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

PRINTED: 08/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIERICLIA {X2} MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED Cc 31216 BWING 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (X4} 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF ROLLA A4751 19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: C. Whenever a significant change has occurred in the resident's condition, which may require a change in services. Il This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility staff failed to update one resident's (Resident #1) community based assessments (CBA), a required assessment tool completed by qualified facility Staff, after the resident left the secured memory care unit of the facility. The facility census was 53; 1. Review of the facility's policy “Resident Assessment", dated 04/21/2014, showed the director of nursing (DON) will assess the resident with a significant change in condition and update the assessment as needed. Review of Resident #1's medical record showed the resident admitted to the facility memory care on 12/27/2021. Review of an incident report, undated and Missouri Department of Heajth and Senior Services LABORATORY OIRECTGR’ - 4 (X6) DATE STATE FORM Mie if continuation sheet 1 of 8 PRINTED: 08/31/2023 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 08/22/2023 31216 6 WING _______ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1600 EAST LIONS CLUB DRIVE OAK POINTE OF ROLLA ROLLA, MO 65401 (X4) ID SUMMARY STATEMENT OF CEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X48) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULI. PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4751 Continued From page 1 unsigned, showed on 08/09/2023 at 7:48 P.M. the resident exited the facility memory care unit. At 7:49 P.M., the resident exited the northeast door of the assisted living unlocked unit. Review of the resident's CBA, undated and unsigned, showed the CBA did not contain updated information after the resident eloped from a secured memory care unit of the facility. During an interview on 8/24/2023 at 1:21 P.M., the DON said he/she was not aware to update the CBA after this incident occurred with Resident #1. The DON said he/she is responsible to complete the resident's CBAs. MO00222750 19 CSR 30-86.047(28)(H) Individual Service Plan A4755 - Review Requirements The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: {H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident “s condition which may require a change in services; Il This regulation is not met as evidenced by: Class tI Based on interview and record review, the facility staff failed to update one resident's (Resident #1) Missouri Department of Health and Senior Services STATE FORM 5899 Mi2111 If continuation sheet 2 of 8 PRINTED: 08/31/2023 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 IDENTIFIGATION NUMBER: A. BUILDING: COMPLETED Cc 31216 B WING 08/22/2023 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 PROVIOER'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 A4755 Continued From page 2 individual service plan (ISP), a required assessment tool completed by qualified facility staff, when the resident had a significant change in their condition and the resident left the secured memory care unit of the facility. The facility census was 53. 1. Review of the facility's policy "Resident Assessment", dated 04/21/2014, showed the director of nursing (DON) will assess the resident with a significant change in condition and update the assessment as needed. 2. Review of Resident #1's medical record showed the resident admitted to the facility memory care on 12/27/2021. Review of an incident report, undated and unsigned, showed on 08/09/2023 at 7:48 P.M. the resident exited the facility memory care unit. At 7:49 P.M., the resident exited the northeast door of the assisted living unlocked unit. Review of the resident's ISP, dated 01/06/2022, showed staff did not document any new interventions for the resident after he/she eloped from the memory care unit. During an interview on 8/24/2023 at 1:21 P.M., the DON said he/she was not aware to update the ISP after the incident occurred with Resident #1. The DON said he/she is responsible to complete the resident's ISPs. M0O00222750 A4?776 19 CSR 30-86.047(35) Protective Oversight A4776 Missouri Department of Health and Senior Services STATE FORM 6899 MI2141 If continuation sheet 3 a1 8 PRINTED: 08/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED Cc 31216 eres 08/22/2023 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 PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) OAK POINTE OF ROLLA A4776 Continued From page 3 Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of tne resident's whereabouts while on voluntary leave. I/II This regulation is not met as evidenced by: Class Il Based on interview and record review, facility staff failed to provide twenty-four (24) hour protective oversight for one resident (Resident #1) when the resident left the secured memory care unit without staff knowledge. The facility census was 53. 