Inspection Reports for
Cedar Pointe
1800 WHITE COLUMNS DR, ROLLA, MO, 65401-2044
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
62 residents
Based on a April 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Date: Apr 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the improper administration of chemical restraints and failure to meet professional standards in medication documentation and narcotic counts.
Complaint Details
The complaint investigation found that Licensed Practical Nurse (LPN) A administered 0.25 ml of Lorazepam to Resident #1 without a physician order or contacting the physician, using medication taken from another resident. The facility census was 62. The Director of Nursing and administrator confirmed that administering medications for behaviors without orders is considered a chemical restraint and not allowed. Additionally, staff failed to properly document controlled substance administration and complete narcotic counts for Resident #2.
Findings
The facility failed to prevent the use of unnecessary psychotropic medications as a chemical restraint without physician orders for one resident, and failed to document controlled substance administration and complete shiftly controlled drug counts for another resident. The facility took corrective actions including suspension of the involved nurse and staff in-service training.
Deficiencies (2)
Facility staff failed to ensure one resident did not receive a chemical restraint medication without a physician order or proper documentation.
Facility staff failed to document the controlled substance administered for one resident and failed to complete shiftly controlled drug counts on the memory care unit.
Report Facts
Facility census: 62
Lorazepam dose administered without order: 0.25
Lorazepam remaining documented: 10.5
Lorazepam observed in bottle: 8.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Admitted to administering Lorazepam without physician order and documented the incident |
| Director of Nursing | Interviewed regarding medication administration policies and confirmed staff are not allowed to administer medications without physician orders | |
| Administrator | Interviewed and confirmed administration of medications for behaviors is considered chemical restraint | |
| CMT B | Certified Medical Technician | Interviewed regarding narcotic medication counts each shift |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care planning requirements, specifically to evaluate whether comprehensive, person-centered care plans were developed and implemented for residents.
Findings
The facility failed to develop and implement comprehensive care plans addressing behaviors such as wandering and physical aggression for two residents out of five sampled. Interviews and record reviews confirmed that care plans lacked documentation of these behaviors despite known incidents and staff awareness.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, including behaviors of wandering and physical aggression.
Report Facts
Residents affected: 2
Facility census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medical Technician A | Certified Medical Technician | Interviewed regarding Resident #1's history of wandering and aggression |
| Certified Nurse Aide B | Certified Nurse Aide | Interviewed regarding Resident #1 and #2's history of wandering and aggression |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding Resident #1's behaviors and care plan |
| Care Plan Coordinator | Interviewed regarding updating and responsibility for care plans | |
| Administrator | Administrator | Interviewed regarding care plan responsibilities and staff audits |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan purpose and staff audits |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted following complaints regarding failure to notify a resident's responsible party upon the resident's death and allegations of narcotic medication misappropriation by a Licensed Practical Nurse (LPN).
Complaint Details
The complaint investigation substantiated that the facility staff failed to notify the next of kin of a resident's death and failed to prevent narcotic diversion by an LPN who was drug tested positive for oxycodone and arrested.
Findings
The facility failed to notify the family of a resident's death in a timely manner and failed to prevent the misappropriation of narcotic medications by an LPN, who was subsequently arrested. The facility census was 67 at the time of the investigation.
Deficiencies (2)
Facility staff failed to contact one resident's responsible party when the resident passed away at the facility.
Facility staff failed to prevent the misappropriation of three residents' narcotic medications by a Licensed Practical Nurse who took the medication without authorization.
Report Facts
Facility census: 67
Number of residents affected by narcotic misappropriation: 3
Number of narcotic medications taken: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in narcotic medication misappropriation finding |
| LPN B | Licensed Practical Nurse | Named in failure to notify family of resident death |
| LPN C | Licensed Practical Nurse | Witnessed suspicious behavior and assisted in narcotic count |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding notification policies and narcotic diversion |
| ADON | Assistant Director of Nursing | Notified of suspicious behavior and conducted narcotic count |
| Human Resource employee | Human Resource employee | Conducted drug testing and witnessed LPN A's drug test |
| Administrator | Administrator | Provided statements regarding notification expectations |
Inspection Report
Routine
Census: 70
Deficiencies: 12
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, staffing, infection control, medication management, and safety.
