Oak Pointe of Rolla, a Viva Senior Living Community.

ti te O34 V/2025 + PETE PTY Ss BE UEIE 1960 FAST LIONS CLUB DRIVE ROLLA, MO 65401 (4) 10 SUMMARY NTATEL AR NT OD OE RICE NEES PPE ELK HATH GAP ICH Ry MM yee CEE D We FL o} Tan CPG GLATE RY OR USI MEM TIE YONG INE ORMATE OAK POINTE OF ROLLA 42264 19 CSR 30 66 022(10K1) Smake Section 2264 , Parttions > than 20 veds Protection fram Hazards (Ui In facies whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilites licensed after August 28 2007 each smoke sectian shall be separated by one- (1-) hour fire-rated smoke parttons The smoke partilions shall be continuous from outside | : wall-to-outside wall and fram floor-to-floor ar floor-te-roofdeck All doors in this wall shall be at igast twenty- {20-} minute fire-rated or its | equivalent self-closing, and may be held open _ only if the door closes automatically upon activation of the complete fire alarm system || This regulation 1s not met as evidenced by Class || ' Based an observation and interview during the fire safety inspection process, the facility. | sed ater Necember 31 1987 for more than ny (20) beds. failed to ensure doars ina sake parttian shall be self-closing The facility | census was forty-five This deficiency affects forty-fhve of forty-five residents feet | Onservation of a smoke partitian door next to recto 124 ravealad that the smoke daor is not } completely an ts Own doors fairy to close will allow smoke and “shy toread to other areas of the gupenrsar advised ti yo staff and would cep-air ‘ade A&als Stim a ra lv) f f a i fH / ; ra. Vip ncn Det LM AEF x PRINTED: 03/12/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREEI ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (FACH DEFICIENCY MUST BE PRECEOED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG RFGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK POINTE OF ROLLA A2269 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such | facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on record review and interview during the fire safety inspection process, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was forty-five. This deficiency affects forty-five of forty-five residents. Record review revealed deficiencies in the fire sprinkler report. There have been no documented corrections. During the exit interview on March 11, 2025 at 1445, the maintenance supervisor advised he | would have the sprinkler campany make repairs. | A2298) 19 CSR 30-86.022(17) Oxygen Storage | Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. I/II | | This regulation is not met as evidenced by: | Class Ill Missouri Department of Health and Senior Services STATE FORM saa9 LQBN11 If conlinuation sheet 2 of § PRINTED: 03/12/2025 FORM APPROVED Missouri Department of Health and Senior Services STAIEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECIION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31216 ee 03/11/2025 NAMF OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATF, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (X4) ID SUMMARY STATEMENT OF DEFICICNCIES PROVIDER'S PLAN OF CORRECTION (%5) PREFIX (EACH DEFICIENCY MUST BE PRECEDCD BY FUL (EACH CORRECIIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK POINTE OF ROLLA A2298 Continued From page 2 Based on observation and interview during the fire safety inspection process, the facility failed to store portable compressed gas cylinders in accordance with NFPA 99, 1999 Edition, The facility census was forty-five. This deficiency affects forty-five of forty-five residents. Observation revealed there was no signage indicating the use of oxygen in the room 115 During the exit interview on March 11, 2025 at 1455, the maintenance supervisor advised he would place a sign on the door. A3214) 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shal! be installed and maintained in accordance with the requirements of the National Electrica! Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes, This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Cade, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. IIflll Missouri Department of Health and Senior Services STATE FORM 6389 LOQBN11 If continuation sheet 3 af 5 PRINTED: 03/12/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMEN| OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED 31216 8. WING 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATF, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (X4) ID SUMMARY STATEMENT OF DEPICIENCIES PROVIDER'S PLAN OF CORRECTION (X9) PREFIX (EACH DEFICIENCY MUST BE PRECEDED AY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE | DEFICIENCY) OAK POINTE OF ROLLA Continued From page 3 This regulation is not met as evidenced by: Class lil Based on observation and interview during the fire safety inspection process, the facility failed to | ensure the facility's electric wiring was praperly maintained. The facility census was forty-five. This deficiency affects forty-five of forty-five residents. Record review revealed no current electrical wiring certificate. During the exit interview on December 16, 2024 at 1500, the maintenance man stated he find the report or have another inspection.. 