ROCK ISLAND VILLAGE.

PRINTED: 07/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30865 BR _____ 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 619 EAST 8TH STREET ELDON, MO 65026 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ROCK ISLAND VILLAGE A2212) 19 CSR 30-86.022(4)(B)(1)(2) Range Hood-After 7/11/80 & Before 10/1/00 Range Hood Extinguishing Systems. (B) In licensed facilities with a total of twenty-one (21) or more licensed beds and whose application was filed after July 11, 1980, and prior to October 1, 2000: 1. The kitchen shall be provided with a range hood and an approved automatic range hood extinguishing system unless the facility has an approved sprinkler system. Facilities with range hood systems shall continue to maintain and test these systems; and 2. The extinguishing system shall be installed, tested, and maintained in accordance with NFPA 96, 1998 edition. II/III This regulation is not met as evidenced by: Class Ill Based on record review and observation during the fire safety inspection process, the facility failed to properly operate and maintain a hood extinguishing system in accordance with NFPA 96. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed deep fryers not protected by the kitchen hood suppression system. During the exit interview on March 24 at 1530, the CMA stated she would have it resolved. 41 19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 04/01/25 STATE FORM 6899 E6JA11 If continuation sheet 1 of 4 PRINTED: 07/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30865 BR _____ 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 619 EAST 8TH STREET ELDON, MO 65026 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ROCK ISLAND VILLAGE A2264| Continued From page 1 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class Il Based on observation and interview during the fire safety inspection process, the facility, licensed after December 31, 1987 for more than twenty (20) beds, failed to ensure doors in a smoke partition shall be self-closing. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation of a smoke partition door next to Memory Care revealed that the smoke door was unable to close on its own. Smoke doors failing to close will allow smoke and toxic gases to spread to other areas of the building. During the exit interview on March 24 at 1535, the CMA stated she would have maintenance look at it tomorrow. 81 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. Missour Department of Health and Senior Services STATE FORM a E6JA11 If continuation sheet 2 of 4 PRINTED: 07/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30865 BR _____ 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 619 EAST 8TH STREET ELDON, MO 65026 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ROCK ISLAND VILLAGE A2278} Continued From page 2 (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. Il This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the facility failed to ensure all emergency lighting was operational. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed an emergency light that failed to illuminate while depressing the test button in the kitchen. Observation revealed the emergency lights on the exit sign failed to illuminate while depressing the test button on the exit next to room 209. During the exit interview on March 24 at 1540, the CMA stated she would have maintenance repair them. 19 CSR 30-86.032(2) Substantially Constructed &| A3201 Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire safety inspection process, the facility failed to Missour Department of Health and Senior Services STATE FORM a E6JA11 If continuation sheet 3 of 4 PRINTED: 07/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30865 BR _____ 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 619 EAST 8TH STREET ELDON, MO 65026 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ROCK ISLAND VILLAGE A3201} Continued From page 3 maintain the building in good repair. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed a wall penetration behind the freezers in the kitchen. Observation revealed three wall penetrations near the ceiling of the electrical room across from room 302. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. During the exit interview on March 24 at 1545, the CMA stated she maintenance would would repair the holes in the drywall. Missour Department of Health and Senior Services STATE FORM a E6JA11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: Rock island Village Assisted Living Street Address, . . 619 East 8" Street, Eldon, MO 65026 City, Zip: Date of Survey: 03/24/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This Plan of Correction serves as a written assertion of compliance regarding the cited deficiencies at this facility. However, submitting this Plan of Correction does not imply that a deficiency exists or that any citation was made correctly. This document is submitted to fulfill requirements established by state and federal law. Additionally, the preparation and submission of this Plan of Correction do not indicate that Rock Island Village agrees with the facts or the conclusions set forth in the statement of deficiencies. This Plan of Correction is submitted solely to comply with state and federal legal requirements. **19 CSR 30-86.022(4)(B)(1)(2) Range Hood - After 7/11/80 & Before 10/1/00** Range Hood Extinguishing Systems. (B) In licensed facilities with a total of twenty-one (21) or more licensed beds and whose application was filed after July 11, 1980, and prior to October 1, 2000: 1. The kitchen shall be provided with a range hood and an approved automatic range hood extinguishing system unless the facility has an approved sprinkler system. Facilities with range hood systems shall continue to maintain and test these A2212 systems; and 2. The extinguishing system shail be installed, tested, and maintained in accordance with NFPA 96, 1998 edition. II/IHI 03/25/2025 This regulation is not met as evidenced by: Class III During the recent fire safety inspection, it was noted that the facility's hood extinguishing system was