Findings
The facility was found deficient in multiple areas including resident access to funds on weekends, grievance policy implementation, investigation of injuries, care plan updates, neurological assessments after falls, weekend activity programming, staffing levels, medication labeling and storage, infection prevention and control program implementation, and designation of a qualified infection preventionist.
Deficiencies (12)
Failed to ensure residents had appropriate access to their trust fund accounts on weekends.
Failed to implement grievance policy and maintain evidence of grievance results for missing items.
Failed to thoroughly investigate and document bruises of unknown origin for a resident.
Failed to develop, review, and revise care plans timely after falls, pressure ulcers, and behavioral incidents.
Failed to complete neurological assessments after unwitnessed falls for three residents.
Failed to provide ongoing weekend activities to meet residents' interests.
Failed to provide adequate nursing staff per facility assessment, lacking two licensed nurses on night shifts.
Failed to provide a registered nurse on duty for at least eight consecutive hours daily, seven days a week.
Failed to store and label medications properly, including undated opened bottles and presence of food in medication refrigerator.
Failed to develop and implement complete water management policies and procedures to inhibit growth of waterborne pathogens and reduce risk of Legionnaire's Disease.
Failed to use appropriate infection control procedures when performing blood sugar tests, including failure to use barriers when placing glucometers on surfaces.
Failed to designate a qualified infection preventionist with specialized training for the infection prevention and control program.
Report Facts
Residents affected: 6
Facility census: 70
Deficiency counts: 12
Falls documented: 5
Pressure ulcers documented: 2
Residents with behaviors: 1
Residents with unwitnessed falls: 3
Residents lacking weekend activities: 3
Licensed nurses missing per shift: 2
Days without RN coverage: 12
Undated medication bottles: 7
Food items in medication refrigerator: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in infection control deficiency related to blood sugar testing without barrier |
| RN F | Certified Nurse Aide Instructor | Named as only RN on staff during weekdays, covering RN duties |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding staffing, care plan, infection control, and medication cart maintenance |
| Administrator | Administrator | Named in multiple interviews regarding staffing, infection control, medication cart maintenance, and weekend activities |
| ADON | Assistant Director of Nursing | Named as designated Infection Preventionist in training |
| LPN A | Licensed Practical Nurse | Named in interviews regarding weekend activities and medication cart maintenance |
| CMT C | Certified Medication Technician | Named in interview regarding medication cart maintenance and labeling |
| CNA B | Certified Nurse Aide | Named in interview regarding lack of weekend activities |
Inspection Report
Routine
Census: 77
Deficiencies: 4
Date: Feb 28, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident privacy, medication administration, controlled substance handling, and medication storage at the nursing facility.
Findings
The facility failed to maintain residents' privacy by leaving Electronic Health Records (EHR) visible, did not follow professional standards for controlled substance destruction and documentation, allowed pre-population of medications contrary to policy, and failed to secure medication carts properly.
Deficiencies (4)
Failed to maintain personal medical information privacy; EHR left open and visible to residents and visitors.
Failed to follow professional standards for controlled substance destruction including lack of witness signatures and improper handling by Director of Nursing.
Failed to ensure the residents' environment remained free of accident hazards by not properly storing medications; medication carts left unlocked and unattended with keys in lock.
Allowed pre-population of medications from ISTAT, which is against facility policy and increases risk of medication errors.
Report Facts
Facility census: 77
Oxycodone tablets: 30
Insulin pens: 15
Hydrocodone card sign out date: Jul 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in findings related to leaving EHR open and medication carts unlocked |
| Assistant Director of Nursing | ADON | Interviewed regarding privacy and medication cart security policies and narcotics handling |
| Director of Nursing | DON | Named in findings related to improper narcotics destruction and documentation |
| RN B | Registered Nurse | Named in narcotics destruction discrepancy |
| CMT C | Certified Medication Technician | Named in narcotics destruction discrepancy |
| Administrator | Interviewed regarding medication administration and security policies |
Inspection Report
Routine
Census: 75
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to evaluate the facility's provision of activities designed to meet residents' interests and needs, based on observation, interviews, and record review.
