OAK POINTE OF MONETT, A VIVA SENIOR LIVING COMMUNITY.

PRINTED: 12/11/2024 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 30206 B.WING 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES D 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 MONETT A4724) 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty | in breathing) screening test was administered for one staff member (Resident Assistant (RAA)) and one resident (Resident #1) and failed to document an annual TB screening evaluation for one resident (Resident #2). The facility census | was 36. General requirements for Tuberculosis Testing for Employees and Residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: | -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) two-step tuberculin test within one month prior to starting employment; | -If the initial test is negative, the second test , should be given as soon as possible within three | weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Missouri Department of Health and Senior Services OVIDER/SUPPLIER REPRESENJATIVE'S SIGNATURE TITLE (X6) DATE E2cy11 If continuation sheet 1 of 3 PRINTED: 12/11/2024 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 30206 B. WING 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 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 MONETT Continued From page 1 Review of the facility's policy titled "Tuberculosis (TB) Testing," updated 12/20/21 ,showed the following: -The Director of Nursing (DON) will ensure that all facility residents have evidence of TB screening completed within 12 months prior to admission; -Screenings will consist of a two-step skin test, blood test, chest x-ray, or other method recommended by the public health authority; -Facilities will conduct an annual risk analysis per State regulations; -The DON will ensure that all staff have evidence of TB screening within 10 days of hire and before occupational exposure; -The DON will ensure that all staff will have a documented baseline two-step tuberculin skin test (TST); -Facilities will conduct an annual risk analysis per State regulations. If the annual risk assessment determines that assessment is needed, the DON will oversee all aspects of staff TB testing, follow up actions, and record keeping. 1. Review of RAA's personnel file showed the following -Hire date of 10/29/24: -Start date of 11/14/24; -Staff did not document a two-part TB screening test completed; -Staff did not have documentation of prior TB test. 2. Review of Resident #1's medical record showed the following: -Admission date of 07/23/24; -Staff did not document a two-part TB screening test administered; Missouri Department of Health and Senior Services STATE FORM 6899 E2cY11 If continuation sheet 2 of 3 PRINTED: 12/11/2024 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 30206 B. WING 11/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 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 MONETT Continued From page 2 -Staff did not have documentation of prior TB test. 3. Review of Resident #2's medical record showed the following: -Admission date of 07/19/22; -Staff last documented an annual TB screening evaluation on 07/23/23. 4. During an interview on 11/25/24, at 4:03 P.M., the DON said the following: -He/She began working at the facility a few weeks ago; -RAA is a nursing student and was supposed to get his/her TB screening at school, but has not provided this documentation; -It is his/her responsibility to complete resident and staff TB screenings. 5. During an interview on 11/25/24, at 4:07 P.M. the Executive Director said the following: -He/She began his/her duties at the facility on 11/18/24; -He/She did not know the TB screenings were missing. Missouri Department of Health and Senior Services STATE FORM 6899 E2cY11 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Oak Pointe Monett Name: Street Address, City, Zip: 1011 Old Airport, Monett MO 65708 Date of Survey: 11/25/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE A4724 1_| Resident #1 was given 1st step TB on 12/02/2024 by the DON. 12/02/24 Resident #2 TB Screen was done by the DON on 12/04/2024. 12/04/2024 RA Staff #1 was given 1st step TB on 11/27/2024 by the DON. 11/27/24 Resident # 2 was transferred to the hospital on 12/13/24. Continue to Resident #2 will be given 2nd step TB test upon return from the : - monitor hospital. RA Staff #1 was given 2nd step TB on 12/11/2024 by the DON. 12/11/24 All resident files were reviewed by the DON on 11/26/2024 to 9 | ensure that all residents had timely TB tests and TB screens. 14/26/24 Any other missed TB tests and screens were corrected immediately. All staff were reviewed by the DON on 11/26/2024 to ensure all staff were up-to-date on TB testing. Any other missed TB tests 11/26/24 and screens were corrected immediately. 3 The DON and Executive Director were inserviced by the Senior 12/04/24 Executive Director on 12/04/2024 on the companies TB policy. The DON will review all residents monthly to ensure all TB 4 | Screens are up-to-date and complete. The DON will review all Onaoin new admits to ensure that the TB test was complete. The DON going will report findings monthly to the Executive Director. The Executive Director will review all new hire files to ensure Ongoing that the TB testing was completed timely. