RIDGEVIEW ASSISTED LIVING CENTER.

PRINTED: 05/14/2025 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 B.WING 05/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13134 STATE HIGHWAY 25 DEXTER, MO 63841 (X4) (0 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} RIDGEVIEW ASSISTED LIVING CENTER A2217| 19 CSR 30-86.022(5)(D) Fire Drill Requirements, in accordance with 19 CSR Evacuation 30-86.022 (5)(D) Fire Drill Requirments, Evacuation 5/19/2025 Fire Drilis and Emergency Preparedness. (D) Aminimum of twelve (12) fire drills shall be New Fire Drill schedule was conducted annually with at least one (1) every . three (3) months on each shift. At least four (4) of Hote ieaatenn trea the required fire drills must be unannounced to : 9 ensure conducted on each shift residents and staff, excluding staff who are assigned to evaluate staff and resident response every (3) months. Weekend and holiday drills are scheduled. to the fire drill. The fire drills shail include a ; . resident evacuation at least once a year. [I/II Drills will not be announced and full evacuation will be completed once yearly. This regulation is not met as evidenced by: Class fil Staff participating in conducting Based on record review and interview, the facility drills have been educated. Will failed to conduct a minimum of twelve (12) fire be monitored by administrator drills per year with at least one drill every three (3) monthly. months on each shift. The facility census was twenty two (22). This deficiency affects twenty two (22) of twenty two (22) residents. Record review showed the following drifls documented: April 2025 day shift March 2025 night shift Feb 2025 evening shift Jan 2025 day shift Dec 2024 day shift Nov 2024 day shift Oct 2024 incomplete documentation Sept 2024 evening shift Aug 2024 incomplete documentation July 2024 day shift June 2024 night shift May 2024 evening shift Five (5) drills were documented as day shift. Three (3) drills were documented as evening Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE JLS111 If continuation sheet 1 of 4 STATE FORM PRINTED; 05/14/2025 FORM APPROVED 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: (X3) DATE SURVEY COMPLETED BAWING 05/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13134 STATE HIGHWAY 25 DEXTER, MO 63841 ¢x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (5) 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) RIDGEVIEW ASSISTED LIVING CENTER Continued From page 1 shift. Two (2) drills were documented as night shift. Two (2) were documented with the information incomplete and not able to determine what shift or time they had been performed. Drills were not completed with at least one drill performed every three (3) months on each shift as required, During an interview on May 12, 2025 at 2:00 P.M., the LPN said he was not sure why the drills were not as required in 2024 as he was not at the facility during that time. He stated he would cover the proper way to document future drills in the future with staff. 19 CSR 30-86.022(10){A) Hazardous Area In accordance with 19 CSR ; Requirements 30-86.022(10)(A) Hazardous Area | 8/4/2025 Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, Estimates received for smoke for more than twelve (12) beds, hazardous areas barrier in kitchen for Pass through shail be separated by construction of at least a serving window to be closed off one- (1-) hour fire-resistant rating. In facilities permanently. Appropriate Smoke equipped with a complete fire alarm system, the barrier solid door and self closing one- (1-) hour fire separation is required only for will be installed furnace or boiler rooms. Hazardous areas , equipped with a compiete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shail 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 shail 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 Hl, and existing prior to November 13, Missouri Department of Health and Senior Services STATE FORM 6399 JLS111 if continuation sheet 2 of 4 PRINTED: 05/14/2025 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 B.WING 05/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 43134 STATE HIGHWAY 25 DEXTER, MO 63841 (X4) 1D 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) RIDGEVIEW ASSISTED LIVING CENTER Continued From page 2 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class Il Based on observation, record review and interview, the facility failed to properly install and or maintain smoke-resistant partition that would seperate the kitchen from the rest of the facility in the event a fire hazard condition were to occur, The facility census was twenty two (22). This deficiency affects twenty two (22) of twenty two (22) residents. Observation showed there is a pass through serving window from the facility kitchen to the dining room area, The window does nat have an automatic or self closing smoke partition installed to seperate the kitchen from the facility during a fire hazard condition. Observation showed the kitchen door is made in two pieces with no self closure attached. Record review shows the facility was originally licensed July 15, 2010. During an interview on May 12, 2025 at 2:15 P.M, the LPN stated he would have this corrected if required, In accordance with 19 CSR 49 CSR 30-86.022(17) Oxygen Storage 30-86.022(17) Oxygen Storage Requirements Requirements 5/12/2025 Oxygen storage shall be in accordance with oxygen tanks were moved to NFPA 99, 1999 Edition. fI/H appropriate storage secured behind chains. Staff educated. Will be monitored by administrator Missourt Department of Health and Senior Services STATE FORM 6899 JLS111 If continuation sheet 