OAK RIDGE ASSISTED LIVING.

PRINTED: 02/25/2026 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 {X2) MULTIPLE CONSTRUCTION ABUILDING: 29711 BWING 02/18/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 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 CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.047(13)(A) Criminal Background 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the 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. II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to request a criminal background check (CBC) and document with the date of such request, prior to allowing three of five sampled employees (Nursing Staff A, Housekeeping Staff A, and Dietary Staff A) to have contact with residents. The facility census was 41. The facility did not provide a policy regarding CBC's. 1. Review of Nursing Staff A's personnel record showed: -A hire date of 11/13/2025; -His/Her first date of contact with residents indicated by his/her first clock in, was on 11/18/2025; -A CBC was not requested until 02/16/2026. 2. Review of Dietary Staff A's personnel record Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 D60B11 If continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER OAK RIDGE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 02/25/2026 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 02/18/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.047(13)(A) Criminal Background 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the 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. II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to request a criminal background check (CBC) and document with the date of such request, prior to allowing three of five sampled employees (Nursing Staff A, Housekeeping Staff A, and Dietary Staff A) to have contact with residents. The facility census was 41. The facility did not provide a policy regarding CBC's. 1. Review of Nursing Staff A's personnel record showed: -A hire date of 11/13/2025; -His/Her first date of contact with residents indicated by his/her first clock in, was on 11/18/2025; -A CBC was not requested until 02/16/2026. 2. Review of Dietary Staff A's personnel record Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 D60B11 If continuation sheet 1 of 4 PRINTED: 02/25/2026 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 02/18/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK RIDGE ASSISTED LIVING Continued From page 1 showed: -A hire date of 09/27/2025: -His/Her first date of contact with residents indicated by his/her first clock in, was on 10/02/2025; -A CBC was not requested until 02/16/2026. 3. Review of Housekeeping Staff A's personnel record showed: -A hire date of 07/18/2025; -His/Her first date of contact with residents indicated by his/her first clock in, was on 07/20/2025; -A CBC was not requested until 07/29/25, after the employee had already begun having contact with residents. During an interview on 02/18/2025, at 1:20 P.M., the Administrator said: -The Business Office Manager were in charge of completing CBC checks on employees at the time of hire; -She expected all staff to have a CBC completed and in their file prior to or within 3 days of the first day of employment. 19 CSR 30-86.047(13)(B) EDL Inquiry 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as provided in section 660.315, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the Missouri Department of Health and Senior Services STATE FORM 6899 D60B11 If continuation sheet 2 of 4 PRINTED: 02/25/2026 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 02/18/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK RIDGE ASSISTED LIVING Continued From page 2 EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department 's website; II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to make an inquiry to the department whether a person was listed on the Employee Disqualification List (EDL) and document such requests, prior to allowing three of five sampled employees (Nursing Staff A, Housekeeping Staff A, and Dietary Staff A) to have contact with residents. The facility census was 41. The facility did not provide a policy regarding EDL checks. 1. Review of Nursing Staff A's personnel record showed: -A hire date of 11/13/2025; -His/Her first date of contact with residents indicated by his/her first clock in, was on 11/18/2025; -An EDL check was not requested until 02/16/2026. 2. Review of Dietary Staff A's personnel record showed: -A hire date of 09/27/2025: -His/Her first date of contact with residents indicated by his/her first clock in, was on 10/02/2025; -An EDL check was not requested until 02/16/2026. 3. Review of Housekeeping Staff A's personnel Missouri Department of Health and Senior Services STATE FORM 6899 D60B11 If continuation sheet 3 of 4 PRINTED: 02/25/2026 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 02/18/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK RIDGE ASSISTED LIVING Continued From page 3 record showed: -A hire date of 07/18/2025: -His/Her first date of contact with residents indicated by his/her first clock in, was on 07/20/2025; -An EDL check was not requested until 07/29/25, after the employee had already begun having contact with residents. During an interview on 02/18/2026, at 1:20 P.M., the Administrator said: - Business Office Manager was in charge of completing EDL checks on employees at the time of hire; -She expected all staff to have an EDL check completed and in their file prior to or within 3 days of the first day of employment. * The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 D60B11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: Oak Ridge