OAK POINTE OF NEOSHO, A VIVA SENIOR LIVING COMMUNITY.

PRINTED: 12/22/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (42) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 42104/2023 29972 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 OAK RIDGE EXTENSION NEOSHO, MO 64850 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) OAK POINTE OF NEOSHO PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 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 potentially serious airborne bacterial infection affecting the lungs that spreads through the air when a person with TB coughs, sneezes, or talks) screening test was completed upon hire for four staff members (Care Givers A and C, Level One Medication Aide (LIMA) B, and Cook D) The facility census was 49. Review of 19 CSR 20-20.100 General Requirements for Tuberculosis Testing in Long-Term Care Facilities showed the following: -Long-term care facilities shall screen their staff for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test for tuberculosis) two-step tuberculin test within one month prior to starting employment; -If the initial test is zero to nine millimeters (mm), 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; -Each facility shall be responsible for ensuring that all test results are completed and documentation is maintained. Review of the facility's policy titled "Tuberculosis Testing,” updated 12/20/21, showed the following: Missouri Department of Health and Senior Services LABORA wai yor (X68) DATE continuation sheet 1 of 7 STATE FORM CJV611 PRINTED: 12/22/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 29972 I 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 OAK RIDGE EXTENSION NEOSHO, MO 64850 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF NEOSHO A4724| Continued From page 1 -The Director of Nursing (DON) will ensure that all staff have evidence of TB screening completed within 10 days of hire and before occupational exposure; -Ensure that all staff will have a documented baseline two-step tuberculin skin test or one blood assay for M.tuberclosis result. 1. Review of Care Giver A's personnel file showed the following: -Hire date of 07/26/23; -Start date of 08/01/23; -No TB screening form was in the file; -The personnel file did not show a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. 2. Review of LIMA B's personnel file showed the following: -Hire date of 11/22/23: -Start date of 11/30/23; -TB form with first step noted as given on 12/01/23; -Staff did not document results of the 12/01/23 test; -The personnel file did not show the facility administered the required initial two-step TB screening test upon hire or a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. Review of an email dated 12/04/23, at 7:14 P.M., from Administrator showed the nurse would not be coming in to read the results. (The test would be read in the 48 to 72 hour window.) 3. Review of Care Giver C's personnel file showed the following: Missouri Department of Health and Senior Services STATE FORM e009 CJV611 if con inua ion sheet 2 of 7 PRINTED: 12/22/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 29972 I 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 OAK RIDGE EXTENSION NEOSHO, MO 64850 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF NEOSHO A4724| Continued From page 2 -Hire date of 10/08/23; -Start date of 11/09/23; -TB screening form showed the first TB step given 10/27/23 and read negative on 10/29/23; -TB screening form showed the second TB step was given 11/17/23. Staff did not document any results for second step; -The personnel file did not show a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. 4. Review of Cook D's personnel file showed the following: -Hire date of 09/20/23; -Start date of 09/28/23; -TB screening form showed the first TB step given on 09/28/23 and read negative on 09/30/23; -TB screening form showed the second TB step given on 12/01/23 with no results noted; -The personnel file did not show a Mantoux PPD test in the past and at least one subsequent annual test within the past two years; 5. During an exit interview on 12/04/23, at 5:02 P.M. with the Assistant Administrator and the Administrator, the Administrator said he/she failed to ensure TB screening requirements were completed according to the facility's policy. A4776| 19 CSR 30-86.047(35) Protective Oversight STATE FORM e800 CuV611 if con inua ion sheet 3 of 7 PRINTED: 12/22/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 29972 I 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 OAK RIDGE EXTENSION NEOSHO, MO 64850 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF NEOSHO A4776| Continued From page 3 Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident's departure, of the resident ' s estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II This regulation is not met as evidenced by: Class Il Based on observation, interview, and record review, the facility failed to provide protective oversight for all residents when one resident (Resident #1) exited through the facility's unattended, unlocked, and unalarmed front door of the facility without the staffs knowledge. The facility census was 49. Review showed the facility did not provide a policy regarding how often staff are required to check on the residents or the policy regarding the front door being attended, locked, or alarmed. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -Admission date of 10/23/23; -Diagnoses included unspecified dementia-memory loss, behavioral changes, and other neurological problems. Review of the resident's "Pre-Screen and Community Based Assessment (CBA - a mandatory assessment tool completed by facility staff)," dated 10/18/23, showed the following: -The resident et point to be admitted to the STATE FORM e800 CuV611 if con inua ion sheet 4 of 7 PRINTED: 12/22/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 29972 I 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 OAK RIDGE EXTENSION NEOSHO, MO 64850 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF NEOSHO A4776| Continued From page 4 community; -Resident had wandering or confusion with some memory lapse. Wandering not intrusive. Review of Individualized Service Plan (ISP) dated 10/28/23 showed the following: -Wandering behavior; -Wanders in public areas, but not intrusive; -Re-direct as needed. Review of the resident's nurse's note dated 11/14/23, at 8:53 P.M., showed the Assistant Administrator documented the following: -Staff notified resident's guardian that facility received a phone