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIERICLIA, AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 30206 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1014 OLD AIRPORT ROAD MONETT, MO 66708 OAK POINTE OF MONETT ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG : CROSS-REFERENCED TO THE APPROPRIATE DATE i DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG ' 19 CSR 30-86.022(7)(E) Locked Exit Doors Exits, Stairways, and Fire Escapes. (E) If it is necessary to lock exit doors, the locks | shail not require the use of a key, tool, special - knowledge, or effort to unlock the door from inside the building. Only one (1} lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 | edition NFPA 101 shall be permitted, provided ; that not more than one (1) such device is located in any egress path. Selftlocking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. Hit This regulation is not met as evidenced by: Class II | Based on observation, review and interview on i May 13, 2024, the facility failed to ensure delayed egress locks were installed in accordance with section 7.2.1.6.1 of the 2000 edition National Fire Protection Association (NFPA) 101, Life Safety | Cade. The facility census on May 13, 2024, was , 40. This deficiency affects 40 out of 40 residents. Observation of a delayed egress locked door, at the south side of the Memory Care unit showed | no required delayed egress signage on the | delayed egress door. Observation of a delayed egress locked door, at the east end of the Memory Care unit showed no required delayed egress signage on the delayed | egress door. Observation of a delayed egress locked door, at the west side of the Memory Care unit showed no required delayed egress signage on the delayed | egress door. Missouri Department of Health ang Senjor Saf LABORATORY DIRECTOR'S OR PI Hp VIDRRE HF : /REPRESENTATIVE'S SIGNATURE TIT _(X6) DATE eo FARCE id RECT shy lde} STATE FORM ' sau 412014 Ifcontinuation sheet 1 of 4 m ir PLAN OF CORRECTION Provider/Supplier Oak Pointe of Monett Name: jo City Zip 1011 Old Airport Road, Monett, MO 65708 Date of Survey: 05/13/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | 19 CSR 30-86.022(7)(E) Locked Exit Doors — Review of NFPA 101, 2000 Edition Section 7.2.1.6.1 (d) states: On the door adjacent to the release device, there shall be a readily visible A2229 durabie sign in letters not less than 1 in. high and not less than 06/10/2024 1/8 in in stroke width on a contrasting background that reads as follows: Push Until Alarm Sounds Door Can Be Opened in 15 Seconds. South Side Memory Care Door, East End Memory Care Door and West Side Memory Care Door have been equipped with the roper signage. A walk thru of the building was completed to make sure no other Delayed Egress Locked Door was without signage. | The Executive Director/Maintenance Director will add Delayed Egress Locked Doors to his monthly checklist to ensure signage hasn't been damaged/removed/etc. | To monitor compliance, the Safety Committee will review any trends and/or checklists for ongoing compliance. 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. PLAN OF CORRECTION | Provider/Supplier 44 Pointe of Monett Name: | Street Address, | 144 Old Airport Road, Monet, MO 65708 City, Zip: Date of Survey: 05/13/2024 30206 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 19 CSR 30-86.022(11)(A) Complete Sprinkler System — Review of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, chapter 2-2.1.1 states “Sprinklers shall be inspected A2268 from the floor level annually. Sprinklers shail be free of 06/10/2024 corrosion, foreign materials, paint and physical damage and shail be installed in the proper orientation. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. The Sprinkler in the closet located on the Northeast side of the main living room has been replaced by a technician from Marmic Fire & Safety. A walk thru of the building was completed to make sure no other Sprinkler Head had been painted over. The Executive Director/Maintenance Director will walk with Marmic Fire & Safety during their Annual Sprinkler inspection to ensure all Sprinkler Heads are free of corrosion, foreign materials, paint, and physical damage. To monitor compliance, the Safety Committee will review any trends, checklists, and inspections for ongoing compliance. 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. Name: Street Address, City, Zip: Date of Survey: /— ID PREFIX TAG A2286 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of Provider/Supplier PLAN OF CORRECTION Oak Pointe of Monett 1011 Old Airport Road, Monett, MO 65708 05/13/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM- Requirements. Only metal or UL- or FM-fire resistant rated wastebaskets shall be used for trash. The Wastebaskets in room 109,110,115, 116, 117, 118, 120, 123, 124, 130, and 132, have been replaced with the proper Fire Resistant Rated wastebasket. 30206 COMPLETION DATE 06/10/2024 A walk through of all apartments was completed to make sure all wastebaskets were only Metal or UL- FM-fire resistant rated. Improper wastebaskets were pulled immediately and replaced with the proper fire resistant rated wastebasket. The Executive Director/Maintenance Director/Designee will complete a monthly check of apartments to ensure proper wastebaskets are in place. New residents/families will be given a copy of the Safety Guidelines upon admission which states that wastebaskets must be Metal or UL- FM-fire resistant rated. To monitor compliance, the Safety Committee will review any trends, checklists, and inspections for ongoing compliance. the plan of correction being submitted on this form.

