MILL CREEK VILLAGE ASSISTED LIVING.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER MILL CREEK VILLAGE-ASSISTED LIVING BY AMERIC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 03/14/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 03/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1990 W SOUTHAMPTON COLUMBIA, MO 65203 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements. (D) The department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two- (2-) hour fire-resistant construction. No section of the building shall present a fire hazard. I/II This regulation is not met as evidenced by: Class II Based on observation and interview during a fire inspection on March 6, 2024 the facility staff failed to keep the facility in a condition to not present a hazard. The facility census was 49. This deficiency affects 49 of the 49 residents. Observation during the inspection process of both the Assisted living building and the Arbors memory care building, showed that the furnace units were fueled by natural gas and no carbon monoxide detectors were located anywhere in either building. During an interview at 4:40 P.M. the maintinace manager stated he was not aware the detectors were not in the buildings and would get some placed throughout both buildings as soon as possible. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4Q0E11 If continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER MILL CREEK VILLAGE-ASSISTED LIVING BY AMERIC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 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 on March 6, 2024, the facility failed to ensure the storage of unnecessary combustible materials in any part of a building in which a licensed facility is located was prohibited. The facility census was 49. This deficiency affects 49 of the 49 residents. Observation at 2:07 P.M., showed several five gallon paint buckets stored in the furnace room, located in hallway C, inside the facility. During an exit interview at 4:40 P.M., the mantinance manager stated he was new to this position and would get the paint removed from the building as soon as possible. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 4Q0E11 PRINTED: 03/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1990 W SOUTHAMPTON COLUMBIA, MO 65203 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 6 PRINTED: 03/14/2024 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 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1990 W SOUTHAMPTON COLUMBIA, MO 65203 (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) MILL CREEK VILLAGE-ASSISTED LIVING BY AMERIC Continued From page 2 19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. Sprinkler Systems. (F) All facilities shall have inspections and written certifications of the approved sprinkler system completed by an approved qualified service representative in accordance with NFPA 25, 1998 edition. The inspections shall be in accordance with the provisions of NFPA 25, 1998 edition, with certification at least annually by a qualified service representative. 1/Il This regulation is not met as evidenced by: Class II Based on record review and interview during the fire safety inspection process on March 6, 2024, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA) 25, 1998 edition. The facility census was 49. This deficiency affects 49 of the 49 residents. During the record review on March 6, 2024 at 3:00 P.M., no current annual sprinkler report was located in the reports binder. The previous annual testing was dated February 16, 2023. During an interview at 4:40 P.M. the maintinance manager stated, he had recently just started at this location and did not know the inspection was recently due. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated Missouri Department of Health and Senior Services STATE FORM oe 4Q0E11 If continuation sheet 3 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER MILL CREEK VILLAGE-ASSISTED LIVING BY AMERIC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 wastebaskets shall be used for trash. Il This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on March 6, 2024 the facility failed to ensure only solid metal, UL- or FM-fire-resistant rated wastebaskets were being used for trash. The facility census was 49. This deficiency affects 49 of 49 residents. Observation throughout the fire inspection showed approximately ten unapproved wastebaskets in use throughout the buildings. The following rooms were noted with one or two violations each during the inspection. Rooms in ALF building: D7, D6, C3, AG, Rooms in the memory care building 2,10, 12 During an interview at 4:40 P.M. the maintenance director expressed his apologies and stated he would get the issue taken care of. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 4Q0E11 PRINTED: 03/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1990 W SOUTHAMPTON COLUMBIA, MO 65203 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 6 PRINTED: 03/14/2024 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 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1990 W SOUTHAMPTON COLUMBIA, MO 65203 (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) MILL CREEK VILLAGE-ASSISTED LIVING BY AMERIC Continued From page 4 does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process on March 6, 2024 the facility failed to properly maintain the buildings electrical wiring to not cause a safety or fire hazard. The facility census was 49. This deficiency affects 49 of the 49 residents. Observation at 1:51 P.M. showed an unapproved extension cord being powered by a second unapproved extension cord in resident room D2. Observation at 1:56 P.M. showed an unapproved multi plug addapter in use in resident room D6. Observation at 2:14 P.M. showed an unapproved multi plug addapter in use in resident room A6. Observation at 2:20 P.M. showed an unapproved extension cord in use in resident room B1. During an interview at 4:40 P.M. the maintinance manager stated he was not aware the electrical Missouri Department of Health and Senior Services STATE FORM oe 4Q0E11 If continuation sheet 5 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1990 W SOUTHAMPTON MILL CREEK VILLAGE-ASSISTED LIVING BY AMERIC COLUMBIA, MO 65203 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PRINTED: 03/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/06/2024 (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 A3214| Continued From page 5 extension cords and multi plug adapters were in use and would see that they all were replaced with approved power strips. Missouri Department of Health and Senior Services STATE FORM oeee 4Q0E11 If continuation sheet 6 of 6 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)