19 CSR 30-86,032(18) Extensian Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance | approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cards are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II’tll This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process, the facility failed to ensure only one appliance shall be connected to Missouri Department of Health and Senior Services STATE FORM cag LQBN11 IFcontinuation sheet 4 of 5 PRINTED: 03/12/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES 041) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B. WING 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ACDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (x4) ID | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (x5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK POINTE OF ROLLA A3219 Continued From page 4 one extension cord and only two electrical appliances may be served by one duplex receptacle. The facility census was forty-five. This deficiency affects forty-five of forty-five residents. Observation revealed a multiplug being used as permanent wiring in room 103. Observation revealed an extension cord being used as permanent wiring in room K During the exit interview on March 11, 2025 at 1505, the maintenance supervisor advised he would remove them. Missouri Department of Health and Senior Services STATE FORM ane LQBN11 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Oak Painte of Rolla Name: Street Address, City, Zip: 1000 E Lions Club Drive, Rolla MO 65401 Date of Survey: 3/11/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 31216 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2264 19 CSR 30-86.022(10)(1} Smoke Section Partition 3/11/25 Smoke Partition Door next to roam 123 has been adjusted and is closing properly All Smoke Partition Doors are checked monthly during each fire drill. Fire Drill completed on 3/11/25 at 1:40pm showed that Smoke Partition Door next to room 123 did not close properly and was placed on Fire Drill Report to be corrected. The Executive Director/Designee will review each Fire Drill Report after each drill to ensure all doors are working properly. To monitor compliance, the Executive Director/Maintenance Director/Designee will review fire drills monthly 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 Street Address, City, Zip: Date of Survey: Oak Pointe of Rolla 1000 E Lions Club Drive, Ralla MO 65401 3/11/2025 ID PREFIX TAG A2269 Maintenance/Testing 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(11)(B) Sprinkler System 31216 COMPLETION DATE 4/9/2025 Semi-Annual Wet & Dry System Insp-Semi-Annual Nitrogen Generator was conducted on 1/27/2025 with a deficiency in that Filters on the Nitrogen Generator were due. Mainline placed order for Filters on 2/3/25. Mainline followed up with supplier on 3/6/25 and filters were scheduled to ship on 3/12/25. All Sprinkler System Inspection Reports will be reviewed by the Executive Director/Maintenance Director and deficiencies will be corrected. The Executive Director/Maintenance Director will put deficiencies in the TELS System to be monitored for completion. To monitor compliance, the Safety Committee will review Sprinkler Inspection Reports brought to them by the Executive Director/Maintenance Director/Designee for ongoing compliance. SEE PLAN OF CORRECTION Provider/Supplier Name: Oak Pointe of Rolla Street Address, , " 1000 E Lions Club Drive, Rolla MO 65401 City, Zip: Date of Survey: 3/11/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 31216 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2298 19 CSR 30-86.022(17) Oxygen Storage Requirements 3/11/25 Room 115 now has a sign indicating Oxygen in use. Maintenance Director/Designee will inspect rooms monthly for oxygen use and place sign on door. The Executive Director/DON/Designee will notify Maintenance Director when a resident is placed on oxygen so proper signage is placed on door. An audit will be completed by the Executive Director/Designee to ensure all residents with oxygen orders has the proper signage on their door. PLAN OF CORRECTION Provider/Supplier Name: Oak Pointe of Rolla Street Address, City, Zip: 1000 E Lions Club Drive, Rolla MO 65401 Date of Survey: 3/11/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 31216 COMPLETION DATE 3/11/25 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 19 CSR 30-86.032(13) Electrical Wiring A3214 Annual Electrical Wiring Inspection completed on 5/13/24. Annual Electrical Wiring Inspection is scheduled in TELS to ensure it is completed. Documents to be uploaded upon completion. rnp EEE TELS is monitored by the Executive Director/Maintenance Director to ensure inspections are complete and done timely TELS will be reviewed by the Executive Director/Maintenance Director/Designee to ensure all inspections complete and documents uploaded. PLAN OF CORRECTION Provider/Supplier Oak Pointe of Rolla Name: Street Address, . : 1000 E Lions Club Drive, Rolla MO 65401 City, Zip: Date of Survey: 3/11/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 31216 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A3219 19 CSR 30-86.032(18) Extension cords/Duplex Receptacles Multiplug has been removed from room 103 and extension cord 3/11/25 has been removed in MC K Maintenance Director/Housekeeper/Designee will inspect rooms monthly for improper use of multiplugs and extension cords. The Executive Director/Maintenance Director/Designee will meet with all new admissions to ensure they understand and only bring approved extension cords. =_— An audit will be completed by the Executive Director/Maintenance Director/Designee to ensure all rooms are incompliance with Extension Cords.

