Inspection Reports for
Cedar Pointe
1800 WHITE COLUMNS DR, ROLLA, MO, 65401-2044
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
178% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
61% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 64
Deficiencies: 2
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to assess compliance with comprehensive care plan requirements for residents, focusing on person-centered care plans and addressing behaviors such as wandering and aggression.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for two residents, lacking documentation of behaviors such as wandering and physical aggression. Staff education and care plan updates were insufficient to address these behaviors adequately.
Deficiencies (2)
F656: The facility did not develop and implement comprehensive person-centered care plans for two residents, failing to include measurable objectives and interventions for behaviors such as wandering and physical aggression.
A4075: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiencies referenced in F656.
Report Facts
Facility census: 64
Sampled residents: 5
Residents with deficient care plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medical Technician (CMT) | Interviewed regarding resident wandering and aggression | |
| Certified Nurse Aide (CNA) B | Interviewed regarding resident behaviors and staff education | |
| Licensed Practical Nurse (LPN) C | Interviewed regarding resident care plan interventions | |
| Care Plan Coordinator | Interviewed regarding care plan updates and interventions | |
| Administrator | Interviewed regarding care plan updates and staff communication | |
| Director of Nursing (DON) | Interviewed regarding care plan purpose and staff direction |
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
Complaint Investigation
Census: 67
Deficiencies: 4
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify responsible parties of resident changes and misappropriation of narcotic medications by staff.
Complaint Details
The complaint investigation substantiated that the facility failed to notify the resident's family after death and failed to prevent narcotic diversion by an LPN. The LPN was drug tested positive for oxycodone and arrested after missing narcotic records and medications were found.
Findings
The facility failed to notify the resident's family and responsible parties promptly after a resident's death and failed to prevent misappropriation of narcotic medications by a Licensed Practical Nurse (LPN). The investigation revealed missing narcotic records and positive drug tests for oxycodone on the involved staff.
Deficiencies (4)
F580 Notification of Changes. The facility failed to notify the resident's responsible party after the resident passed away, as required by regulation.
F602 Free from Misappropriation/Exploitation. The facility failed to prevent misappropriation of narcotic medications by an LPN who took medications without authorization and concealed records.
A4088 Notify Responsible Party-Change in Condition. The facility did not immediately notify the designated person in the resident's record after an accident or significant change.
A8023 Develop/Implement Abuse/Neglect Policies. The facility failed to implement policies to prevent abuse, neglect, and misappropriation of resident property and funds.
Report Facts
Facility census: 67
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in narcotic misappropriation and drug diversion |
| LPN B | Licensed Practical Nurse | Interviewed regarding notification procedures after resident death |
| LPN C | Licensed Practical Nurse | Assisted in narcotic count and investigation |
| Director of Nursing | Director of Nursing (DON) | Provided information on notification expectations and narcotic diversion |
| Administrator | Administrator | Provided information on notification procedures and approved plan of correction |
| Human Resource Employee | Witnessed drug testing and reported suspicious behaviors | |
| ADON | Assistant Director of Nursing | Notified about suspicious behavior and narcotic diversion |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 11
Date: Jul 18, 2024
Visit Reason
The inspection was the annual survey of Cedar Pointe nursing facility to assess compliance with regulatory requirements and investigate allegations of abuse and neglect.
Findings
The facility was found deficient in multiple areas including management of personal funds, grievance procedures, investigation of alleged abuse, comprehensive care plans, medication storage, infection control, staffing, and activity programs. Several residents had unaddressed injuries and missing personal items, and the facility failed to maintain proper documentation and follow policies.
Deficiencies (11)
F567 Management of Personal Funds: Facility staff failed to ensure six residents had appropriate access to their trust fund account on weekends, limiting resident access to funds.
F585 Grievances: Facility staff failed to implement grievance policy for two residents, missing items and failing to maintain evidence of grievance results for at least three years.
F610 Investigation of Alleged Violations: Facility staff failed to thoroughly investigate and document bruises of unknown origin for one resident.
F657 Care Plan Timing and Revision: Facility staff failed to review and revise care plans after falls and update care plans for pressure ulcers and behaviors for sampled residents.
F658 Services Provided Meet Professional Standards: Facility staff failed to complete neurological assessments for three residents after unwitnessed falls.
F679 Activities Meet Interest/Needs: Facility failed to provide ongoing weekend activity programs for residents, limiting engagement opportunities.