1, Review of facility policy, Etopement Prevention, dated 5/1/2014, showed when an outside parameter door alarm is sounded, staff shall immediately respond and determine the cause of the alarm. Review showed staff will search the immediate area near the door to determine if a resident has exited the community. Review showed staff shall remain at the door until it is reset and locked. Review of Resident #1's medical record showed the resident admitted on 12/27/2021 with the diagnosis of dementia (decline in memory and social symptoms which interferes with daily functioning). Review of the resident's community based assessment (CBA), an assessment completed by a trained staff member, showed staff assessed the resident wanders, had confusion, and poor Missouri Department of Heaith and Senior Services STATE FORM sage M2411 If continuation sheet 4 of 8 PRINTED: 08/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED Cc 08/22/2023 {X2) MULTIPLE CONSTRUCTION A BUILDING: 31216 BINS NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CiTY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 OAK POINTE OF ROLLA (X4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 1X5} 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) A4776 Continued From page 4 judgement. Review of the facility incident report dated 08/10/23, showed the facility executive director (ED) documented on 08/09/23 at 7:48 P.M., the resident exited the memory care main door and proceeded to exit through the assisted living Northeast exit at 7:49 P.M. The resident walked to the sidewalk and around the building to the front door of the facility. Level One medication aide (LIMA 8) found the resident at 9:09 P.M. on the front porch. The ED said he/she was notified at 9:15 P.M. Review of the resident's nurses' notes from 08/09/23 through 08/22/23, showed the staff did not document measures implemented to ensure the resident's safety after the resident exited from the memory care unit and the assisted living facility doors. During an interview on 08/22/23 at 11:53 A.M., LIMAA said he/she heard the alarm go off at the main memory care unit doors. LIMAA said he/she went to the door and shut off the alarms. LIMAA said when he/she went to the door another resident, who frequently exit seeks walked away from the main memory care unit's door. LIMAA said he/she thought the resident at the door sounded the alarm. LIMAA said he/she did not open the main memory care unit's doors, and he/she did not complete a resident head count check after he/she turned off the alarms. LIMAA said he/she was not aware he/she needed to complete a head count and was not aware Resident #1 left the memory care unit. LIMAA said LIMA B (who worked on the assisted living side) notified him/her the resident was outside of the facility around 9:00 P.M. LIMAA said he/she did not have a pager and did not receive the alert Missouri Department of Health and Senior Services STATE FORM ean MI24114 H continuation sheet 5 af 8 PRINTED: 08/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA ANG PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 08/22/2623 B, WING 31216 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65404 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 19 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 A4776 Continued From page 5 the Northeast exit door alarmed at 7:49 P.M. LIMAA said he/she was not aware the staff needed pagers to receive alert messages if a resident exits a facility door. LIMAA said the resident has a history of exit seeking behaviors. During an interview on 08/22/23 at 2:10 P.M., LIMA B said he/she remembers the alarm went off on 08/09/23 before 8:00 P.M. He/she said the alarm alerted his/ner pager, the Northeast door exit. LIMA B said he/she did not go to the door and check to see if a resident went out the door. LIMA B said he/she put all his/her residents in bed and knew the residents on his/her hal! did not leave. LIMAB said he/she is aware he/she should go to check if the alarm sounds. During an interview on 08/24/23 at 1:21 P.M., the Director of Nursing (DON) said when the door alarms sound on both the memory care and assisted living, the staff should go to the alerted door, open the door, and complete a full head check of each resident in the facility. The DON said staff will call the executive director, DON, primary care physician, and notify the family if a resident is missing. MQ00222750 19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr In addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer 's disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer ' s disease and related dementias as follows: Missoun Department of Heallh and Senior Services STATE FORM ose9 Mt2111 ff continuation sneet 6 of B PRINTED: 08/31/2023 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 CGRRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED E 31216 i ee 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATF, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (X4} ID SUMMARY STATEMENT OF DEFICIENCIES lo PROVIDER'S PLAN OF CORRECTION {*5) PREFIX (EACH DEFICIENCY MUST SE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD 8E COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) OAK POINTE OF ROLLA A4856 Continued From page 6 (A) For employees providing direct care to such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer ‘s disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues; and N/All This regulation is not met as evidenced by: Class ill Based on interview and record review, the facility failed to ensure staff providing direct care to residents with Alzheimer's disease or related dementia received at least three hours of orientation training regarding mentally confused residents. The facility census was 53. 