OAK POINTE OF MARYVILLE, A VIVA SENIOR LIVING COMMUNITY.

PRINTED: 07/22/2025 FORM APPROVED Missouri Department of Health and Senior Services (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 OAK POINTE OF MARYVILLE PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A8035) 19 CSR 30-88.010(34) Mail A8035 If the resident cannot open mail, written consent by the resident or his or her legally authorized representative shall be obtained to have all mail opened and read to the resident. II/III This regulation is not met as evidenced by: Class III Based on interview and record review the operator failed to ensure compliance with all applicable laws and regulations when staff opened Resident #1's mail without permission. The facility census was 45 residents. Review of the facility's undated Resident Rights policy showed: -All residents had the right to privacy in mail communications; -All residents had the right to send and receive unopened mail. Review of the facility's undated Resident and Family Handbook showed: -The mail carriers were to deliver mail directly to the resident's private mailbox within the facility. 1. Review of Resident #1's record showed: -Diagnoses included severe osteoarthritis (a degenerative joint disease that occurs when the protective cartilage on the ends of bones wears down, causing pain, stiffness, and reduced range of mation in the affected joint). Observation of Resident #1's package on 07/08/25 at 1:58 P.M. the package was sent from a "Fulfillment Center", addressed to Resident #1. During an interview on 07/08/25 at 1:55 P.M. Resident #1 said: Missouri Department of Health and Senio LABORATORY DIRECTOR'S cA se (Je IVE'S SIGNATURE TITLE (X6YEATE FZ —=ztl YZ Z / ) FMA f 7 Cx STATE FORM a “os a8 O9ER11 If cénefnuation sheet 1 of 2 PRINTED: 07/22/2025 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 B. WING 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES j 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 i DATE DEFICIENCY) OAK POINTE OF MARYVILLE Continued From page 1 -He/She had ordered some pills for his/her son recently, and when staff brought the package to him/her, the package was already opened; -An unknown care aide brought the package to him/her but advised Level One Medication Aide (LIMA) A had opened the package prior; -He/She was very frustrated that his/her mail had been opened without his/her consent, and did not think staff were allowed to do that. During an interview on 07/09/25 at 8:38 A.M. LIMA A said: -On 07/05/25 the mail carrier handed the package to him/her because medication could be heard while handling the package; -The package was addressed to Resident #1; -He/She thought the medication inside were supplements for Resident #1 in which the facility administered to Resident #1, so he/she opened the package; -Upon finding the medications were not the resident's supplements, he/she sent the package to Resident #1's room to be delivered to Resident #1. During an interview on 07/08/25 at 12:35 P.M. the Administrator said: -He/She would expect all mail to be given to residents to open no matter the contents inside; -If the package appeared to be medication but addressed to the resident he/she would still expect the resident to open the package themselves, or give staff consent to open in their presence. MO256169 Missouri Department of Health and Senior Services STATE FORM 8499 OSER11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Nani: Oak Pointe of Maryville Street Address, City, Zip: 817 South Country Club Dr, Maryville, MO 64468 Date of Survey: 07/08/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 29544 guerre OSS FT SET | TN TE ARATE TT RT SA a age re PRT ETN ONDER TAT REPT TT aa aE SLT TTS a | ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE All residents have a right to privacy in mail communications and the right to send and receive unopened mail. To adhere and keep this from happening again, an in-service training for all staff by the DON at the monthly meeting in July over the following: 1. All mail received through the United States Postal Service, United Parcel Service, FED X, etc. in a Resident’s name will be opened by the Resident as per law from this plan’s date on. a. Aqualified medication administrator as defined in DHSS regulations and internal policies (Licensed Nurse, Certified Level 1 Medication Aid, Certified Medical Tech, Licensed Doctor of Medicine) can be present if Resident agrees during the opening of such mail. b. A Resident or Resident's designee or legally authorized representative may give written authorization (attached) for a qualified medication administrator as defined in DHSS regulations and internal policies to open mailed medications. This A8035 authorization must be in writing, dated and signed by 8/15/25 the Resident or Resident's designee or legally authorized representative. This form will be kept in Resident Record and a list of residents who have given this permission will be maintained by the DON and shared with the Concierge. 