Assisted Living & Memory Care Street Address, 403 Crispin St. City, Zip: Richmond, MO 64085 February 18',2026 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Criminal Background Check Requirements: Background and nite EDL must be ran within 2 days of hiring the new employee. peuRIee On February 16, 2026, the Executive Director conducted a comprehensive audit of all employee personnel records after BOM no showed. During this audit, errors were identified related to documentation of Criminal Background Checks (CBC) and Family Care Safety Registry (FCSR) verification. Date of Survey: At the time of the audit, this community did not have direct access to run CBC/FCSR reports. Per company procedure, these reports were requested through the corporate office at Shirkey’s Nursing and Rehabilitation Payroll Department. It was identified that this process was not consistently completed or documented in the personnel files. Corrective Action for Affected Employees: All current employee background checks were immediately reviewed and verified. All employees were confirmed to have completed background screenings and were found to be free of disqualifying criminal records. All personnel files were corrected and updated to include the required documentation as of March 6, 2026. No residents or staff were placed at risk. Systemic Changes to Prevent Recurrence: To ensure compliance moving forward, the following processes have been implemented: « A New Hire Personnel File Checklist was created and implemented to ensure all required documentation, including CBC, FCSR, EDL, and E-Verify verification, is completed and documented prior to orientation or working on the floor. The checklist has been reviewed with the Business Office Manager (BOM) and implemented immediately. * A new company policy was implemented on March 4, 2026, stating that all employee orientations will occur on Wednesdays only. This policy ensures there are at least two days between hiring and the employee start date, allowing adequate time for background checks and all required documentation to be completed and verified. * When a hiring manager completes an interview and selects a candidate for hire, the completed application and new hire information will be provided to the Business Office Manager (BOM). The BOM will determine the next available Wednesday orientation date and notify the hiring manager. The hiring manager will then schedule orientation and the employee’s first shifts. * The BOM will complete the New Hire Checklist and submit it to the Executive Director (ED) for review prior to orientation. Monitoring: The Executive Director will review all new employee personnel files each Tuesday prior to Wednesday orientation to ensure CBC, FCSR, EDL, and E-Verify documentation are present and accurate. No employee will be allowed to attend orientation until the Executive Director signs off verifying that all required documentation is complete. Additional Corrective Measure: A request has been submitted for this community to obtain direct CBC/FCSR system access to allow background checks to be completed immediately onsite. This request is currently pending. Until system access is granted, all new hire paperwork will continue to be submitted to Shirkey’s Nursing and Rehabilitation Payroll Department for background check processing, and employees will not be permitted to begin orientation or work until verification has been received and documented. Completion Date: March 6, 2026 On February 16, 2026, the Executive Director conducted a comprehensive audit of all employee personnel records. During this audit, documentation errors were identified related to Employee Disqualification List (EDL) inquiries within several personnel files. The review determined that EDL inquiries had not been consistently documented in employee files at the time of hire. All current employees were immediately reviewed to verify they were not listed on the Missouri Employee Disqualification List. Corrective Action for Affected Employees: All employee EDL inquiries were immediately completed or verified and documentation was placed in the personnel files. All employees were confirmed not to be listed on the Employee Disqualification List, and all personnel files were corrected and brought into compliance as of March 6, 2026. No residents or staff were placed at risk. Systemic Changes to Prevent Recurrence: * A New Hire Personnel File Checklist has been created and implemented to ensure all required documentation, including EDL inquiry verification, CBC/FCSR, and E- Verify, are completed prior to orientation or the employee working on the floor. The checklist has been reviewed with the Business Office Manager (BOM) and implemented immediately. * Anew company policy was implemented on March 4, 2026, stating that all employee orientations will occur on Wednesdays only. This ensures there are at least two days between hiring and orientation, allowing sufficient time for required background checks and EDL verification. * When a hiring manager selects a candidate for hire, the completed application and new hire information will be provided to the Business Office Manager (BOM). The BOM will determine the next available Wednesday orientation date and notify the hiring manager. The hiring manager will then schedule the employee for orientation and their first scheduled shifts. * The BOM will complete the New Hire Personnel Checklist, ensuring EDL inquiry documentation is present, and submit the file to the Executive Director (ED) for review prior to orientation. Monitoring: The Executive Director will review all new employee personnel files each Tuesday prior to Wednesday orientation