PRINTED: 02/23/2024 FORM APPROVED Missouri Depariment of Health and Senior Services SYATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIF‘CATION NUMBER: {X2] MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 02/06/2024 31216 B WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (44) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION _ mon PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY “ULL PREFIX {EACH CORRECTIVE ACTION SHOULD SE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} IAG CROSS-REFERENCED TO THE APPROPRIATE CATE DEFICIENCY) OAK POINTE OF ROLLA A4724 19 CSR 30-86.047(19) TB Screen Residents & A4724 Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Class {i Based on interview and record review, the facility staff 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 as required for one of five sampled residents (Resident #3) and two of three sampled staff members Level One Medication Aide (LIMA) Aand Certified Medication Technician (CMT) B in accordance with 19 CSR 20-20.100. The facility census was 48. 1. Review of Missouri state regulations 19 CSR 20-20.100 (tuberculosis (TB) testing for residents and workers in long-term care facilities showed: -Long-term care facilities shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test (TST). Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained: -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -All employees are required to obtain Mantoux PPD two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second l (X86; OATE 1¥Y711 if continuation shee! 1 of B PRINTED: 02/23/2024 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 02/06/2024 31216 Bewlnie NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 OAK POINTE OF ROLLA (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) A4724: 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staft for : tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Class Il ' Based on interview and record review, the facility | Staff 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 as required for one of five sampled | residents (Resident #3) and two of three sampled staff members Leve! One Medication Aide (LIMA) | Aand Certified Medication Technician (CMT) B in | , accordance with 19 CSR 20-20.100. The facility | : census was 48. 1. Review of Missouri state regulations 19 CSR | 20-20.100 (tuberculosis (TB) testing for residents ! and workers in long-term care facilities showed: | _ -Long-term care facilities shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test (TST). Each facility shall be responsibie for ensuring that all test results are completed and that documentation is ' maintained; | -Within one month prior to or one week after | admission, all residents new to long-term care are required to have the initial test of a two-step; TB test: | -All employees are required to obtain Mantoux PPD two-step TB test within one month prior to | starting employment in the facility. If the initial ' test is zero to nine millimeters (mm), the second Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X68) DATE STATE FORM SeN8 1YY711 If continuation sheet 1 of 8 PRINTED: 02/23/2024 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 02/06/2024 31216 BoMuis NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 OAK POINTE OF ROLLA (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) GROSS-REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) A4724 Continued From page 1 test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the resident's or employee's initial test is negative, the second test should be given one to ; three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 | hours after administration; | -All long-term care facility residents shall have a - documented annual evaluation to rule out signs and symptoms of TB disease: -Employees with an initial zero to nine mm TB two, step test shall have one step tuberculin testing annually and the results recorded in a permanent i record; -All positive findings shail require a chest X-ray to! rule out active pulmonary disease: ; -Individuals with a positive finding need not have | repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs _ i and symptoms of tuberculosis disease. 2. Review of the facility's TB testing Policy dated 12/20/2021, showed individuals admitted into the . community shall have evidence of tuberculosis screening on record of the intradermal skin test, chest x-ray, or methods that the local health | authority recommends within 12 months before | admission. Staff hired will need to have evidence with in 10 days of hire and occupational exposure | | of TB screening completed. Review showed the community will foliow state regulations for employees TB testing. | 3. Review of Resident #3's face sheet showed an! admission date of 11/30/23 with a return on 12/28/23. Review showed the record did not : contain documentation of a two step tuberculosis _ Missouri Department of Health and Senior Services STATE FORM 6699 tYY7 14 If continuation sheet 2 of 8 PRINTED: 02/23/2024 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: A. BUILDING: COMPLETED C 31216 B. WING ___________ 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK POINTE OF ROLLA A4724, Continued From page 2 testing being administered. 