2. Medication delivered for a Resident in Care of Oak Pointe of Maryville from a pharmacy not via United States Postal Service, United Parcel Service, FED X, etc. will continue to be handled by a qualified medication administrator as defined in DHSS regulations and internal policies. 3. Mail received through the Post Office is delivered by the Post Man/Woman directly to the resident's Post Office Box, which staff do not have access to. 4. All staff will receive this training at orientation by the Executive Director, DON or Management conducting orientation and during in-service training yearly by either the DON or Executive Director as a refresher to insure adherence. Bit Hf Residents will have an opportunity to sign permission at admission. Management will utilize the Daily Standup meeting to formally query as a daily topic of any medication deliveries to ascertain continued adherence to this POC beyond the date of completion of this POC — recorded on the Daily Stand-Up Form by the Executive Director or Management assigned in the Executive Director's absence. Monthly during Resident Council and during each Encircle (Plan Meeting) it will be asked by the DON or Executive Director if any Resident Mail has been inappropriately or illegally opened. 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 thi m. ep [6/22

PRINTED: 05/14/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED 8. WING 04/29/2025 _ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) 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 MARYVILLE A4804| 19 CSR 30-86.047(47)(F)(1)(B) Influenza/Pneumococcal - Policy/Offer Medication Orders. (F) Influenza and pneumococcal polysaccharide immunizations may be administered per physician-approved facility policy after assessment for contraindications- 1. The facility shall develop a policy that provides recommendations and assessment parameters for the administration of such immunizations. The policy shall be approved by the facility medical director for facilities having a medical director, or by each resident's attending physician for facilities that do not have a medical director, and shall include the requirements to: B. Offer the immunization to the resident or obtain permission from the resident's designee or legally authorized representative when the immunization is medically indicated unless the resident has already been immunized as recommended by the policy; II/III This regulation is not met as evidenced by: Class III Based on record review and interview, the facility failed to ensure the Influenza (Flu) vaccine was offered to three of four (Resident #1, #2, and #3) sampled residents. The facility census was 40. Review of the facility policy titled, "Communicable Diseases, Influenza Vaccinations, and Isolation," dated 3/15/24 showed: -Prior to the start of flu season each year the facility would start flu prevention activities including staff and resident vaccinations; -By October 1st of each year nursing staff would arrange a flu clinic and send an informed consent letter to the Durable Power of Attorney (DPOA)/residents. Missouri Department of Health and Senior Sen LABORATORY DIRECTOR'S OR PRQVIDER/GL alah (EE AGPRESENTATIVE'S SIGNATURE BDA —- alee Fhe —AL! STATE FORM Lm QV6K11 If continuation sheet 1 of 4 PRINTED: 05/14/2025 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 COMPLETED 4, BUILDING: | 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 SUMMARY STATEMENT OF OEFICIENCIES 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 MARYVILLE A4804 | Continued From page 1 1. Review of Resident #1's record showed: -Admit date 6/23/23; -His/Her last flu shot consent or declination was dated 9/14/23. 2. Review of Resident #2's record showed: -Admit date 12/20/22; -His/Her last flu shot consent or declination was dated 10/6/23. 3. Review of Resident #3's record showed: -Admit date 10/2/24; -No flu vaccination record or declination. During an interview on 11/16/23 at 2:10 P.M., the Executive Director said: -He understood flu vaccinations were supposed to be offered to every resident; -He would have expected flu vaccinations to be offered and documented; -He was not aware that flu vaccinations had not been offered. 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 Missouri Department of Health and Senior Services STATE FORM a0 QV6K11 If continuation sheet 2 of 4 PRINTED: 05/14/2025 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 B. WING 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET AODRESS, CITY, STATE, ZIP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 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 MARYVILLE A6013| Continued From page 2 Based on observation and interview, the facility failed to maintain carpeting in good condition. The facility census was 46. The facility did not provide a policy for cleaning the carpet. 