PRINTED: 04/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CHIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING: Cc 12/19/2023 30206 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 OAK POINTE OF MONETT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES i ID PROVIDER'S PLAN OF CORRECTION | (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX. : {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG : REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS-REFERENCED TO THE APPROPRIATE DATE ' ! 1 DEFICIENCY) A4711) 19 CSR 30-86.047(13)(A) Criminal Background | A471 Check Requirements | Prior to allowing any person who has been hired : in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted fram an employment agency, the employment agency shall, prior to | sending a temporary employee to a facility: _ (A) Request a criminal background check for the | i | person, as provided in section 660.317, RSMo. Each facility shall maintain documents verifying : that the background checks were requested, the | date of each such request, and the nature of the | response received for each such request. {I This regulation is not met as evidenced by: Based on interview and record review, facility staff failed to request a criminal background check (CBC), including documenting the date of | request, date received, and nature of the ; response, on five staff members of five staff | members reviewed (Resident Assistant (RA) A, | Caok B, Level One Medication Aide (LIMA) C, LIMA D, and LIMA E). The facility census was 41. | Review showed the facility did not provide a ' policy regarding completion of criminal i | | background checks. 1. Review of RAA's personnel record showed the following: -Hire date of 04/19/23 and a start date of 04/21/23: -The file did not contain a criminal background =| check; | i -Staff had documented requesting background check before resident contact, but failed to Missouri Department of Health and Seniog Services LABORATORY DIRECTOR'S AR PROVDE RasUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Af LOY EA ECOVFR. ORE CTA U2 VS he dy STATE FORM 6B99 HZWF11 If continuatian sheet 1 of {1 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED Cc 42/19/2023 {X2) MULTIPLE CONSTRUCTION A. BUILDING: 30206 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 NAME OF PROVIDER OR SUPPLIER OAK POINTE OF MONETT (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG ' CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ' Continued From page 4 follow-up to ensure it was received. 2. Review of Cook B's personnel record showed | the following: ~Hire date of 10/06/23 and a start date of 10/09/23; -The file did not contain a criminal background check; ' -Staff did not document request the check before | resident contact. 3. Review of LIMA C's personnel record showed the following: | -Hire date of 07/11/23 and a start date of 07/13/23; | -The file did not contain a criminal background — check; ; -Staff did not document request the check before | | resident contact. 4. Record review of LIMA D's personnel record showed the fallowing: _ Hire date of 09/25/23 and a start date of | 09/27/23; -The file did not contain a criminal background check; -Staff did not document request the check before : resident contact. 5. Record review of LIMA E's personnel record showed the following: -Hire date of 09/08/23 and a start date of | , 09/11/23; | -The file did not contain a criminal background | | check; -Staff did not document request the check before Missouri Department of Heaith and Senior Services STATE FORM 6899 HZ\WF 14 If continuation sheet 2 of 14 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED Cc 12/19/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 30206 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 NAME OF PROVIDER OR SUPPLIER OAK POINTE OF MONETT (x4) 10 | SUMMARY STATEMENT OF DEFICIENCIES iD | PROVIDER'S PLAN OF CORRECTION i (X5) 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 i DATE DEFICIENCY) Continued From page 2 | resident contact. | 6. During an interview on 12/19/23, at 5:20 P.M., the Executive Director said that he was responsible for the background checks for the staff, and he was aware they had not been | completed. 19 CSR 30-86.047(20)()} Personnel Record-physician statement, employ The administrator shall maintain on the premises | | an individual personnel record on each facility _ employee, which shall include the following: (I) Written statement signed by a licensed physician or physician's designee indicating the | person can work in a long-term care facility and indicating any limitations; il This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure five staff members of the five sampled staff members (Resident Assistant A, Cook B, Level One Medication Aide (LIMA) C, LIMA D, and LIMA E) had a written statement by | a licensed physician or physician's designee indicating the person could work in a long-term | care facility and indicating any limitations The | facility census was 41. | Review showed the facility did not provide a | policy regarding written statements by a licensed | physician or designee indicating a person can work in a