10/28/24 at 2:04 PM Resident #4 said: -His/Her son gave him/her some money on 10/13/24, and he/she last saw all the money still in his/her purse on 10/1/24 when he/she paid the hairdresser; -He/She usually kept the purse on the back of the bedroom door, and it stayed there when he/she went to meals; -He/She did not know who took it, but wanted it back -He/She reported this to the Community Manager directly. 5. Review of Resident #5's record showed: -He/She was admitted to the facility on 04/17/23; -Diagnoses included Type II Diabetes Mellitus, hypertension, and chronic obstructive pulmonary disease (COPD- a chronic lung disease that makes it difficult to breathe). During an interview on 10/28/24 at 2:15 PM Resident #5 said: -He/She was missing about $75; -He/She was unsure of the last time he/she saw the money, but usually kept it in his/her purse and it was not there when he/she went to lunch with his/her adult son on 10/19/24: -He/She reported this to the Community Manager directly. 6. Review of Resident #6's record showed: -He/She was admitted to the facility on 12/29/21; -Diagnoses included abnormalities in mobility, tremors (involuntary quivering movement), and chest pain. Missouri Department of Health and Senior Services STATE FORM 6899 L8Z011 If continuation sheet 4 of 6 PRINTED: 11/06/2024 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 10/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY Continued From page 4 During an interview on 10/28/24 at 2:00 P.M. Resident #6 said: -He/She could not recall the specifics of last seeing his/her jewelry, but knew it was missing, and would like it back due to having sentimental value; -He/She reported this to the Community Manager directly. During an interview on 10/28/24 at 12:45 P.M. LIMA A said: -He/She did take the money from Resident #1, but had returned the money plus an additional $500 to the police as an apology for taking the money; -He/She knew better than to take money from the residents, and had plenty of training to know better; -He/She did not take money or jewelry from any other residents. During an interview on 10/28/24 at 1:25 P.M. the Clinical Care Coordinator (CCC) said: -He/She only knew about the reports of stolen money and jewelry because one of the residents had reported to him/her about missing money; -No other staff members were interviewed about missing money, but staff were talking and making speculations due to which staff member was no longer working. During an interview on 10/28/24 at 3:30 P.M. the Community Manager said: -No other staff were interviewed because the police said they believed LIMAA was connected to all of the reports of missing money and jewelry; -He/She in-serviced the rest of the staff on abuse, neglect and exploitation but did not indicate to them that it was due to the reports of missing money from multiple residents. Missouri Department of Health and Senior Services STATE FORM 6899 L8Z011 If continuation sheet 5 of 6 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 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 PRINTED: 11/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/28/2024 (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 A8023 Continued From page 5 -She didn't know she needed to do her own thorough investigation independent from what the police were doing. MO243594 Missouri Department of Health and Senior Services STATE FORM 6899 L8Z011 DEFICIENCY) If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Oak Pointe of Kearney Name: Street Address, City, Zip: 200 Meadowbrook Drive Date of Survey: 10/28/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 29803 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A8023 19 CSR 30-88.010(23) Develop/Implement A/N Policies Residents #1, #2, #8, #4, #5, and #6 were affected by the deficient practice. Beginning on 10/28/24, all staff were interviewed in regard to the reported money or missing items to determine if there were any additional witnesses to the reports. No new concerns were identified from these interviews. All residents have the potential to be affected by the deficient practice. On 10/28/24 & 11/8/2024, the Regional Director of Clinical in-service the Community Manager with review of the facility's Abuse Prevention Policy and Procedure. 11/28/24 Beginning on 10/15/24, at the time of initial occurrence, through 11/28/24, Director of Nursing in-service all associates on the facility’s Abuse Prevention Policy and Procedure. The Director of Nursing will monitor any complaints of reported money or missing items to initiate immediate investigation, interviews of residents and staff as needed. The administrator will monitor for compliance of the facility’s Abuse Prevention Policy and Procedures ongoing. 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 COULD NOT BE OBTAINED. 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 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 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. I/II This regulation is not met as evidenced by: Class Il. Based on records review and interview on 08/08/24, facility fails to ensure a semi-annual fire alarm inspection. Facility census is forty-three (43). This violation affects forty-three (43) of forty-three (43) residents. Records review at 3:25 p.m. found no current semi-annual fire alarm inspection documentation from a fire alarm company. In an interview with the maintenance supervisor, he/she agrees the facility will call their fire alarm company to have their fire alarm inspected twice annually. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 PMDV11 PRINTED: 08/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2024 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE TITLE DEFICIENCY) (X6) DATE If continuation sheet 1 of 1 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

Could not obtain an administrator signature, since a new administrator took over. PRINTED: 04/07/2025 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 29803 B. WING 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 (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) OAK POINTE OF KEARNEY 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II. Based on observation and interview on 07/26/23, facility fails to ensure doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. Facility census is forty-four (44). Deficiency affects forty-four (44) of forty-four (44) residents. Observations: Kitchen door (west) was open and being held open by a wood wedge. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 L92111 If continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29803 B. WING NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION PRINTED: 04/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/26/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 1 Kitchen door (north) was open and being held open by a bucket. After the bucket was removed, north kitchen door wouldn't close all the way because the self-closure device is worn out. Interview with maintenance supervisor: Facility will address the HVAC issues in the kitchen to keep employees from propping open the doors in the hot kitchen, and will replace the worn out self-closure devices. Missouri Department of Health and Senior Services STATE FORM ease L92i11 CROSS-REFERENCED TO THE APPROPRIATE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 2 of 2