Findings
The facility failed to provide an ongoing program of activities meeting residents' interests for four residents and on weekends. Activities were inconsistently provided, with some residents not participating in activities for extended periods. Staff acknowledged limited activity provision, especially on weekends and in the front unit, and the Activity Director admitted to not providing alternate activities when planned ones were missed.
Deficiencies (1)
Failed to provide an ongoing program of activities designed to meet residents' interests for four residents and on the weekend.
Report Facts
Residents affected: 4
Facility census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Interviewed about activity calendar and activity provision in memory care unit |
| CMT C | Certified Medication Technician | Interviewed about activity provision in memory care unit |
| Activity Director | Interviewed about activity documentation, provision, and issues with missed activities | |
| Administrator | Interviewed about staff not providing activities according to calendar |
Inspection Report
Routine
Census: 69
Deficiencies: 15
Date: Apr 10, 2023
Visit Reason
Routine inspection of Cedar Pointe nursing home to assess compliance with resident rights, safety, care planning, medication management, infection control, staffing, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to respond to resident grievances in writing, failure to post required hotline information, failure to maintain a safe and homelike environment, failure to notify residents of bed hold policies, incomplete resident assessments, incomplete and non-person-centered care plans, unsafe smoking practices, inadequate dialysis communication and monitoring, insufficient RN coverage, incomplete nurse staffing postings, improper medication storage and labeling, failure to maintain food safety standards, inadequate infection control practices, and failure to properly document and offer vaccinations.
Deficiencies (15)
Facility staff failed to follow-up with a written response to resident grievances.
Facility staff failed to post the telephone number for the Department of Health and Senior Services Adult Abuse and Neglect Hotline in an accessible location.
Facility staff failed to provide a comfortable and homelike environment, with multiple maintenance and cleanliness issues observed in resident rooms and dining areas.
Facility staff failed to provide written notification of bed hold policy to residents transferred to hospital.
Facility staff failed to complete required Minimum Data Set (MDS) assessments within required timeframes for five residents.
Facility staff failed to develop comprehensive person-centered care plans addressing medical and nursing needs for multiple residents.
Facility staff failed to ensure safety of a resident who used a vaping device while on oxygen, posing immediate jeopardy to resident health and safety.
Facility failed to provide thorough orders, monitoring, and communication with dialysis facility for residents receiving dialysis.
Facility failed to provide RN coverage for at least 8 consecutive hours per day, seven days a week.
Facility failed to include resident census on daily nurse staffing information posted in the facility.
Facility staff failed to store and label medication properly and failed to dispose of expired and loose medications appropriately.
Facility failed to maintain thermometers in resident room refrigerators, clean vents over resident tables, and ensure ice machine drained through an air gap.
Facility staff failed to use appropriate infection control procedures during perineal care and failed to clean mechanical lifts between uses.
Facility failed to maintain and follow current guidance and procedures for immunizations against pneumococcal pneumonia and influenza for sampled residents.
Facility failed to maintain and follow current guidance and procedures for COVID-19 immunizations for sampled residents.