long-term care facility and indicating any | limitations. j | 1. Review of RAA's personnel record showed the | _ following: Missouri Department of Health and Senior Services STATE FORM 6899 HZWFt1 If continuation sheet 3 of 11 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X3) DATE SURVEY COMPLETED Cc 12/19/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 30206 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL ! PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) : TAG CROSS-REFERENCED TOTHEAPPROPRIATE | = DATE \ DEFICIENCY} NAME. OF PROVIDER OR SUPPLIER OAK POINTE OF MONETT ' Continued From page 3 -Hire date of 04/19/23 and a start date of 04/21/23; -The personnel file did not contain a written i statement by a licensed physician or physician's ; designee indicating the person could work in a : long-term care facility and indicating any limitations. 2. Reiew of Cook B's personnel record showed the following: . -Hire date of 10/06/23 and a start date of 10/09/23; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person could work ina jong-term care facility and indicating any | limitations. 3. Review of LIMA C's personnel record showed the following: -Hire date of 07/11/23 and a start date of i 07/13/23: -The personnel file did not contain a written ' statement by a licensed physician or physician's | designee indicating the person could work ina | long-term care facility and indicating any | limitations. 4. Review of LIMA D's personnel record showed the following: | -Hire date of 09/25/23 and a start date of 09/27/23; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person could work in a Missouri Department of Health and Senior Services STATE FORM Bago HZWF11 If continuation sheet 4 of 11 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3} DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED A, BUILDING: Cc 12/19/2023 30206 BAU STREET ADDRESS, CITY, STATE. ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 (4) ID | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE TAG i REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS-REFERENCED 70 THE APPROPRIATE NAME OF PROVIDER OR SUPPLIER OAK POINTE OF MONETT (X5} COMPLETE DATE DEFICIENCY} Continued From page 4 long-term care facility and indicating any ; limitations. 5. Record review of LIMA E's personnel record showed the following: -Hire date of 09/08/23 and a start date of 09/11/23; i -The personnel file did not contain a written i | statement by a licensed physician or physician's | | designee indicating the person could work in a long-term care facility and indicating any limitations. 6. During an interview on 12/19/23, at 5:20 P.M., the Executive Director said he was responsible | 1 i : for ensure the statements were obtained and he was aware they had not been completed. 19 CSR 30-86.047(20){K) Personnel Record - orientation training The administrator shall maintain on the premises _ an individual personnel record on each facility employee, which shall include the following: (K) Documentation of what the employee was : instructed on during orientation training; Il] This regulation is not met as evidenced by: Based on interview and record review, facility staff failed to ensure prior to or on the first day a new employee worked in the facility he/she received orientation of at least two hours appropriate to his/her job function far five of five | staff members sampled (Resident Assistant (RA), | | Cook B, LIMA C, LIMA D, and LIMA E). The facility | | _ census was 41. Missouri Department of Health and Senior Services STATE FORM S899 HZ2WE11 If continuation sheet 5 of 14 PRINTED: 01/23/2024 FORM APPROVED Missourt Department of Health and Senior Services STATEMENT OF DEFICKENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING: Cc 12/19/2023 30206 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 NAME OF PROVIDER OR SUPPLIER OAK POINTE OF MONETT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ra) i PROVIDER'S PLAN OF CORRECTION | (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL i PREFIX | (EACH CORRECTIVE ACTION SHOULD BE ; COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS-REFERENCED TO THE APPROPRIATE { DATE : : DEFICIENCY) Continued From page 5 Review showed the facility did not provide a policy regarding new staff orientation prior to staff | | working in the facility. _ 1. Review of RAA's personnel record showed the following: -Hire date of 04/19/23 and a start date of 04/21/23; -Staff did not document orientation was completed prior to or on the first day the staff | member worked in the facility. 2. Review of Cook B's personnel record showed the following: -Hire date of 10/06/23 and a start date of i 10/09/23; -Staff did not document orientation was H completed prior to ar on the first day the staff member worked in the facility. 