4. Review of LIMAA's personnel file showed a ___ hire date of 12/15/23. The file did not contain documentation of his/her two-step TB testing being administered. ! Review of CMT B's personnel file showed a hire date of 11/12/24. The file did not contain documentation of his/her two-step TB testing being administered. During an interview on 02/06/24 at 5:33 P.M., the | administrator said the Director of Nursing (DON) is responsible for administering the TB testing and reading the results. The administrator said the DON walked out two or so weeks ago. The administrator said he/she has not been in his/her | position long. 19 CSR 30-86.047(20)(I) 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: | (1) 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; III | This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility Staff failed to ensure three (Level | Medication Aide (LIMA) A, Certified Medication Technician (CMT) B and CMT C) out of three sampled staff, Missouri Department of Health and Senior Services STATE FORM 6899 1VY711 if continuation sheet 3 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31216 NAME OF PROVIDER OR SUPPLIER OAK POINTE OF ROLLA (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING PRINTED: 02/23/2024 ROLLA, MO 65401 (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A4733 Continued From page 3 | had a written statement by a licensed physician or ‘ physician designee to ensure the staff are capable to work in a long-term care facility. The facility census was 49. 1. The facility staff did not provide a policy in regards to new hire employees required documentation of a physician statement to ensure | the staff are capable to work in a long-term care facility. 2. Review of LIMAA's personnel record showed a! hire date of December 15, 2023. Review showed | the personnel record did not contain documentation from a physician or designee to ensure he/she did not have limitations to work in a jong-term care facility. 3. Review of the CMT B's personnel record showed a hire date of January 12, 2024. Review | showed the personnel record did not contain I documentation from a physician or designee to | ensure he/she did not have limitations to work in _along-term care facility. 4. Review of CMT C's personnel record showed a hire date of December 12, 2023. Review showed the personnel record did not contain documentation from a physician or designee to ensure he/she did not have limitations to work in a long-term care facility. _ During an interview on 02/06/24 at 5:33 P.M., the administrator said he/she is responsible for making sure staff have their written statement by | a licensed physician or physician designee that they are capable of working in a long-term care facility. The administrator said the Director of Nursing (DON) who left a week or two ago was also responsible. Missouri Department of Health and Senior Services A4733 STATE FORM 68399 AY? 14 STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE PROVIDER'S PLAN OF CORRECTION FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2024 (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ff continuation sheet 4 of 8 PRINTED: 02/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (XZ) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 02/06/2024 31216 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES fe) 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) OAK POINTE OF ROLLA A7066 19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily The food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens shail be cleaned at least once a day, except that this shall not apply to hot oi!-cooking equipment and hot oil-filtering systems. The food-contact surfaces of all cooking equipment shail be kept free of encrusted grease | | deposits and other accumulated soil. III This regulation is not met as evidenced by: Class Ill Based on observation, interview and record review the facility staff failed to maintain i : equipment in a clean manner for food preparation by cleaning and degreasing, which included a commercial grade oven and two grease trays | located in the oven. The facility census was 48. ' 1. Review of the facility policy for cleaning and : | sanitizing of surfaces, dated 10/15/2020, showed: : -The facility will meet or exceed all state | guidelines and regulations regarding cleaning and. ‘ sanitation procedures for food surfaces and equipment; ~The dining manager will train all new and current employees on cleaning and sanitizing | procedures; -The dining manager and shift supervisors will continually model appropriate practice and monitor for compliance and procedures: -The dining manager and shift supervisor will immediately re-train and counsel employees who do not follow procedures: ‘ -Procedures for cleaning and sanitizing equipment that