Report Facts
Facility census: 69
Number of residents with late MDS assessments: 5
Number of residents with incomplete care plans: 6
Number of residents with missing immunizations: 5
Number of residents receiving dialysis: 2
Number of days without RN coverage for 8 hours: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide D | Certified Nurse Aide | Interviewed about grievance reporting and care plan knowledge |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed about grievance reporting, care plan updates, dialysis communication, medication storage, and infection control |
| Certified Medication Technician J | Certified Medication Technician | Interviewed about catheter care and psychotropic medication orders |
| Director of Nursing | Director of Nursing | Interviewed about grievance follow-up, care plan responsibilities, dialysis communication, infection control, and immunizations |
| Administrator | Administrator | Interviewed about grievance follow-up, hotline posting, bed hold policy, RN staffing, medication disposal, food safety, infection control, and immunizations |
| Maintenance Director | Maintenance Director | Interviewed about environmental repairs, vents, ice machine drainage, and refrigerator maintenance |
| Certified Nurse Aide Q | Certified Nurse Aide | Interviewed about vaping resident and infection control |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed about catheter care, medication disposal, and infection control |
| Certified Nurse Aide E | Certified Nurse Aide | Observed and interviewed about infection control during perineal care |
| Nurse Aide F | Nurse Aide | Observed and interviewed about infection control during perineal care |
| Certified Nurse Aide G | Certified Nurse Aide | Observed about mechanical lift cleaning |
| Nurse Aide H | Nurse Aide | Observed about mechanical lift cleaning |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed about MDS assessments |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed about grievance reporting |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed about grievance reporting and medication storage |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed about reporting broken items and medication disposal |
| Certified Nurse Aide D | Certified Nurse Aide | Interviewed about grievance reporting and infection control |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed about grievance reporting, dialysis communication, medication storage, and infection control |
| Certified Medication Technician O | Certified Medication Technician | Interviewed about medication disposal |
| Licensed Practical Nurse I | Licensed Practical Nurse | Interviewed about medication disposal |
| Director of Nursing | Director of Nursing | Interviewed about medication disposal |
| Administrator | Administrator | Interviewed about medication disposal |
| Maintenance Director | Maintenance Director | Interviewed about refrigerator maintenance, vents, and ice machine drainage |
| Dietary Manager | Dietary Manager | Interviewed about refrigerator thermometer monitoring |
| Certified Nurse Aide D | Certified Nurse Aide | Interviewed about infection control |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed about infection control |
| Director of Nursing | Director of Nursing | Interviewed about infection control |
| Infection Preventionist | Infection Preventionist | Interviewed about immunization procedures |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of narcotic medications by a Certified Medication Technician (CMT A) at the facility.
Complaint Details
The complaint investigation substantiated that CMT A misappropriated narcotic medications from three residents. The employee was arrested on 1/31/23 for possession of controlled substances without a prescription. Interviews with the Director of Nursing, law enforcement, and involved staff confirmed the findings.
Findings
The facility failed to prevent the misappropriation of narcotic medications belonging to three residents by CMT A, who took medications without authorization. Interviews and record reviews confirmed discrepancies in narcotic counts and unauthorized possession of controlled substances by the employee, leading to the employee's arrest.
Deficiencies (1)
Failed to protect residents from wrongful use of their belongings or money, specifically narcotic medications misappropriated by a staff member.
Report Facts
Facility census: 74
Narcotic pills count for Resident #1: 39
Narcotic pills count for Resident #2: 6
Narcotic pills count for Resident #3: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in narcotic medication misappropriation and arrest |
| LPN C | Licensed Practical Nurse | Mentioned in relation to medication cart count and discrepancies |
| DON | Director of Nursing | Provided interview regarding the arrest and narcotic discrepancies |
Inspection Report
Routine
Census: 57
Deficiencies: 3
Date: Feb 4, 2021
Visit Reason
The inspection was conducted to evaluate compliance with nutritional needs, food safety, sanitation, and infection prevention and control standards at the facility.
Findings
The facility failed to serve pureed diet food items according to recipes and nutritional guidelines, improperly thawed food, failed to maintain sanitary food preparation and storage practices, and did not consistently enforce proper facemask use and infection control measures among staff.
Deficiencies (3)
Facility staff failed to serve food items to one resident with a pureed diet order in accordance with nutritionally calculated menus and recipes.
Facility failed to serve food under sanitary conditions by not ensuring safe thawing of food, maintaining separation of food prep and dishwashing areas, storing cleaning rags properly, and ensuring ice machine drain had an air gap.
Facility failed to maintain an infection prevention and control program, including improper facemask use, failure to sanitize hands after touching facemasks, and improper facemask storage.
Report Facts
Census: 57
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager (DM) [NAME] N | Dietary Manager | Named in multiple findings related to food preparation, recipe adherence, and infection control |
| Dietary Aide (DA) Q | Dietary Aide | Observed preparing pureed diced tomato salad and involved in food preparation observations |
| [NAME] P | Observed preparing food, involved in thawing and food prep observations | |
| Maintenance Director (MD) | Maintenance Director | Responsible for ice machine compliance and interviewed regarding air gap |
| [NAME] O | Observed in multiple infection control violations including facemask use and hand hygiene |
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