1. Observation of the carpet in the Memory Care (MC) television (T.V.) room area on 5/6/25 at 11:10 A.M. showed: -Several small dark brown and black stained areas; -One larger brown stain measuring approximately 6 inches x 4 inches. 2. Observation of the carpet in Room #119 showed the carpet had several black and gray spill stains and was overall dirty throughout. During an interview on 7/29/25 at 2:30 P.M., the Administrator said: -He was aware the carpeting should be kept clean and in good condition; -The facility did not currently have a carpet shampooer. 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/Il This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM sano QV6K11 If continuation sheet 3 of 4 PRINTED: 05/14/2025 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 29544 8. WING —______. 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ip PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK POINTE OF MARYVILLE A8004 | Continued From page 3 Class Ill Based on record review and interview, the facility staff failed to ensure the resident, or legally authorized representative or designee, was informed of his/her rights and responsibilities at least annually for two of four (Resident #1 and #2) sampled residents. The facility census was 40. The facility did not provide a policy regarding reviewing annual resident rights. 1. Review of Resident #1's file showed: -Admit date 6/23/23; -No documentation of resident rights being reviewed with resident's legally authorized representative in 2024 or 2025. 2. Review of Resident #2's file showed: -Admit date 12/20/22; -No documentation of resident rights being reviewed with resident's legally authorized representative in 2023, 2024 or 2025, During an interview on 5/6/25 the Director of Nursing (DON) said: -He/she did not know that if a resident had a legally authorized representative that the resident rights needed to be reviewed with that individual. During an interview on 5/6/25 at 1:10 P.M., the Administrator said: -He knew resident rights should be reviewed with each resident or their legally authorized representative annually; -He was not employed at the facility when they last reviewed resident rights. Missouri Department of Health and Senior Services STATE FORM e808 QV6K11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier se Oak Pointe of Maryville Street Address, City, Zip: 817 S. Country Club Drive, Maryville, MO 64468 Date of Survey: 04/29/25 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 1. The Director of Nursing (DON) will initiate a complete review of all resident files and documentation to identify 6/29/25 any resident who was not offered the influenza (Flu) vaccine and do so thusly documented. 2. The DON will arrange for a Flu vaccine clinic this fall as per our policy, for all residents before 10/01/25. There | 6/29/25 will be formal documentation of the offering and acceptance/declination of the respective resident or resident's designee or legally authorized representative in each resident record. This will occur every year as per internal policy. 3. The Flu clinic will be communicated via the Life Loop 6/29/25 Community Board, via the staff during meetings and placed on all manager schedules via “Teams.” 4. The administration will audit resident records prior to 6/29/25 and just after the clinic to ensure completion. A4804 1. Oak Pointe of Maryville has an industrial carpet cleaning machine that is utilized by the maintenance department | 6/29/25 for periodic deep cleaning and for stain removal. The carpet cleaning machine was employed in the last 30 days prior to this survey in the memory support (Aspen Village) area described. Oak Pointe is historically and presently very diligent in cleanliness and maintenance of all flooring types and surfaces. The necessary cleaning and stain removal will be conducted to maintain the flooring to be in good repair and clean as per housekeeping, maintenance scheduling and staff training. 2. Oak Pointe of Maryville will identify any stains as the 6/29/25 new stain cited in this survey in room 119 and employ the carpet cleaning machine to thoroughly clean and sanitize and keep the carpet in good repair. This room has had the industrial carpet cleaning machine utilized several times in the past as well. 3. Oak Pointe of Maryville will continue to utilize the _ 6/29/25 Miler Wns LZ enboe — Exantle Kew bi A6013 appropriate cleaning of.all floor surfaces regularly including any carpeted areas. All common floors are vacuumed and mopped daily or more often. Any stains will be identified promptly and cleaned maintaining floors | in good repair. Resident rooms receive housekeeping weekly and any identified stains will be reported to the Maintenance Director to be cleaned maintaining the floors in good repair. Oak Pointe of Maryville has been and is continuing to turn residence rooms with any carpeting into viny! planking. lf carpeting is desired by a resident at “room turn,” new carpeting is always installed unless it is in near new condition and free from any staining and in good repair. 