F725 Sufficient Nursing Staff: Facility failed to provide sufficient licensed nursing staff to meet resident needs and maintain required staffing levels.
F727 RN 8 Hrs/7 Days/Wk, Full Time DON: Facility failed to provide a registered nurse for at least eight consecutive hours daily, seven days a week.
F761 Label/Store Drugs and Biologicals: Facility staff failed to store and label medications properly, including multi-dose medication bottles and non-medication items in medication storage.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention program, including water management and hand hygiene.
F882 Infection Preventionist Qualifications/Role: Facility failed to designate qualified infection preventionist staff and provide required training and certification.
Report Facts
Facility census: 70
Residents sampled: 18
Residents with access issue: 6
Residents with bruises not investigated: 1
Residents with incomplete neurological assessments: 3
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
Life Safety
Census: 70
Capacity: 102
Deficiencies: 7
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to meet several Life Safety Code requirements including maintaining clear and visible emergency exit signage, securing fire alarm system components, ensuring fire watch policies and procedures were complete, and maintaining fire barrier doors and smoke barriers. Multiple deficiencies related to fire alarm system testing, sprinkler system impairments, fire drills, and fire door maintenance were identified.
Deficiencies (7)
K271 Discharge from Exits: Facility staff failed to maintain visible emergency exit signage and clear exit discharge paths, creating potential tripping hazards and delayed egress.
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to inspect, test, and maintain the fire alarm system properly, including securing the control panel keys.
K346 Fire Alarm System - Out of Service: Facility staff failed to ensure a complete policy for fire alarm system outages over four hours, affecting all occupants' safety.
K354 Sprinkler System - Out of Service: Facility staff failed to ensure a complete policy for sprinkler system outages over ten hours, affecting all occupants' safety.
K372 Subdivision of Building Spaces - Smoke Barrier: Facility staff failed to maintain smoke/fire barrier walls free of openings, affecting containment of smoke and fire in multiple zones.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: Facility staff failed to maintain two of six fire barrier doors to resist smoke and fire passage, affecting containment in three smoke zones.
K712 Fire Drills: Facility staff failed to conduct fire drills at various times and shifts quarterly, and failed to document verification of alarm signal transmissions.
Report Facts
Facility census: 70
Facility capacity: 102
Deficiencies cited: 7
Inspection Report
Plan of Correction
Census: 77
Deficiencies: 6
Date: Mar 5, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident privacy, medication storage, medication destruction, and professional standards of care.
Findings
The facility was found deficient in maintaining personal privacy of residents, proper medication storage and destruction, and adherence to professional standards in medication management. Multiple observations and interviews revealed failures to secure electronic health records, medication carts, and controlled substances, as well as incomplete documentation and improper medication handling.
Deficiencies (6)
F 583 Personal Privacy/Confidentiality of Records: Facility staff failed to maintain personal medical information privacy for three residents, including leaving electronic health records visible to residents and visitors.
F 658 Services Provided Meet Professional Standards: Facility staff failed to follow professional standards in controlled substance destruction and documentation for two residents, including missing signatures and improper medication removal.
F 761 Label/Store Drugs and Biologicals: Facility failed to properly label and securely store medications, including unlocked medication carts, unsecured narcotics, and medication cups without proper labeling.
A4064 Medication Storage: Facility did not store medications at appropriate temperatures in locked compartments and failed to separate discontinued medications from current ones.
A4069 Med Destruction Record: Facility failed to maintain complete records of medication destruction, missing required details and signatures.
A8030 Dignity/Privacy: Facility failed to ensure residents were treated with full consideration and privacy in treatment and care.
Report Facts
Facility census: 77
Weeks of monitoring: 8
Medication cups: 2
Insulin pens: 15
Oxycodone tablets: 30
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
Annual Inspection
Census: 75
Deficiencies: 2
Date: Nov 9, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident activities and care plans at Cedar Pointe.
Findings
The facility failed to provide an ongoing program of activities designed to meet the interests of residents, as evidenced by observations, interviews, and record reviews. Staff did not provide sufficient activities on weekends and did not adequately document or encourage resident participation in activities.
Deficiencies (2)
F 679 Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1). The facility failed to provide an ongoing program of activities to meet residents' interests for four residents and on weekends, limiting independence and interaction.
A4101 19 CSR 30-85.042(92) Activity Program. The facility did not designate an employee responsible for the activity program capable of identifying resident needs and providing regular activity programs.