3 of 4 PRINTED: 05/14/2025 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 B.WING | 05/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, Z)P CODE 13434 STATE HIGHWAY 25 DEXTER, MO 63841 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x) 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 OATE DEFICIENCY) RIDGEVIEW ASSISTED LIVING CENTER Continued From page 3 This regulation is not met as evidenced by: Class il Based on observation and interview, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census was twenty two (22). This deficiency affects twenty two (22) of twenty two (22) residents. Observation showed seventeen (17) oxygen cylinders standing upright and not stored in an approved rack or secured by a chain or band in the closet of the facility med room. During an interview on May 12, 2025 at 2:15 P.M. the LPN said the cylinders had been recently moved from the normal storage area when rooms had been relocated, he said he would ensure the cylinders are corrected. Missouri Department of Health and Senior Services : STATE FORM 6899 JLS144 If continuation sheet 4 of 4

PRINTED; 04/08/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA AND PLAN GF CORRECTION IDENTIFICATION NUMBER: A. BLILDING: (X2) MULTIPLE CONSTRUCTION (43) DATE SURVEY COMPLETED TA 5! a a a we OH27/2025 STREET ADDRESS, CITY, STATE, ZIP CODE RIOGEVIEW ASSISTED LIVING CENTER lag Sel i DEXTER, MO 6384 NAME OF PROVIDER OR SUPPLIER SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IQENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE OfFICIENCY) 19 CSR 30-87.020(12} Floor Surfaces “5 In accordance with 19 CSR 30-87 .020(12)} Floor Surfaces All floors in the facility shall be clean and shall be maintained in good repair, Floors and floor coverings ef all food-preparation, food-storage Estimate received to replace kitchen and utensii-washing aréas, and the floars of all flooring. Repairs to start in May 2025 walk-in refrigarating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealad concrete, terrazzo, ceramic tile, durable grades of iinolaum aor plastic, ar tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip flocr covering in areas Where necessary for safety reasons. Ill This regulation Is not met as evidenced by: Class Ill Based on observalion and Interview, the facility falled to ensure floors were kept clean and in good repair. This had the potential to affect all residents who reside in the tacillty. The facility's census was 24. Cbservation on 03/27/25 at 10:30 A.M. of the kitchen showed: - An eight inch (") x one-half * section of vinyl flooring missing near the sink, exposing the subftoor - Athree “x seven * section of vinyt ilcoring missing near the sink, exposing the subfloar; - Aseven "x one-half * section of vinyl flooring missing near (he sink, expasing the subflcor, - 431" section of vinyi flooring, buckled and cracked, near the stove; - A 48" section of vinyl flooring, buckled and cracked, near the stove. During an interview on 0327/25 at 11:30 A.M., the Administrator sald the klichen flooring needs to be replaced. Missouri Departmant of Hsallh end Senior Services Le LABORATORY OIRECTGA’S OR PROVICER/SUPPLIER REPRESENTATIVE'S SIGNATURE Tey J (Az (XO, CATE ved a (yee LE IMS adn pet eta ht IG Teanlinuation sheet 10f2 STATE FORM wn * aYEVT PRINTED: 04/08/2025 FORM APPROVED Missouri Daparimant of Health and Senior Services STATEMENT GF DEFICIENCIES (1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 2) MULTIPLE CONSTRUCTION {X3) DAYE SURVEY A. BUILDING: COMPLETED ae 101425 B. WING 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13134 STATE HIGHWay 25 RIDGEVIEW ASSISTED LIVING CENTER DEXTER, MO 63944 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (GACH DEFICIENCY MUST BE PRECEDED AY FULL {EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IOENTIFYING INFORMATION) CROSS-REFERENCED TO iy APPROPRIATE DEFICIENCY) Missour Dapartment of Health and Senior Services STATE FORM ate 4YEVI4 (continuation shoot 2 of 2

PRINTED: 08/1 7/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3} DATE SURVEY COMPLETED {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 05/07/2024 STREET ADDRESS, CITY, STATE, Z/P CODE 13134 STATE HIGHWAY 25 DEXTER, MO 63841 NAME OF PROVIDER OR SUPPLIER RIDGEVIEW ASSISTED LIVING CENTER SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5} (x4) 1D PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A6045 19 CSR 30-87.020(45) Lavatory/Fixtures Clean/Good Repair In accordance with 19 CSR 30-87 .020(45) Lavatories, soap dispensers, hand-drying devices and all related fixtures shall be kept clean and in good repair, [I Estimate received to replace flooring, vanity, trim, and caulking in bathroom by 7/ 3 i 14 room #106 and room #210. Repairs to start in June 2024. This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to ensure two of three resident use bathrooms were kept clean and well maintained. The facility census was 23, 1. Observation on 05/07/24 between 10:15 A.M. and 10:25 A.M. of the resident use bathroom by room #106 showed: - Avanity with broken doors and peeling paint from top to bottom; ~ An uneven line of caulking around the base of the toilet and behind the sink; - Adirt stained floor. 2. Observation on 05/07/24 between 11:00 A.M. and 11:10 A.M. of the resident use bathroom across the hall from room # 210 showed: - Avanity with no doors; - The area above and behind the sink stained and coming apart; - Ail the baseboards around the perimeter of the roam missing and the exposed area above the floor stained and coming apart. During an interview on 05/07/24 at 11:00 A.M., the Administrator said the facility was waiting for the corporate office to approve the remadel of the bathrooms. When the approval is given, the bathrooms will be fixed. Missouri Department of Heaith and Senior Services f j LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE yy, 7 y, é/ THU (X6) DATE Sf, y ef bu lo UN MM admunuatatbr 7? STATE FORM bs09 ZRS511_— If continuation sheet 1 of 4