call from a deputy sheriff stating that the resident was at the Newton County courthouse; -Guardian and Assistant Administrator arrived at the courthouse at the same time. The resident was sitting with three deputy officers in the lobby of the courthouse. The resident was relieved when he/she saw his/her family member and the staff member; -The resident was transported back to the facility via guardian's private vehicle. Review of the facility's investigation, dated 11/15/23, showed the following: -The facility received a phone call from a county deputy at 3:35 P.M. that resident was at Newton County Courthouse on the Neosho Square; -The Assistant Administrator notified guardian at 3:40 P.M. -The resident returned back to the community via family vehicle at 4:15 P.M. During an interview dent! at 12:30 P.M., the STATE FORM e800 CuV611 if con inua ion sheet 5 of 7 PRINTED: 12/22/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 29972 I 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 OAK RIDGE EXTENSION NEOSHO, MO 64850 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF NEOSHO A4776| Continued From page 5 Assistant Administrator said the following: -He/she reviewed the facility's security footage for 11/24/23; -At approximately 1:49 P.M., the resident walked out the front door with his/her books in his/her arms; -The front door was not alarmed or locked at the time the resident left the facility; -There were no staff at the front desk at the time the resident left through the front door; -Staff were not aware of the resident's elopement prior to the phone call from the deputy at the court house; -It was two miles to the court house; -The resident was out of the facility about two hours; -The facility does not have a policy regarding how often residents are checked on; -The resident was last seen by staff at lunch; -Staff were not at the front desk when the resident left. The care giver assigned to work the desk that day was at lunch when the resident left the facility. Observation on 12/05/23, at 8:30 A.M. showed the following: -The route to the courthouse was approximately two miles without sidewalks most of the way; -The route included having to cross a main street without a crosswalk, signal, or sidewalk; -The route included walking by railroad tracks with no side walk; -The route included walking through a round a bout with no crosswalk, signal, or side walk. During an interview on 12/04/23, at 11:00 A.M., Concierge E said the following: STATE FORM e800 CuV611 if con inua ion sheet 6 of 7 PRINTED: 12/22/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 29972 I 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2601 OAK RIDGE EXTENSION NEOSHO, MO 64850 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF NEOSHO A4776| Continued From page 6 -He/She heard from other staff that the resident exited through the front door; -He/she was doing activities the day of the elopement so they had Care Giver F at the front desk that day; -The family said the resident had eloped from a previous facility; -He/she had been told the door should be locked when unattended. During an interview on 12/04/23, at 1:15 P.M., the Wellness Director said the following; -She did the pre-screening for the resident prior to move in and her elopement score was a 10. A score of 12 or higher on the evaluation indicates they need a Memory Care unit; -She was not aware of a prior elopement history. During interviews on 12/04/23, at 12:30 P.M. and at 5:02 P.M., with Administrator and Assistant Administrator, the elopement due to the a lack of protective oversight. MO00227411 STATE FORM e800 CuV611 if con inua ion sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier Name; Oak Pointe of Neosho Street Address, ae 2601 Oak Ridge Extension, Neosho, MO 64850 City, Zip: Date of Survey: 12/4/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 29972 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Protective Oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at minimum, a procedure to inquire of the A4776 resident or resident's guardian of the resident's departure, of the 2/5/2024 resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave in accordance with 19 CSR 30-86.047(35) Protective Oversia This Plan of Correction is being submitted in accordance with State and Federal Regulations. The submission of this plan of correction does not constitute an admission by the provider of the alleged violations contained within the statement of deficiency. The submission of this plan of correction does not constitute admission by the provider that the alleged findings constitute a deficiency, or that the class determinations are correct. This plan of correction is intended to constitute the providers credible letter alleging compliance. 1, Resident #1 no longer resides at this community was transferred to with an available room on Memory Support 2. All Staff were re-educated regarding our elopement policy. All new staff are educated prior to the start of the first shift during orientation. All education documented and in associate file. Responsibility - DON and/or Designee 3. Front Door will remain locked when Concierge/Designee is away from the front desk. | 4. Executive Director and/or Designee to check front door randomly when Concierge and/or Designee is away from the front desk to ensure the door is locked. 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/Supgiter Oak Pointe of Neosho Name: Street Address, . . 2601 Oak Ridge Extension Neosho, MO 64850 City, Zip: Date of Survey: 12/4/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 29972 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The facility shall screen residents and staff for tuberculosis as 2/5/2024 required for long-term care facilities by 19 CSR 20-20.100 A TB Test will be conducted on all employees prior to their hire date. L1MA B, Caregiver C, and Cook D. An audit will be completed by the Executive Director/Designee to ensure that all current employees have a TB Test completed and on file A re-education has been provided to the Wellness Director by the Executive Director/Designee indicating that all employees must have a TB Test prior to hire date. The Executive Director/Designee will review the TB Filing Book to ensure that each newly hired employee's file has a TB Test completed. To monitor compliance, the Executive Director and/or the Wellness Director will conduct monthly reviews of the TB Book to ensure employees/residents are up to date. 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.