1. During an interview on 08/22/23 at 11:53 A.M., Level One Medication Aide (LIMA A) said he/she does not remember staff trained him/her to work with dementia residents. The LIMA said when the former administrator hired him/her, the former administrator put him/her in a room with a packet to read. The LIMA said he/she started working in the memory care unit of the facility. Review on 08/22/23 of the employee's personnel file showed staff did not document LIMAA received dementia training. During an interview on 08/24/2023 at 1:21 P.M. the Director of Nursing (DON) said he/she was Missouri Department of Health and Senior Services STATE FORM Se89 M2114 lf continuation sneei 7 of & PRINTED: 08/31/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 31216 B. WING _ ce 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZiP CODE 1000 EAST LIONS CLUS DRIVE OAK POINTE OF ROLLA ROLLA, MO 65401 (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FUL. (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4856 Continued From page 7 not aware LIMAA didn't receive dementia training. The DON said we are currently restructuring the charts for all staff. MOQ00222750 Missoun Department of Health and Senior Services STATE FORM #es9 Mi2141 i{ continuation shest 8 of 8 - PLAN OF CORRECTION Provider/Supplier Name: Oak Pointe of Rolla Street Address, City, Zip: Date of Survey: 1000 E Lions Club Dr. Rolla, MO 65401 8/22/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER This plan of correction is being submitted in accordance with State and Federal Regulations. The submission of this plan of correction does not constitute an admission by the provider of the alleged violations contained within the statement of deficiency. The submission of this plan of correction does not constitute admission ID PREFIX TAG 19 CSR 30- 86.047 (28)(F)(1)(C) A4751 by the provider that the alleged findings constitute a deficiency, or that the class determinations are correct. This plan of correction is intended to constitute the providers credible letter alleging compliance. PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCED TO THE APPROPRIATE DEFICIENCY) 26D2152654 COMPLETION DATE Community Based Assessment-Significant Change Resident #1 was affected by the deficient practice. Ail residents have the potential to be affected. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? Director of nursing and/or designee will complete a significant change community based assessment on Resident #1. How will you identify other residents having the potential to be affected by the same deficient practice? Director of Nursing and/or designee will conduct an audit on all current in-house residents to ensure that each resident has a current Community Based Assessment. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur? Director of Nursing and/or designee will ensure that all residents that have a change in condition will have a new Community Based Assessment completed. 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 Executive Director and or Director of Nursing will conduct monthly reviews of the Community Based Assessment to ensure that they are accurate and up to date with any change of condition. 10/27/2023 individual Service Plan — Review Requirements Resident #1 was affected by the deficient practice. All residents have the potential to be affected. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? All residents must have an Updated Individual Service Plan when there is a change of condition. All resident ISPs will be updated and current. How wilf you identify other residents having the potential to be affected by the same deficient practice? A review of every resident will be conducted by the Executive Director, Director of Nursing and/or designee to ensure all Individual Service Plan's are up to date. 19 CSR 30- 86.047(28)(H) 10/27/2023 What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur? A4755 The Executive Director and/or Director of Nursing will review the daily shift report for change of condition to ensure all documents are current and the Individual Service Plans will be reviewed quarterly and with any change of condition. 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 Executive Director and or Director of Nursing will conduct monthly reviews of Individual Service Plans to ensure that they are accurate and up to date with any change of condition. Protective Oversight Resident #1 was affected by the deficient practice. All residents have the potential to be affected. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? All staff in the building have been educated regarding checking doors when 19 CSR 30- alarm sounds, to include visualization outside. All new staff are to be educated 86.047(35) prior to the start of the first shift. All education documented in associate file. 40/27/2023 Aer DON and/or designee will be responsible for training. How will you identify other residents having the potential to be affected by the same deficient practice? Facility will identify residents with an elopement risk assessment by completing elopement form on residents that are at risk every 6 months and/or significant change. 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, Director of Nursing and/or designee wiil perform random door drills as follows: Each shift weekly for 2 weeks, then each shift every other week, and then monthly moving forward. 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, Director of Nursing and/or designee will discuss results of drills during morning Standup meeting, to discuss how the drills went and where additional training may be needed. 19 CSR 30- 86.047(63)(A) A4856 A4751 A4755 A4776 _ A4856 Alz-Dementia Training-Direct Care Staff, 3 hr Resident #1 was affected by the deficient practice. All residents have the potential to be affected. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? All current staff will have the required 3 hour dementia training. How will you identify other residents having the potential to be affected by the same deficient practice? All residents have the potential to be affected by alleged deficient practice. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur? All new staff are to be educated prior to the start of the first shift for the required Aizheimer's/Dementia training. All education documented in associate file. DON and/or designee will be responsible for training. 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 employee files 1x a week for 1 month and every other week for 1 month and then monthly thereafter to ensure that the required Alzheimer’s/Dementia training are completed prior to the associate's first shift. See corresponding tag above See corresponding tag above See corresponding tag above See corresponding tag above 10/27/2023 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: 11/30/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF OEFICIENCIES (41) PROVIDFR/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY A. BUILDING COMPLETED R-G 11/13/2023 STREET ADDRESS, CITY, STATE. ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (x4) ID SUMMARY S1ATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN GF CORRFCTION (x5) PREFIX (FACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THF APPROPRIATE DATF DEFICIENCY) NAME OF PROVIDER OR SUPPLIER OAK POINTE OF ROLLA {44751} 19 CSR 30-86.047(28)(F)(1)(C) Community {A4751} Based Assessment-Significant Change The facility may admit or retain an individuat for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: {F} Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: C. Whenever a significant change has occurred in the resident ' s condition, which may require a change in services. I This regulation is not met as evidenced by: This deficiency is uncorrected. For previaus examples, please refer to the Statement of Deficiencies dated 08/22/2023. Based on interview and record review, the facility staff failed to update four resident's (Resident #1, #2, #3, and #4) community based assessment (CBA}, a required assessment tool completed by qualifted facility staff, after the residents experienced a change in condition which required a change in their care services. The facility census was 51, Review of the facility's policy "Resident Assessment," dated 04/21/2014, showed the director of nursing (DON) will assess resident's with a significant change in condition and update the assessment as needed. 1. Review of Resident #1's medical record showed the resident admitted to the facility on 08/10/2021. Missouri Department of Hialth and Senior Services LABORATORY DIRECTO PLIER REMRESENTATIVE'S SIGNATURE (M6) DATE STATE FORM 6809 Mil2112 If continualion sheet 1 of 3 PRINTED: 11/30/2023 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) MULTIPLF CONSTRUCTION A, BUILDING: R-C 11/13/2023 B, WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STAIE. ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 OAK POINTE OF ROLLA (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDFR'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE IAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-RFFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {44751} Continued From page 1 {A4751} Review of the resident's Individual Evacuation Plan (IEP), undated, showed staff documented the resident was not able to independently exit the building and needs assistance to exit during an emergency. Staff are directed to assist the resident to his/her wheelchair and push the resident to the nearest exit or area of refuge. Review of the resident's CBA, dated 09/11/2023, showed the CBA did not contain the updated information for the resident's need for an IEP. Review showed the resident was able to safely evacuate the facility with minimal assistance. 2. Review of Resident #2's medical record showed the resident admitted to the facility on 12/14/2022, Review of an IEP, undated and unsigned, showed staff documented the resident was not able to independently exit the building and needs two person assist to transfer to the resident's wheelchair. Review of the resident's CBA, dated 09/11/2023 and unsigned copy, showed the CBA did not contain updated information the resident requires two person assist to safely transfer to the resident's wheelchair. The resident's CBA showed the resident required a one person assist to transfer. 3. Review of Resident #3's medical record showed the resident admitted to the facility on 08/15/2018. Review of the resident's IEP, undated and unsigned, showed the resident was not able to independently exit the building and needs one Missouri Department of Health and Senior Services STATE FORM ‘6859 Mi2112 If cantinuation sheet 2 of 3 PRINTED: 11/30/2023 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 R-C B. WING 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE ROLLA, MO 65401 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EAGH CORRECTIVE AG IION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE OEFICIENCY) OAK POINTE OF ROLLA {44751} Continued From page 2 {A4751} person assist to transfer to the resident's wheelchair. Review of the resident's CBA, dated 09/20/2023 and unsigned copy, showed the CBA did not contain updated information the resident required one person assist to safely transfer to the resident's wheelchair. The resident's CBA showed the resident was able to safely evaluate the facility with minimal assistance. 4. Review of Resident #4's medical record showed the resident admitted to the facility on 08/01/2018. Review of the resident's IEP, undated and unsigned, showed the resident was not able to independently exit the building and needs two person assist to transfer to the resident's wheelchair. Review of the resident's CBA, dated 02/23/2023 and unsigned copy, showed the CBA did not contain updated information the resident required two person assist to safely transfer to the resident's wheelchair. The resident's CBA showed the resident was able to safely evacuate the facility with minimal assistance. 