to verify that all required documentation, including EDL inquiry verification, CBC/FCSR documentation, and E-Verify confirmation, are present and accurate. No employee will be allowed to attend orientation until the Executive Director signs off verifying that all required documentation is complete. Completion Date: March 6, 2026 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: 09/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 08/19/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5) 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) A4777 19 CSR 30-86.047(36) Proper Care Per A4?777 Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. I/II _ This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to provide proper care as defined in the individualized service plan (ISP), when Resident Assistant (RA) A performed a mechanical lift on Resident #1, by himself/herself which resulted in a fall and injury. The facility census was 47. Review of the facility's undated policy titled "Hoyer (mechanical) Lift Use" showed: -The mechanical lift was to be used only by trained staff; -At no time were mechanical lifts to be used without proper training or alone; -Two trained staff members were required for all mechanical transfer; -Staff were to demonstrate knowledge of equipment use, sling placement, and emergency procedures during on the job training. | 1. Review of Resident #1's record showed: -Diagnoses included: heart failure, depression, and dementia (a progressive decline in mental ability that interferes with daily life, affecting memory, thinking, and behavior). Review of the resident's individual service plan dated 03/11/25 showed: -The resident was a two person assist for all transfers; -Staff were to utilize a mechanical lift for all transfers. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE If canlinuation sheet 1 of 6 “ou ATE FORM Bons 62JL11 PRINTED: 09/02/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: C 08/19/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION x6) 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 RIDGE ASSISTED LIVING A4777 | Continued From page 1 A4777 Review of Resident #1's current physician's orders for August 2025 showed as of 12/27/24 the resident required a mechanical lift by two staff for all transfers. Review of a progress note for Resident #1 dated 07/28/25 showed: -RAAwas putting Resident #1 in a mechanical lift , Sling to transfer, when RA C heard a loud bang from outside the room followed by RAA yelling for help; -Upon RAC entering Resident #1's room, he/she | found Resident #1 on the floor under the mechanical lift with one strap of the sling not | attached to the lift. During an interview on 08/19/25 at 11:50 A.M., RAA said: -He/She performed a mechanical lift on Resident #1 by himself/herself despite other staff being available to assist; -He/She placed Resident #1 in the sling, and had only began lifting the resident from his/her wheelchair when one of the straps of the sling slipped from the lift hooks, causing Resident #1 to fall out of the sling to his/her knees; - Resident #1 ultimately hit his/her head during the incident, leaving a large laceration which required staples; -He/She knew Resident #1 was a two person | transfer with the mechanical lift, but was trying to get things done quickly and did not wait for help _ like he/she should have. During an interview on 08/19/25 at 10:30 A.M. the Administrator said: -He/She expected all residents transferred with the mechanical lift to be conducted by two trained | staff; -He/She expected all staff to provide care to Missouri Department of Health and Senior Services STATE FORM 6899 62JL11 If continuation sheet 2 of 6 PRINTED: 09/02/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 08/19/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (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 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4777| Continued From page 2 A4777 residents in accordance to their ISP. MO257588 A4860) 19 CSR 30-86.047(65)(A) Safe Transfers A4860 Training Requirements Requirements for training related to safely transferring residents. (A) The facility shall ensure that all staff responsible for transferring residents are appropriately trained to transfer residents safely. Individuals authorized to provide this training | include a licensed nurse, a physical therapist, a physical therapy assistant, an occupational therapist or a certified occupational therapy assistant. The individual who provides the | transfer training shall observe the caregiver's skills when checking competency in completing safe transfers, shall document the date(s) of training and competency and shall sign and maintain training documentation. Initial training shall include a minimum of two (2) classroom instruction hours in addition to the on-the-job training related to safely transferring residents who need assistance with transfers. II/III This regulation is not met as evidenced by: Class II* “Higher classification merited due to the extent of the violation. Based on interview and record review, the facility failed to document and ensure that staff who were responsible for transferring residents, were _ appropriately trained and competency was checked in safe transfers. This affected one of one sampled residents (Resident #1). The facility Missouri Department of Health and Senior Services STATE FORM 6699 62JL11 If continuation sheet 3 of 6 PRINTED: 09/02/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: C 08/19/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (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 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4860 | Continued From page 3 A4860 census was 47. Review of the facility's undated policy titled "Hoyer (mechanical) Lift Use" showed: -The mechanical lift was to be used only by trained staff; -At no time were mechanical lifts to be used without proper training or alone; -Two trained staff members were required for all mechanical transfers; -Staff were to demonstrate knowledge of equipment use, sling placement, and emergency procedures during on the job training. 