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 OAK POINTE OF KEARNEY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 08/01/2023 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED Cc 07/21/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 200 MEADOWBROOK DRIVE KEARNEY, MO 64060 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A6013 19 CSR 30-87.020(13) Carpeting Carpeting, if used as a floor covering, shall be of closely woven construction, properly installed, easily cleanable and maintained in good repair. Carpeting is prohibited in food-preparation, equipment-washing and utensil-washing areas where it would be exposed to large amounts of grease and water, in food-storage areas and toilet room areas where urinals or toilet fixtures are located. III This regulation is not met as evidenced by: Class Ill Based on observation and interview, the facility failed to maintain carpeting in good condition. The facility census was 46. 1. Observation of the Memory Care (MC) television (T.V.) room area on 7/21/23 at 11:10 A.M. showed: -Several dark ring like stains on the carpet; -Several dark brown/black stained areas. 2. Observation of Room MC-H on 7/21/23 at 11:17 A.M. showed the carpet was dirty and discolored in the area in front of and around the resident's chair. 3. Observation of Room MC-K on 7/21/23 at 11:18 A.M. showed the carpet was dirty and discolored throughout the room. 4. Observation of Room MC-L on 7/21/23 at 11:20 A.M. showed the carpet was dirty and discolored with black/gray ring like stains throughout the room. 5. Observation of Room 114 on 7/21/23 at 11:36 A.M., showed the carpet was dirty/dingy Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 NN6S11 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 throughout the room. 6. Observation of Room 123 on 7/21/23 at 11:40 A.M., showed the carpet was dirty/dingy throughout the room. During an interview on 7/21/23 at 11:36 A.M., Resident #1 said the dirty carpet made the whole room look dirty. During an interview on 7/21/23 at 2:30 P.M., the Administrator said he was aware the carpeting should be kept clean and in good condition but that the facility did not currently have a carpet shampooer. 19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected Containers of food shall be stored above the floor in a manner that protects the food from splash and other contamination and that permits easy cleaning of the storage area, except that metal pressurized beverage containers, and cased food packaged in cans, glass or other waterproof containers need not be elevated when the food container is not exposed to floor moisture; and containers may be stored on dollies, racks or pallets, provided the equipment is easily movable. HT This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure food was stored above the floor in a manner that protects the food from splash and other contamination when several boxes of frozen food were stored on the floor of the walk-in Missouri Department of Health and Senior Services STATE FORM 6899 NN6S11 PRINTED: 08/01/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/21/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 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 200 MEADOWBROOK DRIVE OAK POINTE OF KEARNEY KEARNEY, MO 64060 PRINTED: 08/01/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/21/2023 (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 2 freezer. The facility census was 46. 1. Observation on 7/21/23 at 10:47 A.M. of the walk-in freezer showed three boxes of food being stored on the floor, including: -One box of rye swirl bread; -Two boxes of frozen ice popsicles. During an interview on 7/21/23 at 12:32 P.M. the dietary manager said: - All food items should be stored at least 6 inches off of the floor. During an interview on 7/21/23 at 3:15 P.M., the administrator said: -Food should not be stored on the floor of the walk-in freezer. Missouri Department of Health and Senior Services STATE FORM oeee NN6S11 DEFICIENCY) If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Oak Pointe of Kearney Name: Gti 200 Meadowbrook Drive, Kearney, Missouri 64060 Date of Survey: July 215, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER S| ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE - Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility’s credible allegation of compliance. 19 CSR 30-87.020(13) Carpeting The resident(s) in the Memory Care including the following rooms: MC- H, MC-K, MC-L as weil as the resident(s} in rooms 114 and 123 were directly affected by the deficient practice. All residents have the potential to be affected by the deficient practice. On 08/01/2023, the Maintenance Manager was educated by the Executive Director regarding the expectation of all facility carpets to be kept in good repair. On 08/02/2023, the Maintenance Manager performed an audit on all resident rooms and common areas to identify any additional stained and/or dirty carpets that may need attention. Any areas identified as needing attention were addressed. AG6013 10/30/2023 A third-party vendor was contracted to correct the areas identified in the DHSS inspection {including the Memory Care (MC) television (T.V.) room area, Memory Care rooms - MC-H, MC-K, MC-L, Room 114, and room 123 that were identified during the survey) and any other areas identified through aforementioned audit. Beginning 08/16/2023 through 08/25/2023, an In-service education was completed by the Maintenance Manager to all staff regarding 19 CSR 30-87.020(13) Carpeting. The education included the expectation of all staff to utilize the work order system (TELS) at the community to log carpeted areas upon stain identification. Beginning on 08/14/2023, a preventive maintenance task has been added to the facility’s TELS program for an audit of all carpeted areas to be inspected quarterly to determine fi any areas need addressed. ibe Wes Zz yecut Ve Detesley- B- 10-2823 Licence & 6497 Any areas identified during this quarterly audit will be corrected following identification. On 08/07/2023, a carpet extractor was purchased for the community so that the Maintenance Manager can address areas needing attention timely. The equipment is expected to be delivered around 8/11/2023. 19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected No residents were directly affected by the deficient practice. All residents have the potential to be affected by the deficient practice. On 07/24/2023, the Executive Director educated the Dining Manager regarding the expectation that food items should not be stored on the floor, Upon identification by the DHSS surveyor, the food items were removed and thrown away. 10/30/2023 On 07/24/2023, the Dining Manager completed an audit to ensure that no other food items were identified as being stored improperly. No other concerns were noted. Beginning 08/16/2023 through 08/25/2023, an in-service was completed by the Dining Manager to all staff on the expectation that no food items are to be stored on the floor. Beginning 08/14/2023 through 10/09/2023, the dining manager or designee will conduct weekly audits for the eight weeks to verify adherence to the regulation. Any identified concerns will be addressed at the time of the audit. 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.