Report Facts
Facility census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lynn | Administrator | Signed the statement of deficiencies and plan of correction |
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: 2
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property and narcotics by a Certified Medication Technician (CMT) at Cedar Pointe.
Complaint Details
The complaint was substantiated. The investigation revealed that a Certified Medication Technician was arrested for possession of controlled substances without a prescription and misappropriation of $1100 in cash from a resident. Police and facility staff reviewed camera footage and conducted interviews confirming the incident.
Findings
The facility failed to prevent the misappropriation of narcotic medications for three residents and $1100 in cash from a resident. The investigation included review of medication logs, interviews with staff, and police involvement, resulting in the arrest of the employee involved.
Deficiencies (2)
F 602: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility failed to prevent misappropriation of narcotic medications for three residents and $1100 in cash from a resident by a Certified Medication Technician.
A8023: The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, abuse, and misappropriation of resident property and funds, and failed to require reporting to the department for vulnerable persons.
Report Facts
Resident census: 74
Missing cash amount: 1100
Medication pills count discrepancy: 39
Medication pills count discrepancy: 37
Medication pills count discrepancy: 6
Medication pills count discrepancy: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in misappropriation of narcotics and cash findings; arrested for possession of controlled substances |
| CMT B | Certified Medication Technician | Interviewed and questioned regarding missing narcotics and cash |
| Director of Nursing | Director of Nursing | Notified of missing money and involved in investigation |
| Administrator | Administrator | Notified of missing money and involved in investigation |
| LPN C | Licensed Practical Nurse | Interviewed regarding narcotic counts and discrepancies |
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
Annual Inspection
Census: 72
Deficiencies: 11
Date: Feb 14, 2022
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for Cedar Pointe nursing facility in Rolla, MO.
Findings
The facility was found deficient in multiple areas including notification of changes in resident condition, comprehensive resident assessments, care plan timing and revision, ADL care, nutrition and hydration maintenance, and clinical record retention. The facility submitted plans of correction to address these deficiencies.
Deficiencies (11)
F580 Notification of Changes: Facility failed to notify family/resident representative and physician timely of a resident's significant change in condition including weight loss and decline.
F636 Comprehensive Assessments & Timing: Facility failed to complete comprehensive resident assessments using the Minimum Data Set within required timeframes for multiple residents.
F641 Accuracy of Assessments: Facility failed to document complete and accurate Minimum Data Set assessments, including hospice services coding, for sampled residents.
F657 Care Plan Timing and Revision: Facility failed to update and revise care plans timely with specific interventions for six sampled residents and failed to allow participation of residents, representatives, and physicians.
F677 ADL Care Provided for Dependent Residents: Facility failed to provide adequate bathing and shower care for six sampled residents, including documentation of refusals.
F692 Nutrition/Hydration Status Maintenance: Facility failed to ensure timely interventions for residents with weight loss and failed to maintain acceptable nutritional parameters.
A4076 Clean, Dry, Odor Free: Facility failed to maintain residents clean, dry, and free of offensive body and mouth odor.
A4087 Dr Notification-Change in Condition: Facility failed to notify physician timely of significant changes in resident condition as required by emergency treatment policies.
A4108 Clinical Records - assessment/interventions: Facility failed to ensure clinical records contained sufficient information reflecting assessments and interventions.
A4117 Clinical Records Retention: Facility failed to retain clinical records for the required period of time as mandated by state law.
A5001 Nutritional Needs Met, Assess Res, Inform Dr: Facility failed to serve nutritious food and properly assess and inform physician of nutritional needs.
Report Facts
Facility census: 72
Weight loss percentage: 10.56
Weight loss percentage: 5.24
Weight loss percentage: 3.51
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 4
Date: Oct 22, 2021
Visit Reason
The inspection was conducted in response to allegations of verbal abuse by a Certified Nursing Assistant (CNA) towards a resident, including the use of racial slurs and failure to report the abuse in a timely manner.
Complaint Details
The complaint investigation substantiated that a CNA verbally abused a resident using racial slurs. The facility failed to report the abuse within the required timeframe. The CNA was terminated following the investigation.
Findings
The facility failed to ensure a resident was free from verbal abuse by staff, specifically a CNA who used racial slurs and derogatory language. Additionally, the facility did not report the alleged verbal abuse to the appropriate authorities within the required timeframe.
Deficiencies (4)
F600: The facility failed to ensure one resident remained free from verbal abuse, as a CNA used racial slurs and derogatory language towards the resident.