3. Review of LIMA C's personnel record showed the following: | -Hire date of 07/11/23 and a start date of 07/13/23; -Staff did not document orientation was completed prior to or on the first day the staff i H | member worked in the facility. | 4. Review of LIMA D's personnel record showed the following: -Hire date of 09/25/23 and a start date of 09/27/23; -Staff did not document orientation was completed prior to or on the first day the staff member worked in the facility. Missouri Deparment of Health and Senior Services STATE FORM see HZWF 11 If continuation sheet 6 of 11 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) BATE SURVEY COMPLETED Cc 12/19/2023 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 30206 Bees STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 NAME OF PROVIDER OR SUPPLIER OAK POINTE OF MONETT (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID ' PROVIDER'S PLAN OF CORRECTION ! (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' PREFIX : (EACH CORRECTIVE ACTION SHOULD BE ; GOMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE H DATE DEFICIENCY) Continued From page 6 5. . Record review of LIMA E's personnel record showed the following: ' -Hire date of 09/08/23 and a start date of / 09/11/23; -Staff did not document orientation was campleted prior to or on the first day the staff member worked in the facility, 6. During an interview on 12/19/23, at 5:20 P.M., : the Executive Director said he was responsible | for the training and documentation and he was aware they had not been completed. A4837 A4837;, 19 CSR 30-86.047(58}(B) Resident Condition/Medication Review The facility shall maintain a record in the facitity | for each resident, which shail include the following: (B) A review monthly or more frequently, if indicated, of the resident 's general condition and | needs; a monthly review of medication consumption of any resident controlling his or her | own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medicatian regimen | | review process; a monthly weight: a record of each referral of a resident for services from an | outside service; and a record of any resident : incidents including behaviors that present a | reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries invalving the resident; Hl j y { i j Missouri Deparment of Health and Senior Services STATE FORM 6898 HZWF11 if continuation sheet 7 of 14 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED A, BUILDING: Cc B, WING 42/19/2023 30206 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID | PROVIDER'S PLAN OF CORRECTION OKs) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE DATE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG -_~—-CROSS-REFERENCED TO THEAPPROPRIATE | DEFICIENCY) OAK POINTE OF MONETT Continued From page 7 This regulation is not met as evidenced by: Based on interview and record review, the facility | failed to ensure each resident's monthly review : included a monthly weight when staff did not document monthly weights for for two residents | (Resident #1 and #5) out of five sampled | residents. The facility census was 41. 1. Review of Resident #1's medical record showed the following: _ -Admission date of 03/09/23; -Staff did not document a resident weight in March, April, May, June, July, August, September, or October for 2023. 2. Review of Resident #5's medical record | showed the following: | Admission date of 02/09/23; -Staff did not document a resident weight in June, July, September, or October for 2023. i 3. During an interview on 12/19/23, at 5:20 P.M., the Director of Nursing said that he/she failed to | ensure weights were being done at least monthly | i on residents. MO00228744 A8004| 19 CSR 30-88.010(4) Resident | A8004 Rights-Admission/Annuail 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, Missouri Department of Health and Senior Services STATE FORM 6898 HZWF11 If continuation sheet B of 71 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Heaith 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 30206 Be WING 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 a) 0 | SUMMARY STATEMENT OF DEFICIENCIES / ip PROVIDER'S PLAN OF CORRECTION xa} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE =| COMPLETE TAG : REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG | CROSS-REFERENCED TOTHEAPPROPRIATE =| DATE DEFICIENCY) OAK POINTE OF MONETT Continued From page 8 legally authorized representative ar designee, either in a group session or individually. HAM This regulation is not met as evidenced by: | Class Ill _ Based on interview and record review, the facility | | failed to review resident rights for health-care decision making at least annually with each } resident and/or their next of kin, legally authorized | representative, or designees, for three residents (Resident #2, #3, and #4) out of five sampled residents. The facility census was 41. i 1. Review of Resident #2's medical record showed the following: _-Admission date of 11/12/21: | on 06/16/22: -Staff did not document an annuai review of resident rights in 2023. 2. Review of Resident #3's medical record showed the following: -Admission date of 03/17/21; -Staff did not document an annual review of | resident rights in 2022 or 2023. : 3. Review of Resident #4’s medical record showed the following: -Admission date of 11/19/20; -Staff did not document an annual review of resident rights in 2021, 2022 and 2023. 