5. During an interview on 11/08/2023 at 5:30 P.M., the DON said he/she was not aware the CBAs were not updated. The DON said he/she started a couple of weeks ago and was still learning his/her job responsibilities. The DON said he/she was responsible to complete the resident's CBAs. Missouri Department of Health and Senior Services STATE FORM age MI2112 IF cantinualion sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier | O24 pointe of Rolla Name: Street Address, City, Zip: 1000 E Lions Club Dr. Rolla, MO 65401 Date of Survey: 11/13/23 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2152654 This plan of correction is being submitted in accordance with State and Federal Regulations. The submission of this plan of correction does not constitute an admission by the provider of the alleged violations contained within the statement of deficiency. The submission of this plan of correction does not constitute admission by the provider that the alleged findings constitute a deficiency, or that the class determinations are correct. This plan of correction is intended to constitute the providers credible letter alleging compliance. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE Community Based Assessment-Significant Change Resident #1, #2, #3, and #4 as well as all other current residents have the potential to be affected. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? Director of nursing and/or designee will review Resident #1, Resident #2, Resident #3, and Resident #4's current CBA’s, ISP’s, and if applicable IEP’s to ensure that they are up to date. How will you identify other residents having the potential to be affected by the same deficient practice? 19 CSR 30- 86.047 Director of Nursing and/or designee will conduct an audit on all current in-house (28)(F)(1)(C) residents CBA’s, ISP’s, and if applicable IEP’s to ensure that each resident’s 12/29/2023 information is up-to-date and all match. A4751 What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur? Director of Nursing and/or designee will ensure that all resident's that have a change in condition will have a new CBA, ISP and if applicable {EP. 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 Director of Nursing will conduct monthly audits on all residents CBA’s, ISP’s and IEPs to ensure that they are accurate and up to date with any change of condition. AA751 See corresponding tag 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: 07/27/2023 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 31216 $$$ i$ 07/25/2023 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 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY OAK POINTE OF ROLLA 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review and interview during a fire safety inspection on July 25, 2023, the facility failed to insure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census July 25, 2023, was forty-one (41). This deficiency affects forty-one (41) out of forty-one (41) residents. Record review on July 25, 2023, at 10:45 A.M. showed no semi-annual inspection had been performed on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. No record available for previous semi-annual fire alarm inspection. During an interview on July 25, 2023, at the time of discovery the Maintenance director stated he would call the alarm company. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 R9OF411 If continuation sheet 1 of 3 PRINTED: 07/27/2023 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 31216 $$$ i$ 07/25/2023 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 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY OAK POINTE OF ROLLA Continued From page 1 This regulation is not met as evidenced by: Class II Based on observation and interview on July 25, 2023, the facility failed to ensure that curtains shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. Observation on July 25, 2023, at 9:57 A.M., the facility failed to provide documentation of properly certified or treated curtains on the closet of resident room K in the Memory Care wing. During an exit interview on July 25, 2023, the maintenance director said they would treat or remove the curtains. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class II Based on observation and interview on July 25, 2023, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census was forty-one (41). This deficiency affects forty-one (41) of forty-one (41). residents. Observation on July 25, 2023 at 9:32 A.M. showed Missouri Department of Health and Senior Services STATE FORM oeee R9OF411 If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 31216 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 EAST LIONS CLUB DRIVE OAK POINTE OF ROLLA ROLLA, MO 65401 PRINTED: 07/27/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/25/2023 (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 DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE Continued From page 2 multiple oxygen cylinders, standing upright and not stored in an approved rack, or secured by a chain or band in the closet of room 129. Observation on July 25, 2023 at 9:36 A.M. showed multiple oxygen cylinders, standing upright and not stored in an approved rack, or secured by a chain or band in the closet of room 132. Observation on July 25, 2023 at 9:45 A.M. showed multiple oxygen cylinders, standing upright and not stored in an approved rack, or secured by a chain or band in the Memory Care Nursing Station During an interview on July 25, 2023 at 10:45 A.M. the maintenance manager said he would secure the cylinders. Missouri Department of Health and Senior Services DEFICIENCY If continuation sheet 3 of 3 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).