1. Review of Resident #1's record showed: -Diagnoses included: heart failure, depression, and dementia (a progressive decline in mental ability that interferes with daily life, affecting memory, thinking, and behavior). Review of Resident #1's individual service plan dated 03/11/25 showed: -The resident was a two person assist with all mechanical lifts. Review of Resident #1's current physician's | orders for August 2025 showed as of 12/27/24 the resident required a mechanical lift by two staff for all transfers. Review of a progress note for Resident #1 dated 07/28/25 showed: -Resident Assistant (RA) A placed Resident #1 in a mechanical lift sling to transfer him/her, when RAB heard a loud bang from outside the room followed by RAA yelling for help; -Upon RAB entering Resident #1's room, he/she found Resident #1 on the floor under the mechanical lift with one strap of the sling unattached to the lift; Missouri Department of Health and Senior Services STATE FORM 6899 62JL11 If continuation sheet 4 of 6 PRINTED: 09/02/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 08/19/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (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 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4860! Continued From page 4 A4860 , Review of an Incident Report dated 07/28/25 showed: -RAAwas putting Resident #1 in a mechanical lift sling when RAC heard a loud bang, RAA yelling for help, and upon RAC entering Resident #1's room, found the resident on the floor under the mechanical lift with one strap not attached and the resident's head bleeding; -The resident went to the local hospital for evaluation, and received staples for the laceration to his/her head; -Neurological assessments were resumed upon the resident's return from the hospital later that evening. Review of RAA employee record showed: -He/She was hired on 05/06/25; -No orientation checklist was found to indicate transfer training had been completed. During an interview on 08/19/25 at 11:50 A.M., RAA said: -He/She performed a mechanical lift transfer with Resident #1 by himself/herself despite other staff being available to assist: -He/She had completed this type of transfer at past jobs, but was never educated or trained on this facility's policies regarding mechanical lifts requiring two people; -He/She had never used a mechanical lift like the one at this facility -He/She started working at the facility within the last 3 months; -Upon hire, he/she did not receive training for proper transfers, nor were his/her past skills checked for competency . During an interview on 08/19/25 at 10:58 A.M. RA B said: Missouri Department of Health and Senior Services STATE FORM 6899 62JL11 If continuation sheet 5 of 6 PRINTED: 09/02/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 08/19/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (X4) ID 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) A4860| Continued From page 5 | A4860 -He/She learned proper transferring during Certified Nursing Aide (CNA) training, but was " never trained or skills checked for competency upon hire to this facility; -He/She knew residents transferred with the mechanical lift should be completed by two trained staff. During an interview on 08/19/25 at 10:30 A.M. the Administrator said: -RAA did not receive any formal transfer training upon hire to the facility; -Training for safe transfers was gone over in an all staff meeting on 05/21/25, amongst many other topics; -The facility did not have a formal orientation training checklist for newly hired staff; -He/She expected all residents transferred by a mechanical lift to be conducted by two trained staff. M0O257588 Missouri Department of Health and Senior Services STATE FORM 6299 62JL11 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Neve: Oak Ridge Assisted Living Street Address, City, Zip: 403 Crispin St. Richmond, MO 64067 Date of Survey: 08/19/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER-- 26D2198433 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A4860 Safe Transfers Training Requirements: This deficiency resulted in a possible potential to harm any resident that receives assistance with a transfer. One resident was harmed resulting in a fall with a Hoyer lift transfer. The resident was sent to the ED at Ray County Memorial Hospital and received CT scan with a negative result and stitches. Resident returned to Oak Ridge and was then monitored by Shirkey Hospice and Oak Ridge staff to determine no further concerns or negative outcome to the resident. This was investigated upon survey of self report. A Safe Transfer Training Checklist has been developed by the ED, DON and Therapy Team (Shirkey Premiere Therapy- COTA and PTA)-- whom we contract through for all therapy services and training, and will be attached to this submission. All new hires must complete Safe Transfer Training during orientation before working alone with residents and will be signed off by HR and filed with each employees record. The training will be completed by an LPN or Memory Care Coordinator (CMT) whom has completed the training. An annual refresher training will be required for all hands-on staff provided by DON and/or