F609: The facility failed to report an allegation of employee verbal abuse towards a resident within the required two-hour timeframe to the Department of Health and Senior Services.
A4073: The facility did not meet the requirement for protective oversight and supervision for residents on voluntary leave, as per 19 CSR 30-85.042(66).
A8025: The facility failed to immediately report or cause to be reported to the department any suspected abuse or neglect of a vulnerable person, violating 19 CSR 30-88.010(25).
Report Facts
Facility census: 73
Deficiency severity count: 2
Deficiency severity count: 2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Apr 14, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding an emergency discharge and transfer of a resident from the facility.
Complaint Details
The complaint investigation found that the facility improperly discharged a resident with an emergency discharge notice dated 4/2/21 without proper documentation or notification. The discharge was substantiated as improper.
Findings
The facility failed to allow one resident to return after a hospital stay and did not provide a location for the resident upon issuing an emergency discharge notice. The discharge notice lacked required specific information and was deemed an improper discharge.
Deficiencies (2)
F622 Transfer and discharge requirements were not met as the facility failed to permit a resident to remain in the facility and did not properly document or notify regarding the emergency discharge.
A8018 Emergency discharge regulations were not met as the facility failed to provide a timely written notice of discharge to the resident or next of kin and did not send a copy to the Missouri State Ombudsman’s office.
Report Facts
Facility census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator interviewed regarding the emergency discharge and transfer process |
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 |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 10
Date: Feb 4, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations related to food service, infection control, and other facility operations at Cedar Pointe nursing facility.
Findings
The facility was found deficient in multiple areas including nutritional adequacy of menus, food preparation and safety, infection prevention and control, and proper use of personal protective equipment. Several food safety and infection control policies were not followed or adequately implemented.
Deficiencies (10)
F803 Menus did not meet nutritional adequacy requirements; facility failed to serve food items to one resident in accordance with a pureed diet order and did not follow recipes for pureed meals.
F812 Facility failed to ensure food was procured, stored, prepared, and served under sanitary conditions; thawing procedures and storage of cleaning rags were improper.
F880 Infection prevention and control program was deficient; staff failed to properly wear and handle face masks and did not maintain hand hygiene after removing masks.
A4085 Facility failed to use acceptable infection control procedures to prevent spread of infection; report to health division was not made within seven days for communicable disease.
A5001 Nutritional needs were not met; residents did not receive properly prepared and seasoned food according to physician orders and nutritional guidelines.
A7015 Food was not protected from contamination; temperature controls and handling procedures were inadequate.
A7035 Potentially hazardous foods were not thawed properly in refrigerated units to prevent bacterial growth.
A7042 Ice storage and dispensing did not prevent contamination; ice storage bins lacked proper air gap drainage.
A7069 Moist cloths and sponges used for wiping food contact surfaces were not stored properly in sanitizing solution.
A7086 Equipment and utensils were not air dried or stored in a self-draining position after sanitization.
Report Facts
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook N | Named in findings related to food preparation and thawing procedures | |
| Dietary Aide Q | Named in findings related to food preparation and serving | |
| Dietary Manager (DM) | Interviewed regarding food preparation policies and infection control | |
| Cook P | Named in findings related to food preparation and sanitation | |
| Cook O | Named in findings related to infection control and mask usage | |
| Maintenance Director (MD) | Interviewed regarding ice machine maintenance and sanitation | |
| Administrator | Interviewed regarding food preparation and infection control policies |
Inspection Report
Life Safety
Census: 57
Capacity: 102
Deficiencies: 5
Date: Feb 3, 2021
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain unobstructed means of egress, failed to maintain doors with proper locking arrangements, failed to conduct fire drills quarterly on each shift, failed to maintain smoking areas free from fire hazards, and failed to properly store oxygen cylinders. These deficiencies have the potential to affect all facility occupants.
Deficiencies (5)
K211 Means of Egress - General: Facility staff failed to maintain means of egress free of obstruction and unsecured furniture, including vending machines and chairs blocking corridors and exits.
K222 Egress Doors: Facility staff failed to maintain doors in a means of egress readily accessible at all times and failed to post codes to exit doors equipped with magnetic locking devices.
K712 Fire Drills: Facility staff failed to conduct fire drills quarterly on each shift for the months of February 2020 through January 2021, potentially delaying response procedures.
K741 Smoking Regulations: Facility staff failed to maintain two smoking areas free from fire hazards and ensure proper disposal of cigarette waste in ashtrays.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to store oxygen cylinders in accordance with NFPA 99, including failure to separate full and empty cylinders and store combustibles away from oxygen.