6/29/25 A8004 Each resident or resident's designee or legally authorized representative receives and reviews their “Resident Rights” as per internal policy and this regulation upon taking residency at Oak Pointe of Maryville. Each year, the resident or resident's designee or legally authorized representative will receive and review their “Resident Rights” and formal documentation will be kept in their record. This will now occur during their Encircle, which is their 6-month review for planning in which every department participates as well as the resident, resident ' s designee or legally authorized representative and family that the resident agrees with. The DON will facilitate a review of all resident records identifying who has not had a review as per regulation and internal policy. If there is no record of their “Resident Rights” meeting internal policy and regulation, it will be completed formally with the resident, resident's | designee or legally authorized representative. It will then be placed in the resident record. The administration will audit resident records quarterly to ensure completion. 6/29/25 6/29/25 6/29/25 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. Slaifos | Z owta ; hebhe —-ExcarHle A precter

PRINTED: 62/09/2024. FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B. WING 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 5) 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 MARYVILLE 19 CSR 30-86.022(9)(B)(1)(B) Alarm/Detectors- Correct Faults Complete Fire Alarm Systems. | (B) Facilities that are required to install a sprinkler system in accordance with section (11) of this rule shall comply with the following requirements: 1. Until the required sprinkler system is installed, each resident room or any room designated for sleeping shall be equipped with at least one (1) battery-powered smoke alarm installed, tested, and maintained in accordance with manufacturer 's specifications. In addition, the facility shall be equipped with interconnected heat detectors installed, tested, and maintained in accordance with NFPA 72, 1999 edition, with detectors in all areas subject to nuisance alarms, including, but not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. IAL B. Upon discovery of a fault with any detector or alarm, the facility shall correct the fault. i/ll This regulation is not met as evidenced by: Class I). Based on observation and interview, facility fails to maintain its fire alarm system in good repair, : and correct any faults. Facility census is 34. ; Violation affects 34 of 34 residents. Observation: (10:05 a.m.): Fire alarm panel shows "trouble" status, and has two faults: Memory Care Room H Utility Monitor, and Memory Care Work Station Pull Station. Visual inspection was made in both rooms and no obvious signs of damage were found. Interview with Maintenance Director: Sometimes when the computer controlled alarm panel does its self tests daily, it will throw an Missouri Department of Health and Senior Services LABORATORY D!RECTO LIER REPRESENTATIVE'S SIGNATURE {X6) DATE y) §f continuation sheet 1 of 4 STATE FORM 699 NKIM11 PRINTED: 09/12/2024 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 29544 B.WING 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 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 MARYVILLE A2248 19 CSR 30-86.022(9)(B)(1)(B) Alarm/Detectors- Correct Faults Complete Fire Alarm Systems. (B) Facilities that are required to install a sprinkler system in accordance with section (11) of this rule shall comply with the following requirements: 1. Until the required sprinkler system is installed, each resident room or any room designated for sleeping shall be equipped with at least one (1) battery-powered smoke alarm installed, tested, and maintained in accordance with manufacturer "s specifications. In addition, the facility shall be equipped with interconnected heat detectors installed, tested, and maintained in accordance with NFPA 72, 1999 edition, with detectors in all areas subject to nuisance alarms, including, but nat limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. il B. Upon discovery of a fault with any detector or alarm, the facility shall correct the fault. {I This regulation is not met as evidenced by: Class Il. Based on observation and interview, facility fails to maintain its fire