Therapy Company. Training records will be maintained in employee files and audited quarterly. Supervisors (DON and MCC) will conduct random observations to ensure transfer techniques are being followed throughout to ensure others are not affected by the same deficient practice. This was done with current employees on the dates of 8/18/25-8/25/25 and will be completed with each new hire before hands on care as listed above. Proper Care Per Individual Service Plans: This deficiency resulted in a possible potential to harm any resident as all residents have an ISP, which is re-assessed and new one completed every 6 months as regulated. One resident was harmed resulting in a fall with a Hoyer lift transfer. The resident was sent to the ED at Ray County Memorial Hospital and received CT scan with a negative result and stitches. Resident returned to Oak Ridge and was then monitored by Shirkey Hospice and Oak Ridge staff to determine no further concerns or negative outcome to the resident. This was investigated upon survey of self report. All current ISPs have been reviewed and updated for accuracy by DON and ED, whom are both CBA certified. A change was made and instead of keeping ISP's in the residents individual charts, ISPs are now stored in a centralized binder located in the staff workroom, accessible to all care staff at all times. A Running Service Plan Summary Sheet has been created and will be attached to this submission. This sheet includes:Resident transfer methods (e.g., one-person assist, gait belt, mechanical lift). Dietary requirements (e.g., diabetic, low-sodium, texture modifications). Medication administration instructions (e.g., time-sensitive meds, PRNs). Incontinence care protocols (e.g., scheduled toileting, product use). ISPs will be reviewed monthly by the DON. Any changes in resident condition will trigger an immediate ISP update. Staff will sign off monthly to confirm review of ISP binder and summary sheet. This was completed on 8/21/2025 and will be an ongoing audit and assessment as listed above. 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: 06/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED B. WING 29711 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (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 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.047(13)(A) Criminal Background 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the 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. II This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to request a criminal background check (CBC) and document with the date of such request, prior to allowing four of four sampled employees (Nursing Staff A, Nursing Staff B, Nursing Staff C, and Nursing Staff D) to have contact with residents. The facility census was 48. The facility did not provide a policy regarding CBC's. 1. Review of Nursing Staff A's personnel record showed: -A hire date of 8/4/24, -His/Her first date of contact with residents indicated by his/her first clock in, was on 8/8/24: -A CBC was not requested until 8/15/24, after the employee had already begun having contact with residents. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ; TITLE {X6) DATE If continuation sheet 1 of 4 STATE FORM I99N11 PRINTED: 06/16/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (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 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 1 2. Review of Nursing Staff B's personnel record showed: -A hire date of 12/2/24: -His/Her first date of contact with residents indicated by his/her first clock in, was on 12/11/24: -There was no CBC on file. 3. Review of Nursing Staff C's personnel record showed: -A hire date of 1/27/25; -His/Her first date of contact with residents indicated by his/her first clock in, was on 1/27/25; -A CBC was not requested until 5/13/25, after the employee had already begun having contact with residents. 4. Review of Nursing Staff D's personnel record showed: -A hire date of 5/6/25; -His/Her first date of contact with residents indicated by his/her first clock in, was on 5/6/25; -A CBC was not requested until 5/12/25, after the employee had already begun having contact with residents. During an interview on 6/5/25, at 1:45 P.M., the Administrator said: -The Business Office Manager were in charge of completing CBC checks on employees at the time of hire; -She expected all staff to have a CBC completed and in their file prior to or within 3 days of the first day of employment. 19 CSR 30-86.047(13)(B) EDL Inquiry Prior to allowing any person who has been hired Missouri Department of Health and Senior Services STATE FORM 699 I99N11 If continuation sheet 2 of 4 PRINTED: 06/16/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 ! OAK RIDGE ASSISTED LIVING (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (%5) 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) Continued From page 2 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as provided in section 660.315, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department's website: II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to make an inquiry to the department whether a person was listed on the Employee Disqualification List (EDL) and document such requests, prior to allowing three of four sampled employees (Nursing Staff A, Nursing Staff B, and Nursing Staff C) to have contact with residents. The facility census was 46. The facility did not provide a policy regarding EDL checks. 