PRINTED: 10/18/2023 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 40128 B.WING 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13134 STATE HIGHWAY 25 DEXTER, MO 63841 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (X8) PREFIX (EACH DEFICIENCY MUST 8€ PRECEDED BY FULL. PREFIX (EACH CORRECTIVE ACTION SHOULD BE trial TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE RIDGEVIEW ASSISTED LIVING CENTER 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shail be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff wno are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. HAI This regulation is not met as evidenced by: Class III Based on record review and interview on October 16, 2023 the facility failed to conduct a minimum of twelve (12) fire drills per year with at least one drill every three (3) months on each shift. The facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Record review an October 16, 2023 at 10:42 A.M., showed the following drills documented: 10/--/22 no drill documented 11/-/22 no drill documented {2/--/22 no drill documented 01/01/23 day shift 02/05/23 evening shift 03/05/23 night shift 04/08/23 day shift 05/29/23 day shift 06/07/23 day shift 07/05/23 evening shift 08/08/23 night shift 09/02/23 day shift Missouzi Department of Health and Senior Services TITLE (X6) DATE. If continuation sheet 1 of 6 9RF711 STATE FORM PRINTED: 10/18/2023 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 10128 $$$ i$ 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13134 STATE HIGHWAY 25 DEXTER, MO 63841 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY RIDGEVIEW ASSISTED LIVING CENTER 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/Ill This regulation is not met as evidenced by: Class III Based on record review and interview on October 16, 2023 the facility failed to conduct a minimum of twelve (12) fire drills per year with at least one drill every three (3) months on each shift. The facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Record review on October 16, 2023 at 10:42 A.M., showed the following drills documented: 10/--/22 no drill documented 11/--/22 no drill documented 12/--/22 no drill documented 01/01/23 day shift 02/05/23 evening shift 03/05/23 night shift 04/08/23 day shift 05/29/23 day shift 06/07/23 day shift 07/05/23 evening shift 08/08/23 night shift 09/02/23 day shift Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 QRF711 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: 10128 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 13134 STATE HIGHWAY 25 RIDGEVIEW ASSISTED LIVING CENTER DEXTER, MO 63841 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG TAG Continued From page 1 No fire drills were documented for the months of October,November & December 2022. Five (5) fire drills were documented as Day shift. Two (2) fire drills were documented as evening shift. Two (2) fire drills were documented as night shift. Fire drills were not completed with at least one drill performed every three (3) months on each shift as required. During an interview on October 16, 2023 at 1:46 P.M. the Maintenance person had no answer for why the drills were not performed properly. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on October 16, 2023 the facility failed to maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Record review on October 16, 2023 at 01:06 P.M., showed the excusion ring on the sprinkler head in resident room two hundred (200) was missing Missouri Department of Health and Senior Services STATE FORM 6899 PREFIX 9RF711 PRINTED: 10/18/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/16/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 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 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 10128 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 13134 STATE HIGHWAY 25 RIDGEVIEW ASSISTED LIVING CENTER DEXTER, MO 63841 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG TAG Continued From page 2 which leaves a gap around the sprinkler head that hot gas, smoke or fire could travel through in the event of a fire. Record review on October 16, 2023 at 01:26 P.M., showed the excusion ring on the sprinkler head in resident room one hundred two (102) had fallen about one half (1/2") inch which leaves a gap around the sprinkler head that hot gas, smoke or fire could travel through in the event of a fire. During an interview on October 16, 2023 at 01:46 P.M., the maintenance person said he would have this corrected. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. || This regulation is not met as evidenced by: Class II Based on observation and record review on October 16, 2023 the facility failed to ensure all curtains and drapes in a licensed facility are certified or treated with flame-resistant material as defined in NFPA 101, 2000 edition. The facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Observation on October 16, 2023 showed full length curtains in multiple resident rooms Missouri Department of Health and Senior Services STATE FORM 6899 PREFIX 9RF711 PRINTED: 10/18/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/16/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY 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: 10128 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 13134 STATE HIGHWAY 25 RIDGEVIEW ASSISTED LIVING CENTER DEXTER, MO 63841 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG TAG Continued From page 3 throughout the facility, the curtains showed no tags attached of being manufactured with or being treated with a flame resistant material. Record review on October 16, 2023 at 01:30 P.M. showed no documentation for curtains in the resident rooms, being manufactured with or being treated with a flame resistant material. During an interview on October 16, 2023 at 01:46 P.M. the maintenance person had no answer for the curtains. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FI-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview on October 16, 2023 the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being used for trash. Facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Observation on October 16, 2023 at 01:12 P.M. showed an unapproved plastic wastebasket in use in the living room of resident room two hundred five (205). Observation on October 16, 2023 at 01:33 P.M. showed an unapproved plastic wastebasket in use Missouri Department of Health and Senior Services STATE FORM 6899 PREFIX 9RF711 PRINTED: 10/18/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/16/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 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 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 10128 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 13134 STATE HIGHWAY 25 RIDGEVIEW ASSISTED LIVING CENTER DEXTER, MO 63841 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG TAG Continued From page 4 in the restroom of resident room one hundred three (103). During an interview on October 16, 2023 at 01:46 P.M. the maintenance person said the facility has been trying to find fire resistant wastebaskets and he will take care of them. 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 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 Missouri Department of Health and Senior Services STATE FORM 6899 PREFIX 9RF711 PRINTED: 10/18/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/16/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY If continuation sheet 5 of 6 PRINTED: 10/18/2023 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 10128 $$$ i$ 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 13134 STATE HIGHWAY 25 DEXTER, MO 63841 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY RIDGEVIEW ASSISTED LIVING CENTER Continued From page 5 Based on observation and interview on October 16, 2023 the facility failed to properly maintain the electrical wiring system so as not to cause a safety and/or fire hazard. The facility census was twenty three (23). This deficiency affects twenty three (23) of twenty three (23) residents. Observation on October 16, 2023 at 01:16 P.M. showed an unapproved electrical multiplug in use in resident room two hundred eight (208) being used to power a refrigerator. Observation on October 16, 2023 at 01:30 P.M. showed a power strip bar in use in resident room one hundred one (101) being used to power a refrigerator,microwave and coffee pot. Observation on October 16, 2023 at 01:17 P.M. showed a power strip bar in use in resident room two hundred eight (208) being used to power a refrigerator and microwave. During an interview on October 16, 2023 at 01:46 P.M. the maintenance person said he was not aware the power strip bars were in use to power the units and would have them corrected. Missouri Department of Health and Senior Services STATE FORM oeee QRF711 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Name: RIDGEVIEW ASSISTED LIVING Street Address, City, Zip: 13134 St Hwy 25, Dexter MO 63841 Date of Survey: 10/16/2023 10128 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE 10/18/2023 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 19 CSR 30-86.022 (5) (D) Fire Drill Requirements, Evacuation Fire drills are conducted monthly in accordance with 19 CSR 30- 86.022 (5) (D) October, November, December 2022 drills were in the 2022 maintenance binder located within the administrator office. Upon review of these. The alternating Day, Evening, Night shifts were not followed accordingly. Administrator will review monthly and plan dates for each quarter to ensure all shifts are covered with fire drills. Po In accordance with 19 CSR 30-89.022 (11) {B) Sprinkler A2269 System, Maintenance/Testing 10/26/2028 Escutcheon was replaced by Marmic on 10/25/2023. Maintenance will inspect and replace any with regular checks as scheduled. | In accordance with 19 CSR 30-86.022 (13)(D) Curtains/Drapes, Flame Resistant. All curtains and drapes have been treated with Fire Guard annually, upon purchase of new and any time after laundered. List of these treated drapes are kept in binder in administrator office. Copy of this list was added to the maintenance binder. 10/18/2023 A2282 A2286 19 CSR 30-86.022 (15) (A) Wastebaskets, Metal/UL/FM- 40/18/2023 Requirements Maintenance and housekeeping will check rooms daily to ensure residents have not purchased and brought in unapproved wastebaskets. Unapproved wastebaskets were discarded and replaced with all metal wastebaskets. Administrator will check monthly to ensure. A38214 19 CSR 30-86.032 (13) Electrical Wiring, Maintained, Inspected 10/17/2023 Maintenance and housekeeping will check rooms daily to ensure refrigerators, microwaves, and coffee pots are not plugged into a power strip. Residents are aware that this is unsafe, administrator will check monthly to ensure residents are not utilizing power strips to power these items. 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.