alarm system in good repair, and correct any faults. Facility census is 34. Violation affects 34 of 34 residents. Observation: (10:05 a.m.): Fire alarm panel shows “trouble” status, and has two faults: Memory Care Room H Utility Monitor, and Memory Care Work Station Pull Station. Visual inspection was made in both rooms and no obvious signs of damage were found. interview with Maintenance Director: Sometimes when the computer controlled alarm panel does its self tests daily, it will throw an Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) DATE STATE FORM sao NKIMt11 If continuation sheet 1 of 4 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 29544 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 09/18/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED 12/27/2023 STREET ADDRESS, CITY, STATE, ZiP CODE 817 SOUTH COUNTRY CLUB DRIVE OAK POINTE OF MARYVILLE (X4) ID PREFIX TAG A2248 MARYVILLE, MO 64468 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 occasional error, so he/she believes this could be a temporary communication error between a device and the panel. He/she plans to contact their alarm company for troubleshooting. 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 nat required to have this one- (1-} hour fire separation. Doors to hazardous areas shail 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 Il. Based on observation and interview, facility fails to ensure doors to hazardous areas shall be self-closing and shall be kept closed. Facility census is 34. Violation affects 34 of 34 residents. Missouri Department of Health and Senior Services STATE FORM CROSS-REFERENCED TO THE APPROPRIATE NKIM11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE {x5} COMPLETE DATE DEFICIENCY} if continuation sheet 2 of 4 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 29544 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 09/18/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED 12/27/2023 STREET ADDRESS, CITY, STATE, ZiP CODE 817 SOUTH COUNTRY CLUB DRIVE OAK POINTE OF MARYVILLE A2256 MARYVILLE, MO 64468 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Observation: (10:05 a.m.): Kitchen door has self closing hinges, but they don't have enough force to close the door. Door is staying open several inches each of the three times the door was tested. The door won't close fully on its own. interview with Maintenance Director: Recently tightened hinges but they aren't enough to overcome the airflow through the kitchen. Facility will install a heavier-duty self-closure device on the door instead. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. IAI This regulation is not met as evidenced by: Class II.* Based on observation, records review, and interview, facility fails to maintain its generator in good repair. Facility census is 34. Violation affects 34 of 34 residents. Observation: (12:41 p.m.): Kohler generator panel shows two faults: “Low Coolant Temperature", and “Gommon Fault”. Records review (12:08 p.m.): Central Power Systems (CPS) generator maintenance inspection report dated 10/19/23 states the following failures: Air Filter: “Dirty, will need to be replaced.” Batteries: "55% health. Will need to be replaced.” Missouri Department of Health and Senior Services STATE FORM CROSS-REFERENCED TO THE APPROPRIATE NKIM11 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} if continuation sheet 3 of 4 PRINTED: 09/12/2024 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 29544 B.WING 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 817 SOUTH COUNTRY CLUB DRIVE MARYVILLE, MO 64468 (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 MARYVILLE A3201 Continued From page 3 interview with maintenance director (12:20 p.m.) The generator needs an engine block heater replaced. He/she received the CPS maintenance inspection report and notified management about the deficiencies, but corporate is still negotiating a contract rate with CPS. *Higher classification merited due to the combination of the extent of the violation and affect on the residents, since some residents use oxygen concentrators. Missouri Department of Health and Senior Services STATE FORM 5899 NK1Mt11 if continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Oak Pointe of Maryville Name: Street Address, City, Zip: 817 S Country Club Drive Maryville MO 64468 Date of Survey: 12-27-2023 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 Marmic Fire safety came in 02/22/24 and fixed the alarm. The A2248 alarm system will continue to be monitored daily to make sure it 1-23-24 is not in trouble status Maryville Glass and lock fixed door on 12/28/2023. All doors are A2256 F 12-28-23 now closing fully. A3201 Generator heater block fixed 01-11-24 Air filter and batteries will be replaced 2-28-24 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.