4, During an interview on 12/19/23, at 5:20 P.M., the Director of Nursing said that he/she failed to a; review of resident's rights annually. Missouri Department of Health and Senior Services STATE FORM 6899 HZWFi1 If continuation sheet 9 of 14 PRINTED: 01/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED Cc 30206 B. WING 42/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID ] PROVIDER'S PLAN OF CORRECTION Ks) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG ~=o|~Ss«CROSS-REFERENCED TOTHEAPPROPRIATE | DATE DEFICIENCY) OAK POINTE OF MONETT A8010) 19 CSR 30-88.010(10) Advance Directive Requirements Prior to or upon admission and at least annually after that, each resident or his or her next of kin, legally authorized representatives or designees ' shail be informed of facility policies regarding , provision of emergency and life-sustaining care, | of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents’ next of kin, legally authorized representatives or designees shallbe informed, | upon request, regarding state laws related to i _ advance directives for health-care decision | 1 making as well as the facility's policies regarding the provision of emergency or life-sustaining medical care or treatment. If a resident has a written advance health-care directive, a copy ! shall be placed in the resident's medical record | and reviewed annually with the resident unless, in the interval, he or she has been determined | incapacitated, in accordance with section 475.075 | - or 404.825, RSMo. Residents’ next of kin, legally - | authorized representatives or designees shallbe | contacted annually to assure their accessibility | and understanding of the facility policies regarding emergency and life-sustaining care. HVA This regulation is not met as evidenced by: Class Il* - Based on interview and record review, the facility | | failed to review advanced directives for health-care decision making at least annually with | each resident and/or their next of kin, legally authorized representative, or designees, for three Missouri Department of Health and Senior Services STATE FORM 6699 HZWF 11 If continuation sheet 10 of 11 PRINTED: 01/23/2024 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: & BULBINE: COMPLETED Cc 30206 B. WING 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1011 OLD AIRPORT ROAD MONETT, MO 65708 (x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION 8) 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 OAK POINTE OF MONETT DEFICIENCY) Continued From page 10 | residents (Resident #2, #3, & #4) out five | sampled residents. The facility census was 41. | 1. Review of Resident #2's medical record showed the following: -Admission date of 11/12/21: -Staff documented an annual advance directive review on 06/16/22: | -Staff did not document an annual review of . advanced directives for 2023. 2. Review of Resident #3 's medical record showed the following: -Admission date of 03/17/21; | -Staff did not document an annual review of advanced directives for 2022 or 2023. | 3. Review of Resident #4's medical record showed the following: -Admission date of 11/19/20; -Staff did not document an annual review of advanced directives for 2021, 2022, or 2023. _ 4. During an interview on 12/19/23, at 5:20 P.M., | the Director of Nursing said that he/she failed to a} review advanced directives annually. j ] j *The higher classification merited due to extent of | violation. Missouri Department of Health and Senior Services STATE FORM 5899 HZWF11 If continuation sheet 11 of 11 —__— PLAN OF CORRECTION fp Provider/Supplier | O24 Pointe of Monett | Name: Street Address, Ci ' 1011 Old Airport Road, Monett, MO 65708 ity, Zip: Date of Survey: 12/19/2023 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 The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (K) Documentation of what the employee was 02/17/2024 instructed on during orientation training in accordance with 19 CSR-30-86.047(20)(K RA A and L1MA C have received orientation, and their orientation checklist is in their personnel file. Cook B, LIMA D, and L1MA E are no Jonger employed here. A signed acknowledgement of Orientation will be on file for all employees on their first day indicating he/she were appropriately orientated to his/her job function. The Executive Director/Designee will review each newly hired employee’s personnel record to ensure Orientation is complete and on file. A review will be done monthly for three months and then randomly thereafter. To monitor compliance, the Safety Committee will review any trends and/or actions brought to them by the Executive Director/DON/Designee for ongoing compliance monthly for three months and then quarterly. 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. PLAN OF CORRECTION Provider/Suppiier Name: Oak Pointe of Monett Street Address, _— 1011 Old Airport Road, Monett, MO 65708 City, Zip: Date of Survey: 12/49/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include a written statement signed by a licensed physician or physician's designee indicating the person can work in long-term care facility and indicating any limitations in accordance with 19 CSR 30-86.047(20)(I) ee A Physician Statement will be on file for ail employees prior to their hire date indicating the employee can work in a long-term care facility and any limitations RA A, and LiMA C have been corrected and have a physician statement in their personne! file. Cook B, LIMA D and LIMA E are no longer employed here. ID PREFIX TAG A4733 2/17/23 An audit will be completed by the Executive Director/Designee to ensure that all current employees have a physician statement on file. The Executive Director/Designee will review each newly hired employee's personnel record to ensure a physician statement is on file. A review will be done monthly for three months and then randomly thereafter. To monitor compliance, the Safety Committee will review any trends and/or actions brought to them by the Executive Director/DON/Designee for ongoing compliance monthly for three months and then quarterly. 