not maintained in accordance with NFPA 96 standards. This raises concerns for the safety of the thirty-eight residents. Specifically, the kitchen hood suppression system did not cover he deep fryers. While no residents were directly affected, the alleged deficiency had the potential to affect all 38 residents. To address this issue, the following actions were taken, and changes will be implemented to prevent the recurrence of the deficiency: In response, the facility removed the fryer from the kitchen on March 25, 2025, and staff have been instructed not to use it. The kitchen cooking equipment will be inspected by the Maintenance Director and or Dietary Manager weekly for the next four weeks and monthly for the following 6 months to ensure compliance with the said alleged fryer/ hood deficiency. The following measures and systemic changes will be taken to ensure the alleged deficiency does not recur. The Maintenance Director will audit kitchen cooking equipment to ensure they complies with fire safety code. The Maintenance Director and or Dietary Manager will do quarterly audits to make sure kitchen cooking equipment is in the correct spots and that fire safety codes are being met. Any new kitchen cooking equipment purchases will be reviewed to confirm compliance with the fire safety code **19 CSR 30- 86.022(4\(B)(1}(2) Range Hood - After 7/11/80 & Before 10/1/00** A2264 19 CSR 30-86.022(10)(I) Smoke Section 03/31/2025 Partitions > than 20 beds Protection from Hazards. (|) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from the outside wail to the outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wail shall be at least twenty- (20-) minute fire-rated or its equivalent, self- closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. ll This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the facility, licensed after December 31, 1987, for more than twenty (20) beds, failed to ensure that doors in a smoke partition shall be self-closing. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation of a smoke partition door next to Memory Care revealed that the smoke door was unable to close on its own. While no residents were directly affected, the alleged deficiency had the potential to affect all 38 residents. To address this issue, the following actions were taken, and changes will be implemented to prevent the recurrence of the deficiency: The malfunctioning smoke partition door was adjusted by maintenance on March 25, 2025 ensuring that it is now self-closing and compliant with safety standards. Verification: The maintenance director conducted several tests to confirm that the said alleged door closed automatically upon activation of the fire alarm. All Com digital was out for inspection. A mock fire drill was performed on March 31, 2025 and said alleged door closed properly upon activation. Ongoing monitoring: The facilities maintenance director and or designee will watch said alleged door monthly at each mock fire drill to ensure door closes properly upon activation of the fire alarm. A log will be maintained to document inspections, findings, and corrective actions. A2278 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the facility failed to ensure all emergency lighting was operational. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed an emergency light that failed to illuminate while depressing the test button in the kitchen. Observation revealed the emergency lights on the exit sign failed to illurninate while depressing the test button on the exit next fo room 209. While no residents were directly affected, the alleged deficiency had the potential to affect all 38 residents. 03/27/2025 To address this issue, the following actions were taken, and changes will be implemented to prevent the recurrence of the deficiency: The facility ordered and installed a new light in the kitchen and a new battery for alleged exit sign above the exit door down from 209. Both lights were repaired and fully operational on March 27,2025. Verifcation: Maintenance director tested both repaired emergency lights to confirm said alleged lights were working according to fire safety codes. Ongoing monitoring: Maintenance director will test all emergency lighting throughout the facility once monthy by pressing the test button. Any defective lights will be replaced immediately. A log will be maintained to document inspections, findings, and corrective actions. A3201 19 CSR 30-86.032(2) Substantially Constructed & Maintained 03/27/2025 The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. HV/IH This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process, the facility failed to maintain the building in good repair. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed a wall penetration behind the freezers in the kitchen. Observation revealed three wall penetrations near the ceiling of the electrical roam across from room 302. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. While no residents were directly affected, the alleged deficiency had the potential to affect all 38 residents. To address this issue, the following actions were taken, and changes will be implemented to prevent the recurrence of the deficiency: Plastic wall plate was reinstalled in kitchen. All four wall penetrations were properly sealed and repaired by the maintenance director on March 27, 2025 to restore the fire barrier and prevent smoke or fire from spreading. Verification: The Maintenance director conducted a visual inspection to confirm the repairs were completed to code. On going monitoring: The maintenance director will conduct quarterly inspections of all fire-rated walls, especially in high-risk areas like utility rooms, kitchens, and electrical rooms. Any penetrations or damage will be immediately repaired. A log will be maintained to document inspections, findings, and corrective actions. Provided staff in service, maintenance director and or designee of importance of fire-safety rating in walls. And actions to take to make maintenance director aware of any damage or holes to walls. | 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.