1. Review of Nursing Staff A's personnel record | showed: -A hire date of 8/4/24: -His/Her first date of contact with residents indicated by his/her first clock in, was on 8/8/24; -An EDL check was not requested until 8/15/24, after the employee had already begun having contact with residents. Missouri Department of Health and Senior Services STATE FORM 6699 I99N11 If continuation sheet 3 of 4 PRINTED: 06/16/2025 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 OAK RIDGE ASSISTED LIVING (x4) ID 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) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 3 2. Review of Nursing Staff B's personnel record showed: -A hire date of 12/2/24: -His/Her first date of contact with residents indicated by his/her first clack in, was on 12/11/24: -An EDL check was not requested until 12/16/24, after the employee had already begun having contact with residents. 3. Review of Nursing Staff C's personnel record showed: -A hire date of 1/27/25; -His/Her first date of contact with residents indicated by his/her first clock in, was on 1/27/25; -An EDL check was not requested until 1/31/25, after the employee had already begun having contact with residents. During an interview on 6/5/25, at 1:45 P.M., the Administrator said: - Business Office Manager was in charge of completing EDL checks on employees at the time of hire; -She expected all staff to have an EDL check completed and in their file prior to or within 3 days of the first day of employment. * The higher classification merited due to the severity of the regulatory non-compliance. Missouri Department of Health and Senior Services STATE FORM ase 199N11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier | oak Ridge Assisted Living Name: Street Address, City, Zip: 403 Crispin St. Richmond, MO 64085 Date of Survey: 06/05/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER (| PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Criminal Background Check Requirements: This issue was identified during an audit on May 15, 2025 with current Business Office Manager and a Performance Improvement Plan (PIP) was put in place and signed by both the ED and BOM (attached). There was no harm found to any of the residents and all staff met regulation and background/EDL screenings as necessary. This PIP was presented at Survey and includes the following: With a new Business Office Manager hired and in place as of 06/10/25 June 10", 2025: All new and current employees will have a checklist of required documents before hire to be done by the BOM. This checklist includes the background screening request ID PREFIX TAG A4711 date and the folder will be submitted to ED each time for 3 months and then a spot check of 10% of new hires thereafter. Before oncoming employees are allowed contact with residents the ED will have to sign the checklist too. This checklist has been updated and in place as of 6/10/25. EDL Testing Requirements: This issue was identified during an audit on May 15, 2025 with current Business Office Manager and a Performance Improvement Plan (PIP) was put in place and signed by both the ED and BOM (attached). There was no harm found to any of the residents and all staff met regulation and background/EDL screenings as necessary. This PIP was presented at Survey and includes the following: With a new Business Office Manager hired and in place as of June 10", 2025: All new and current employees will have a checklist of required documents before hire to be done by the BOM. This checklist includes the EDL inquiry request date and the folder will be submitted to ED each time for 3 months and then a spot check of 10% of new hires thereafter. Before oncoming employees are allowed contact with residents the ED will have to sign the checklist too. This checklist has been updated and in place as of 6/10/25. 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. A4714 06/10/25

PRINTED: 04/22/2024 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 Be AMING a 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL } {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK RIDGE ASSISTED LIVING 19 CSR 30-86.047(13)(A) Criminal Background 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: ; (A) Request a criminal background check for the 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. II This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to request a criminal background check (CBC) and document with the date of such request, prior to allowing three of three sampled employees (Housekeeper A, Nursing Staff A, and Nursing Staff B) to have contact with residents. The facility census was 48. The facility did not provide a policy regarding CBC's. 1. Record review on 04/18/24 of Housekeeper A's personnel record showed: -A hire date of 07/24/23; -His/Her first date of contact with residents indicated by his/her first clock in, was on 07/26/24; -A CBC was not requested until 07/27/23, after the employee had already begun having contact with residents. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROYIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE = (X6) DATE LL #12) {24/24 STATE FORM CP2Y11 If continuation sheel 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER OAK RIDGE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 04/22/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 04/18/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.047(13)(A) Criminal Background 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the 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. II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to request a criminal background check (CBC) and document with the date of such request, prior to allowing three of three sampled employees (Housekeeper A, Nursing Staff A, and Nursing Staff B) to have contact with residents. The facility census was 48. The facility did not provide a policy regarding CBC's. 1. Record review on 04/18/24 of Housekeeper A's personnel record showed: -A hire date of 07/24/23; -His/Her first date of contact with residents indicated by his/her first clock in, was on 07/26/24; -A CBC was not requested until 07/27/23, after the employee had already begun having contact with residents. