COLLINS HOUSE, THE.

PRINTED: 02/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1), PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (%3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFIGATION NUMBER A BUILDING COMPLETED 33443 B. WING 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY, STATE, ZIP CODE 102 COLLINS RD FESTUS, MO 63028 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING |NFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COLLINS HOUSE, THE — 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on January 31, 2025, 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 6. This affects 6 out of 6 residents. Record review at 1:00 P.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. No documentation of the semi-annual fire alarm inspection was available. During an interview on January 31, 2025 at the time of discovery, the Administrator stated he/she would contact the fire alarm company. 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/ll This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services LAI ORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE OTD, LPAA If continuation sheet 1 of 2 PRINTED: 02/05/2025 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 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 102 COLLINS RD FESTUS, MO 63028 (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) COLLINS HOUSE, THE Continued From page 1 Based on record review and interview on January 31, 2025 the facility failed to ensure the buildings sprinkler system was being maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. The facility census on was 6. This deficiency affects 6 out of 6 residents. Record review at 1:15 P.M. showed no documentation of the required monthly visual inspection of the sprinkler system. During an interview on January 31, 2025at the time of discovery, the Administrator stated he/she was not aware the monthly inspection was needed. Missouri Department of Health and Senior Services STATE FORM 6899 EJL911 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier The Collins House (33443) Name: Street Address, ; 3 102 Collins Dr. Festus, MO 63028 City, Zip: 1/30/2025 Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2249 Owner(s)/Administrator reviewed contact with ADT/Everson (fire monitoring company) and phone conference on 2/13/2025 revealed the contracted company failed to meet the terms of their contract by routinely scheduling and conducting a semi- annual inspection of the fire alarm system. Plan: The contracted company will schedule a semi-annual inspection of the fire alarm system moving forward. The Owner(s)/Administrator will add the semi-annual inspection report to the Monthly Life Safety Code Checklist to hold the contracted company accountable for their semi-annual inspection. 2/13/2025 A2269 Plan: Monthly visual inspection of the sprinkler system has been added to the Monthly Life Safety Code Checklist. Re-inservice reviewing the gauges and pressures was completed on 2/7/25. 2/7/2025 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.

PRINTED: 01/30/2025 FORM APPROVED re Bn oe ee ee, (X2) MULTIPLE CONSTRUCTION A. BLALDING. (£3) DATE SURVEY COMPLETED Xt) See eRelia IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 8. WING 33443 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 102 COLLINS RD COLLINS HOUSE, THE FESTUS, MO 63026 (%4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE Tac REGULATORY OR LSC IDENTIFYING INFORMATION) | CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4782. 19 CSR 30-86.047(41) Medication Storage/Accessibility : All medication shall be safely stored at proper temperature and shalt be kept in a secured ' location behind atleast one (4) locked door or cabinet. Medicatian shall be accessible only to Persons authorized ta administar medications. WANT | The observed _khitthen | Cabine! is being velro-Let | include tro. lock bores, | The employre frat viola kal fhe policy on theles hes Unles hen write up ard | » This regulation is not met as evidenced by: Class III i i Based on observation and interview, the facility ‘ failed to ensure medications were properly stored within a secured location behind at least one | locked door or cabinet and not accessible to residents for one of one day of observation. The | facility's census was six. tetwed from Yue schode ld, Ihe hs | The. antic pehd Conup chen ek of ter rebo- ft worl! | be m ot bebve thee les. In the Neantine, whale | Observation on 0116/25 at 11:45 A.M. showed: - An unlocked cabinet in the dining room/kitchen area, open to all residents, containing pre-prepped pilis In pill boxes labeled with | residents’ names; i = Two medication cups containing pre-prepped ; medications for tha residents, were sitting on top | of the counter and no staff attending te the i medication cups; | - Several residents were walking around and ; Seated near the area. Awarhity Stepplies and | During an interview on 01/16/25 at 11:50 A.M., ' the Administrator sald the facility does not use a ' Medication cart because It doesn't present a | homelike atmosphere. She said the medications | were pre-prepped anc put in the residents’ pill | boxes to be given during the shif. She said there ’ had been discussion of having a lock put on the cabinet, but had not done so yet. Oithactr aval ahi lty, | all Mca ica hon has | bun streA in a [octacl Med benet as of Yo Missouri Department of Heallh and Senior Services LABORATORY CTOR'S OR PROVIDERSUPPLIER REPRESENTATIVE'S SIGNATURE TLE 0X6) DATE \ Li ) Da 2 OT) LOHA 2 lip/2025— STATE FORM od SUYLi1 {f confnumtion sheet 1 of 4 PRINTED 1430/2025 FORM APPROVED _ Missour| Cepartment of Heath and Senior Services | (%7. MUC TIPLE CONSTRUCTION S”ATEWENT OF OEFIGIENCIES (xt) PROWIDERSUPPLIERCLIA {0x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BLALOING 7 COMPLETED — 62025 NAME OF PROVIDER OR SUPPLIER ATREET ADDRESS, CITY, STATE ZIP COOE COLUNS HOUSE, THE 102 COLLINS RD FESTUS, MO 63028 oray ia