JEFFERSON GARDENS ASSISTED LIVING.

NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM). PRINTED: 02/11/2026 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 20603D B. WING 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 509 WEST ROGERS CLINTON, MO 64735 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) JEFFERSON GARDENS ASSISTED LIVING 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed ensure hazardous areas are separated from the rest of the facility by a one hour fire-resistant rating or if the area is sprinkled, they shall have a smoke-resistant partitions and doors. The facility census was twenty-two (22). This affected twenty-two (22) of twenty-two (22) residents. At 1:10 P.M., Observation and record review, showed the activity room's kitchen did not have a smoke-resistant separation from the rest of the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 L76511 If continuation sheet 1 of 2 PRINTED: 02/11/2026 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 20603D B. WING 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 509 WEST ROGERS CLINTON, MO 64735 (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) JEFFERSON GARDENS ASSISTED LIVING Continued From page 1 facility or a granted exception posted. This building is fully sprinkled. The kitchen stove has a keyed shut off and the key is kept in a secured location and has to be checked out for use. During an interview on January 8, 2024 at 3:00 P.M., the administrator and director of maintenance said they were unaware of the requirement and will look into it. Missouri Department of Health and Senior Services STATE FORM 6899 L76511 If continuation sheet 2 of 2

PRINTED: 12/26/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 20603D Se UN aes 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 509 WEST ROGERS CLINTON, MO 64735 (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 i | DEFICIENCY) | JEFFERSON GARDENS-ASSISTED LIVING BY A4733 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: Based on interview and record review, the facility | failed to ensure all personnel files contain a statement by a licensed physician or physician designees indicating the staff member could work | in a long-term care facility and any limitation when | the personnel files of five staff members (Certified Medical Assistant (CMAA), Activities Director B, Director of Nursing (DON) C, Executive Director (ED) D and Certified Nursing | Assistant (CNA) E), of the five sampled staff member, did not contain the physician statement regarding the staff member's ability to work in a long-term care facility. The facility census was 23. Review showed the facility did not provide a policy regarding written statements by a licensed physician or designee indicating a person can work in a long-term care facility and any limitations. 1. Record review of CMAA's personnel file showed the following: -Hire date of 07/21/23; -Start date of 08/17/23; -The personnel file did not contain a written statement by a licensed physician or physician's Missouri Department of Health and Senior Services _- STATE FORM KQ4xX11 IfZontinuation sheet 1 of 3 PRINTED: 12/26/2023 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 C 20603D B. WING 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 509 WEST ROGERS CLINTON, MO 64735 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) JEFFERSON GARDENS-ASSISTED LIVING BY Continued From page 1 designee indicating the person can work ina long-term care facility and any limitations. 2. Record review of Activities Director B's personnel file showed the following: -Hire date of 06/27/23; -Start date of 07/14/23; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person can work in a long-term care facility and any limitations. 3. Record review of DON C's personnel file showed the following: -Hire date of 01/18/23: -Start date of 02/09/23; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person can work ina long-term care facility and any limitations. 4. Record review of ED D's personnel file showed the following: -Hire date of 09/14/23; -Start date of 10/21/23; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person can work ina long-term care facility and any limitations. 5. Record review of CNA E's personnel file showed the following: -Hire date of 11/22/23; -Start date of 11/24/23; -The personnel file did not contain a written statement by a licensed physician or physician's Missouri Department of Health and Senior Services STATE FORM 6899 KQ4X11 If continuation sheet 2 of 3 PRINTED: 12/26/2023 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 C 20603D B. WING 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 509 WEST ROGERS CLINTON, MO 64735 (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) JEFFERSON GARDENS-ASSISTED LIVING BY Continued From page 2 designee indicating the person can work ina long-term care facility and any limitations. 6. During an interview on 12/21/23, at 3:00 P.M., the Executive Director said he/she did not know this was a state requirement and is not sure who is responsible for employee health statements. Missouri Department of Health and Senior Services STATE FORM 6899 KQ4X11 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Jefferson Gardens Name: Street Address, 509 West Rogers Street City, Zip: Clinton, MO 64735 Date of Survey: 12/21/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 045594 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE “This Plan of Correction is prepared and submitted as required by law. By submitting this Plan of Correction, Jefferson Gardens | does not admit that the deficiencies listed on this form exist, nor does the Center admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiencies. The Center reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiencies, statements, facts | and conclusions that form the basis for the deficiencies. The filing of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the summary Statement of Deficiencies dated 12/021/2023 by the Missouri Department of Health and Senior Services this plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law” A4733 Personnel Record-Physician Statement-Staff in LTC facilit Personnel files must contain a written statement by a licensed physician or designee indicating a person can work in a long- term care facility and any limitations. 1/25/2024 Statement indicating they can work in a LTC facility and an eee ene 1/25/2024 sacra eect Nas deere Fae aE aot Lt = 3) ED, DON, and Bookkeeper will review the regulation and 1/25/2024 and company policy in regard to the physician statement Be el ee ee ee going Un ee 5) Compliance will be monitored through personnel file audits going on an annual and prn basis. The Administrator sighing anda@ ating the first page of the CMS-2567/State Form is indicating théir approval of the plan of correction being submitted on this form. aA 7 7