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. PLAN OF CORRECTION Provider/Supplier Oak Pointe of Monett Name: Citi 1011 Old Airport Road, Monett, MO 65708 —_ of Survey: 12/19/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 30206 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Each resident admitted to the facility, or his/her next of kin, or legally authorized representative/designee, shall be informed of facility policies regarding provision of emergency and life- sustaining care, an individual's right to make treatment decisions for himself/herseif and of state laws related to advance directives for health-care decision making. Resident’s next of kin, legally authorized representatives or designees shall be contacted annualy to assure their accessibility and understand of the facility policies regarding emergency and life-sustaining care in accordance with 19 CSR 30-88.010(10) 2/17/23 A8010 Residents 2, 3, and 4 have an updated advance directive J —_— acknowledgement form in their file. J An audit has been completed by the Executive Director/Designee of ail residents admitted prior to 2023 to ensure they have an annual acknowledgement form in their file The Executive Director/Designee will review the Advance Directives at each Care Plan Meeting to ensure it has been reviewed annually. To monitor compliance, the Safety Committee will review any trends and/or actions brought to them by the Executive Director/DON/Designee for ongoing compliance monthly for three months and then quarterly. 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. PLAN OF CORRECTION Provider/Supplier Name: Oak Pointe of Monett Street Address, City, Zip: 1011 Oid Airport Road, Monett, MO 65708 Date of Survey: 12/19/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Each resident admitted to the facility, or his/her next of kin, or legally authorized representative/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/her next of kin, legally authorized representative or designee in accordance to 19 CSR 30- 88.010(4 ID PREFIX TAG 2/17/23 An audit has been completed by the Executive Director/Designee of all residents admitted prior to 2023 to ensure they have an annual acknowledgement form in their file The Executive Director/Designee will review the resident rights at each Care Plan Meeting to ensure it has been reviewed annually. To monitor compliance, the Safety Committee will review any trends and/or actions brought to them by the Executive Director/DON/Designee for ongoing compliance monthly for three months and then quarterly. 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. PLAN OF CORRECTION Provider/Supplier Oak Pointe of Monett Name: Street Address, 444 Old Airport Road, Monett, MO 65708 City, Zip: Date of Survey: | 12/19/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 30206 SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The facility shall maintain a record in the facility for each resident, which shall include the following: (B) A review monthly or more frequently, if indicated, of the resident's general 2/17/23 condition and needs; a monthly weight in accordance to 19 CSR 30-86.047(58)(B) Resident 1 & 5 have an updated weight listed on their file. fs fe A4837 A task has been attached to ail residents requesting monthly weights. The task will alert care staff to obtain the resident's weight. An audit will be completed by the Wellness Director/Designee to ensure that all resident's have an updated weight on their file. The Weilness Director/Designee will run a monthly report to ensure each resident has a weight documented on their file. To monitor compliance, the Safety Committee will review any trends and/or actions brought to them by the Executive Director/DON/Designee for ongoing compliance monthly for three months and then quarterly. 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. PLAN OF CORRECTION proud }/Suppiler Oak Pointe of Monett Name: Street Address, . City, Zip: | 1011 Old Airport Road, Monett, MO 65708 Date of Survey: 42/19/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 30206 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Prior to allowing any person who has been hired in a full time, part time, or temporary position to have contact with any resident, the facility shall request a criminial background check for the person as provided in section 660.317, RSMo. Each 9/47/23 facility shail maintain documents verifying that the background A4711 checks were requested, the date of each request and the nature of the response received in accordance with 19 CSR 30- 86.047(13)(A RA A, Cook B, LIMA C, L1MAD, and L1MA E all have a criminal background check in their personnel file. An audit has been completed by the Executive Director/Designee of all employee personnel file to ensure each one has a background check. The Executive Director/Designee will review each new hire file to ensure the criminal background check has been requested, reviewed, and printed for their personnel file. To monitor compliance, the Safety Committee will review any trends and/or actions brought to them by the Executive Director/DON/Designee for ongoing compliance monthly for three months and then quarterly. — ;— 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.