SUMMARY STATEMENT OF DEFICIENTIES 10 PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICRINCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD 5E TAG REGULATORY OR LSC IDENTIFYING INFORMATION) : TAG CROSS-REFERENCED TD THE APPROPRIATE DEFICIENCY) AATBA Continued From page 1 ATR 19 CSR 30-86 047(41)(B) Medication ; Storage-Schedule 4 Ail medication shall be safely stored at proper { temperature and shail ve kept in a secured fA fl additd add final, | z } | wir 4 | iocation behind atleast one (1) locked door or -_ 2 cabinet. Medication shall be accessibia only to : . Spe! persons authorized fo administer medications, ' do ble lock io) twdicine | Teall | (B) Schedule II controlled substances shall be Cabine! yoas justtled | stored in locked compartments separate from ; Non-controlled medications, except that single ich ec iA doses of Schedule 'll controlied substances may “ h “ hous s 4 be controiled by a resident in compliance with the requirements for sélf-contro! of medication of this | Stha dule - ll. Meds. rite. H/Ill This regulation is not met as evidenced by: Cass Ill | Based on observation and interview. the facility i failed to ensure all Schedule |! controlied substances (medications which have a high potentiai for abuse) were Safaly stored in a . secure location behind at least two jocks when ! Resident #1's liquid: Morphine Sulfate : (concentrate) 20 milligrams/milliliters (mg/m) : medication was bsihg Kept In a locked box in the opened medication room, The facility's census was six. Observation on 01/16/25 at 10:30 A.M. in the opened door back room leading from the kitchen : area showed two locked metal medication : cabinets on the wall and a smaller locked medication bax on top of ane af the medication boxes on the wall. The smaller box was within teach and contained the liquid Morphine Sulfete ‘ concentrate 20mg/nv. tissouri Department of Health and Seniot Services STATE FORM on SUYLI VW contnuation aheat 2 of 4 Misscuir] Department of Health and Senior Services __ j STATEMENT OF DEFENCES (X14) PROVIDER'SUPPLIERCLIA A4784 Continued From page 2 | During an interview on 01/16/25 at 11:50 A M., | ; the Administrator said the facility hasa | Medication cart, but had not Implemented using it i SO to make a more home Iike environment, She said they will work on getting a place for the Narcotics box so it will be double locked. A4817 49CSR 30-86.047(51)(A)(1) Schedule 1! _ Meds-Reconcile Each Shift, Record Records shall be maintained upon receipt and ' disposition of all controlled substances and shall : be maintained saparately from other records, for two (2) years. (A} inventories of controlled stibstances shall be reconciled as follows: 1 Controlled Substance Schedule li medications . Shall be reconciled each shift: Il This regulation is not met as evidenced by: Class I! Based on interview and record review, the facility failed to ensure inventories of Schedule II controlled substances (medications which have a high potential for abuse) were reconciled each shift for one resident (Resident #1) of three sampled residents, The facllity’s census was six. : 1. Review of Resident #1's face sheet showed: : « Admitted to the facility on 12/26/24; ' - Diagnoses included Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), vascular disorder of intestine, unspacified, anxiety disorder Missouri Department of Heath and Sen.or Services STATE FORM PRINTF OD: O41 RNHM025 FORM APPROVED {X21 MULTIPLE CONSTRUCTION (43) DATE SURVEY AND PLAN OF CORRECTION IOENTIFIGATION NUMBER: \ BUILDING COMPLETEG | | ! 33443 8 WING ee A. NAME OF PROVIDER OR SUPPLIER STREET ACDRESS CITY. STATE ZIP CODE | 192 NS RO j COLLINS HOUSE, THE 02 COLLINS FESTUS, MO 63028 ! a ae Md td SUMMARY STATENENT OF OEFICIENCES Io PROVIDER'S PLAN OF CORRECTION MA) | PREF (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE i REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEF IGIENGY) A separale avd dishnet form has heen | iMplemenkd , fr Ahfes A4817 : ttemelizahm of al} Sthiaduled 1/- Cm trolled. | Substances per ShiA. one SUYLI1 it continushon sheet 3 of 4 PRINTED: 01012025 FORM APPROVED _ Missouri Departmant of Health and Senior Services | ! STATEMENT OF DEF IENCTIES (X1) PROVIDER 'SUPPLERUCLIA + AND PLAN OF CORRECTION (DENTIFICATION NUMBER. “Tica; DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A BUILDING BWIRG 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDACSS, CITY, STATE, ZIP CODE 102 COLLINS RO FESTUS, MO 63028 COLLINS HOUSE, THE i \ J PROVIDER'S PLAN OF CORRECTION ™%5) | i (Xap 1D SUMMARY STATEMENT OF DEFICIENCEES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH GORRECTIVE ACTION SHOULD BE COMPLETE | TAG REGULATORY OR LSC IDENTIFYING INFORMATION} : TAG CROSS-REFERENCED TO THE APPROPRIATE DATE ! : DEFICIENCY) Asal | Continued From page 3 aasiy | (persistent worry and fear about everyday situations), gastro-esophageal reflux disease | (stomach acid being forced back into the throat region} and entergcolitis due to clostridium difficile {a bacteria that can contribute to . excessive diarrhea.) Review of the resident's Physician's Order Sheet, _ dated December 2024, showed . « An order for liquid morphine sulfate concentrate ' (a Schedule Il controlled medication/narcotic : anaigesic) in a solution of 20 milligrams (mg) af medication for eagh milliliter (mf) of solution to be administered as .25 mi by mouth every two hours " as needed for pain. Review of the electronic weekly narcotic count 1 showed the jast caunt was done on 01/08/25 and the liquid morphing 6ulfate concentrate 20mg/ml _ was included in the count. No other : documentation was shown for a daily shift change count. , During an interview on 01/16/25 at 11:30 A.M., ' the Administrator said she was not aware the : liquid morphine sutfate concentrate should be : documented at each shift change, but this would be fixed as scon as possible, i Missouri Oepariment of Heath and Seng Services STATE FORM baked SUYL11 Hf contnuabon sheet 4 of 4