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CP2Y11 If continuation sheet 1 of 4 PRINTED: 04/22/2024 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 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK RIDGE ASSISTED LIVING Continued From page 1 2. Record review on 04/18/24 of Nursing Staff A's personnel record showed: -A hire date of 10/13/23; -His/Her first date of contact with residents indicated by his/her first clock in, was on 10/13/23; -A CBC was not requested until 10/13/23, the date Nursing Staff A began contact with residents. 3. Record review on 04/18/24 of Nursing Staff B's personnel record showed: -A hire date of 08/28/23; -His/Her first date of contact with residents indicated by his/her first clock in, was on 08/28/23; -A CBC was not requested until 08/30/23, after the employee had already begun having contact with residents. During an interview on 04/18/24, at 2:05 P.M., the Director said: -The Assistant Administrator and Business Office Manager were in charge of completing CBC checks on employees at the time of hire; -She expected all staff to have a CBC completed and in their file prior to or within 3 days of the first day of employment. 19 CSR 30-86.047(13)(B) EDL Inquiry 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 from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as Missouri Department of Health and Senior Services STATE FORM 6899 CP2Y11 If continuation sheet 2 of 4 PRINTED: 04/22/2024 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 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 403 CRISPIN STREET RICHMOND, MO 64085 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK RIDGE ASSISTED LIVING Continued From page 2 provided in section 660.315, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department's website; II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to make an inquiry to the department whether a person was listed on the Employee Disqualification List (EDL) and document such requests, prior to allowing three of three sampled employees (Housekeeper A, Nursing Staff A, and Nursing Staff B) to have contact with residents. The facility census was 48. The facility did not provide a policy regarding EDL checks. 1. Record review on 04/18/24 of Housekeeper A's personnel record showed: -A hire date of 07/24/23: -His/Her first date of contact with residents indicated by his/her first clock in, was on 07/26/24; -An EDL check was not requested until 07/27/23, after the employee had already begun having contact with residents. 2. Record review on 04/18/24 of Nursing Staff A's personnel record showed: -A hire date of 10/13/23; -His/Her first date of contact with residents indicated by his/her first clock in, was on 10/13/23; Missouri Department of Health and Senior Services STATE FORM 6899 CP2Y11 If continuation sheet 3 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER 403 CRISPIN STREET OAK RIDGE ASSISTED LIVING RICHMOND, MO 64085 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 3 -An EDL check was not requested until 10/13/23, the date Nursing Staff A began contact with residents. 3. Record review on 04/18/24 of Nursing Staff B's personnel record showed: -A hire date of 08/28/23: -His/Her first date of contact with residents indicated by his/her first clock in, was on 08/28/23; -An EDL check was not requested until 08/30/23, after the employee had already begun having contact with residents. During an interview on 04/18/24, at 2:05 P.M., the Director said: -The Assistant Administrator and Business Office Manager were in charge of completing EDL checks on employees at the time of hire; -She expected all staff to have an EDL check completed and in their file prior to or within 3 days of the first day of employment. * The higher classification merited due to the severity of the regulatory non-compliance. Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: CP2Y11 PRINTED: 04/22/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/18/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 4 of 4 - PLAN OF CORRECTION Provider/Supplier Name: Oak Ridge Assisted Living & Memory Care Street Address, City, Zip: 403 Crispin St. Richmond, MO 64085 Date of Survey: 04/18/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Criminal Background Check Requirements: all new employees will have a checklist of required documents before hire. This checklist will include Background screening request date and this will be double checked by the business office manager before contact with residents has taken place. This system will be checked by the Administrator monthly for 3 months, then every other month for 4 months and 10 % of all new employees quarterly there after. The check list is attached and has been in place as of 04/19/2024. A4711 EDL Testing Requirements: all new employees will have a checklist of required documents before hire. This checklist will include EDL inquiry request date and this will be double checked by the business office manager before contact with residents has taken place. This system will be checked by the Administrator monthly for 3 months, then every other month for 4 months and 10 % of all new employees quarterly there after. The check list is attached and has been in place as of 04/19/2024. A4714 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.