Report Facts
Facility census: 57
Total capacity: 102
Fire drills missed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding means of egress obstructions, door locking codes, and fire drill scheduling | |
| Administrator | Interviewed regarding policies on corridor maintenance, door locking codes, fire drills, smoking areas, and oxygen storage |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Report Facts
Regulatory citation: 42
Inspection Report
Abbreviated Survey
Census: 85
Deficiencies: 1
Date: May 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess infection prevention and control compliance related to COVID-19 protocols.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness. However, staff failed to consistently follow infection control protocols, including improper facemask use and inadequate hand hygiene.
Deficiencies (1)
F880 Infection Prevention & Control: Staff failed to follow infection control protocols for COVID-19, including improper facemask use and failure to sanitize hands after touching facemasks.
Report Facts
Census: 85
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 6
Date: Mar 21, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for nursing facilities, including resident rights, privacy, infection control, abuse/neglect policies, transfer/discharge notices, and immunization requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by knocking before entering rooms, protecting resident privacy during medication administration, implementing abuse/neglect policies, providing proper transfer/discharge notices, infection prevention and control procedures, and immunization documentation and education.
Deficiencies (6)
F550 Resident Rights: Staff failed to knock before entering residents' rooms and pulled a resident backwards in a Broda chair, compromising dignity.
F583 Privacy and Confidentiality: Staff failed to protect residents' privacy by leaving medication administration records open and not closing doors or curtains during care.
F607 Abuse/Neglect Policies: Facility failed to ensure CNA registry checks for four of ten sampled employees hired since last survey.
F623 Notice Before Transfer/Discharge: Facility failed to notify resident and representative in writing of transfer to hospital and failed to provide transfer letters.
F880 Infection Prevention & Control: Facility failed to use appropriate hand hygiene and glove use, clean glucometer properly, and conduct annual IPCP review.
F883 Influenza and Pneumococcal Immunizations: Facility failed to maintain and document vaccination education, history, and administration for residents.
Report Facts
Census: 60
New employees hired: 120
Sampled residents: 15
Employees without CNA registry check: 4
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 21, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The Emergency Preparedness portion of the survey resulted in no deficiencies. The facility met the applicable provisions of the Life Safety Code. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 5
Date: Apr 19, 2018
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Rolla Manor Care Center following a survey completed on April 19, 2018. It addresses deficiencies found related to the facility environment and resident care.
Findings
The facility failed to provide a safe, clean, and comfortable environment, with issues such as damaged walls, missing wood, and black substances in the shower room. Staff also failed to provide adequate personal care, grooming, hydration, and nail care to residents.
Deficiencies (5)
F584 Safe Environment: The facility did not maintain a clean, safe, and comfortable environment, with damaged walls, chipped paint, missing wood, and black substances in the shower room.
F677 ADL Care: Staff failed to provide necessary grooming, personal hygiene, and hydration services to residents, including not offering fluids and not assisting with nail care.
A4076 Residents Groomed/Dressed Appropriately: Residents were not consistently well-groomed and dressed appropriately according to their preferences and medical conditions.
A4078 Sufficient Fluids/Hydration: The facility did not ensure residents had access to sufficient fluids to maintain proper hydration.
A6015 Walls/Ceilings/Doors/Windows Clean: Walls, ceilings, doors, and windows were not clean and maintained in good repair.
Report Facts
Facility census: 53
Inspection Report
Life Safety
Census: 53
Capacity: 102
Deficiencies: 3
Date: Apr 18, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with emergency preparedness and emergency lighting requirements as part of a life safety code survey.
Findings
The facility failed to develop and implement an emergency preparedness communication plan involving residents and their representatives. Additionally, the facility did not document required monthly and annual functional testing of emergency lighting equipment.
Deficiencies (3)
E035: The facility failed to develop and maintain an emergency preparedness communication plan that includes sharing information with residents and their families or representatives. The administrator was not aware that residents and families needed to be notified of the emergency preparedness program.
K291: The facility failed to document monthly 30-second functional tests and annual 1.5-hour functional tests of all battery-powered emergency lighting equipment. The maintenance supervisor was aware of the testing requirements but did not know about documentation procedures.
A2058: The facility did not have a written fire drill and emergency preparedness plan as required by state regulations. This deficiency is linked to E035.
Report Facts
Facility census: 53
Total capacity: 102
Emergency lighting fixtures: 15
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