MEADOWVIEW MEMORY CARE.

PRINTED: 05/15/2024 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 12549N B. WING ________H_..... 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 555 WOODLAND VILLAS LANE MEADOWVIEW MEMORY CARE ARNOLD, MO 63010 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2249| 19 CSR 30-86,022(9)(C) Fire Alarm A2249 System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the compiete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class ll Based on record review and interview on May 9, 2024, the facility failed to insure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition.. The facility census was 16. This affected 16 out of 16 residents. Record review at 11:45 A.M. showed no semi-annual inspection had been done on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1 and 7.3.2. Futher review showed the annual inspection was done in October 2023, making the semi-anjual due in April of 2024. During an interview on May 9, 2024 at the time of discovery, the Maintenance Director stated he/she would schedule a semi-annual test. Missouri Department of Health and Senior Services J ABQRATORY DIRECTOR'S ER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE ; — eb oSni4 Me tor VOfp 2] “STATE FORM 6a98 UXEH11 lf continuation sheet 1 of 4 PLAN OF CORRECTION Provider/Supplier Meadowview Name: Street Address, | 555 Woodland Villas, Amold, MO 63010 City, Zip: Date of Survey: 05/09/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D0436799 ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE It is the intent of Meadowview to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. Corrective Action On 05/10/2024 the semi-annual inspection was performed on A2249 the fire alarm system as required. See attached inspection 05/10/2024 report. Action to prevent occurrence On 05/10/2024 the semi-annual fire inspection was added the preventive maintenance program. NT 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.