cannont be immersed in a sink Missouri Department of Health and Senior Services STATE FORM 6899 4YY711 If continuation sheet 5 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER. 31216 NAME OF PROVIDER OR SUPPLIER OAK POINTE OF ROLLA (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING ROLLA, MO 65401 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A7066 Continued From page 5 are often highly specific to the piece of equipment; -The dining manager and shift supervisor perform | continual observations to make sure all procedures for cleaning and sanitizing or surfaces | and equipment are followed; -Check lists for noting the time of equipment cleaning/sanitizing and employee initials are posted. Review of the kitchen cleaning schedule showed the schedule did not contain documentation of the: oven/flat top stove being cleaned. | 2. Observations on 2/6/2024 at 10:50 A.M. showed a commercial grade oven, with a gas range cook top, coated with thick, black residue inside the bottom of the oven. Observation showed the residue included large, black, crumbled pieces which surround the burners on the gas range, surrounded by thick coats of grime : and grease build up. Multiple charred food particles. The grease tray to the right of the oven was thick with build up and could not be opened. The grease tray to the left of the oven when - Opened, showed several layers of black charred food particles and layers of grease particles. During an interview on 2/6/2024 at 11:15 A.M., the dietary cook A said he/she was not aware | when the last time the gas stove was cleaned. The dietary cook said he/she was aware of the grease build up but he/she said the build up is so | bad it would take more time than what they have to clean it well. He/She said he/she is unsure if a cleaning schedule is fotlowed. During an interview on 2/6/2024 at 5:33 P.M., the administrator said he/she was not aware the oven/flat top was not being cleaned per the Missouri Department of Health and Senior Services STATE FORM 6899 TYY711 PRINTED: 02/23/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE PROVIDER'S PLAN OF CORRECTION FORM APPROVED (X3) DATE SURVEY COMPLETED C 02/06/2024 {X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 8 PRINTED: 02/23/2024 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 31216 EN yg a re 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION {X5} PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE , COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE : DATE DEFICIENCY) OAK POINTE OF ROLLA A7066° Continued From page 6 - schedule. The administrator said he/she is overall responsible to ensure the kitchen is clean. 19 CSR 30-88.010(4) Resident | Rights-Admission/Annual Review 1 _ Each resident admitted to the facility, or his or her | next of kin, legally authorized representative or | designee, shall be fully informed of the | individual's rights and responsibilities as a resident. These rights shall be reviewed annually | with each resident, and/or his or her next of kin, | legally authorized representative or designee, _ either in a group session or individually. IV/IIl This regulation is not met as evidenced by: Class III _ Based on record review and interview, facility "staff failed to ensure the resident or legally _ authorized representative's individual rights and ; responsibilities were signed when admitted for ‘ three (Resident #2, #3, and #5) of five sampled residents. The facility census was 48. , 1. Review of the facility's resident rights, responsibilities, and grievance process policy, dated 11/12/19, showed residents are provided a ' Resident and Family Handbook as part of the ‘ admissions process and each resident is to sign an acknowledgement in agreement. 2. Review of Resident #2’s medical record showed an admission date of 11/17/2023. Review showed the record did not contain a signed copy of the resident's rights and | responsibilities by the resident or his/her representative. Missouri Department of Health and Senior Services STATE FORM 6899 Pert If continuation sheet 7 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31216 PRINTED: 02/23/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A BUILDING COMPLETED Cc OO 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 OAK POINTE OF ROLLA (M4) 10 | SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG: REGULATORY OR LSC IDENTIFYING INFORMATION) | A8004' Continued From page 7 ' 3. Review of Resident #3's medical record showed an admission date of 11/30/2023. Review showed the record did not contain a signed copy of the resident's rights and responsibilities by the resident or his/her representative. 4. Review of Resident #5's medical record showed an admission date of 02/23/2023. Review showed the record did not contain a signed copy of the resident's rights and responsibilities by the resident or his/her representative. During an interview on 02/06/24 at 5:33 P.M., the PROVIDER'S PLAN OF CORRECTION {(X5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) | | | administrator said he/she is responsible to assure ' the resident's rights are being signed upon . admission and reviewed annually by the resident ' or the resident's designee are completed. The ‘ administrator said the Director of Nursing (DON) helps with admission paperwork and the DON left a week or two ago. Missouri Department of Health and Senior Services STATE FORM 6899 4YY7 11 \f continuation sheet 8 of 8 PLAN OF CORRECTION __ | Provider/Supplier | Oak Pointe of Rolla Name: | SiteebAddress, | 1000 E Lions Club Dr. Rolla, MO 65401 City, Zip: Date of Survey: 2/6/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2152654 : This pian 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 aileging compliance. IDPREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS- | | _. . _ REFERENCED TO THE APPROPRIATE DEFICIENCY) TB Screen Residents & Staff What corrective actions will be accomplished for those residents and employees found to have been affected b y the deficient practice? Director of nursing and/or designee will ensure that Resident #3, LIMA A, and | ; CMT B will have the required TB tests. the same deficient practice? Director of Nursing and/or designee wil! conduct an audit on all current in-house residents and staff to ensure that each resident and staff member has a current | TB test . 19 CSR 30- . . P . : What measures will be put into place or what systemic changes you will : 86.047(19) a : : Make to ensure that the deficient Practice does not recur? A4724 Director of Nursing and/or designee will ensure that ail new residents and staff ' have the required TB testing upon admission or hire | How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a pian for ensuring that | corrections achieved are sustained. This plan must be implemented, and : | the corrective action evaluated for its effectiveness. | The Director of Nursing and/or designee will conduct audits of all newly _ admitted residents or staff for one month and then randomly thereafter. i ! 1 ¢ How will you identify other residents having the potential to be affected by OMPLETION DATE 3/21/2024 = 5s M rats SET ene 7 ore i Personnel Record-Physician Statement, Employ What corrective actions will be accomplished for those employees found to have been affected by the deficient practice? , LIMA A, CMT B, and CMT C will have a physician statement on file. - How will you identify other employees having the potential to be affected by the same deficient practice? An audit will be completed by the Executive Director and/or Designee to ensure ! 49 CSR 30- that all current employees have a physician statement on file. 86.047(20)(I (20)(1) _ What measures will be put into place or what systemic changes you will 3/21/2024 A4733 _ Make to ensure that the deficient practice does not recur? 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 How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that . , Corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The Executive Director and/or 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 | | Grills/Griddles/Microwaves/Other-Clean Daily ' What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? | The stove will be cleaned per our weekly cleaning list by completion date. What measures will be put into place or what systemic changes you will _ make to ensure that the deficient practice does not recur? | 19 CSR 30- ; Dining manager will ensure that the dining staff are cleaning the stove perthe | weekly cleaning list by reviewing the siqn off sheets being turned in. | SSOie4) ey aie gies : 3/21/2024 How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a pian for ensuring that corrections achieved are sustained. This Plan must be implemented, and | | the corrective action evaluated for its effectiveness. ' A7066 : Dining manager and/or designee will turn in the weekly cleaning list to the Executive Director weekly on Friday's for 1 month and then biweekly for 1 : month and then Executive Director and/or designee will periodically spot check for completeness. | 19 CSR 30- | 88.010(4) _ A8004 | A4724 | A4733 _ , A7066 : A8004 ! i i ' a er [Toe were 8 7 OM 8 : — | | . resident's rights and responsibilities in his/ner file i How will you identify other residents having the potential to be affected by | See corresponding tag above _ See corresponding tag above See corresponding tag above . See corresponding tag above ' sure there is a signed copy of the resident's rights and responsibilities in their Resident Rights-Admission/Annual Review What corrective actions will be accomplished for those residents found to | have been affected by the deficient practice? Resident #2, Resident #3, and Resident #5 will have a signed copy of the the same deficient practice? Executive Director and/or Designee will audit all resident's charts to see make file. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur? Executive Director and/or Designee will review each new admission packet to | ensure that the resident's rights and responsibilities paperwork as been signed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a pian for ensuring that | corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Executive Director and/or designee will review all new resident files for 1 month and then periodically to ensure that there is a signed resident's rights and responsibilities in their file. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of correction being submitted on this form. 3/21/2024 the plan of