OZARK MANOR.

PRINTED: 04/18/2025 FORM APPROVED »iMlissouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA ANP PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION i: BUILDING ea, av neee ne ate meen one B. WING 22947C 04/16/2025 NAME OF PROVIDER OR SUPPLIER QZARK MANOR STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 (X%4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION : sade PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD B' Nae JAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A2214| 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation A2214 Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility 's entire plan shall be provided to the local jurisdiction 's emergency management director. WA This regulation is not met as evidenced by: Class Ill Based on record review and interview on April 16, 2025 the facility failed to request the required annual consultation from the local fire authority. The facility census was 41. This deficiency affects 41 of 41 residents. Record Review on April 16, 2025 at 10:30 A.M. showed no current fire department consultation on file for review. The last consultation paperwork on file was dated in 2023. | During an interview on April 16, 2025 at 10:30 A.M. the Owner/Director stated he was not sure __ | they had a Fire Consultation completed for this _| current year's inspection period. A2251 ) Fac lities shall test by activating the complete alarm system at eas, once arponth. I/II SIGNATURE TITLE (X6) DATE SeAVA SS @\an\alt sce es Sur XVOD eo) (2)! 2075 If continuation sheet 1 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22947C NAME OF PROVIDER OR SUPPLIER OZARK MANOR (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 04/18/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 04/16/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility 's entire plan shall be provided to the local jurisdiction 's emergency management director. I/II This regulation is not met as evidenced by: Class III Based on record review and interview on April 16, 2025 the facility failed to request the required annual consultation from the local fire authority. The facility census was 41. This deficiency affects 41 of 41 residents. Record Review on April 16, 2025 at 10:30 A.M. showed no current fire department consultation on file for review. The last consultation paperwork on file was dated in 2023. During an interview on April 16, 2025 at 10:30 A.M. the Owner/Director stated he was not sure they had a Fire Consultation completed for this current year's inspection period. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 K78S11 If continuation sheet 1 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 22947C NAME OF PROVIDER OR SUPPLIER 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 OZARK MANOR SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 1 This regulation is not met as evidenced by: Class II Based on record review and interview on April 16, 2025, the facility failed to insure the complete fire alarm system was tested monthly. The facility census on April 16, 2025 was 41. This deficiency affects 41 out of 41 residents. Record review on April 16, 2025 between 10:30 A.M. and 2:00 P.M., showed no documentation the fire alarm system had been activated monthly in the previous 12 months. . During an interview on April 16, 2025 at the time of discovery, the Owner/Director stated he/she was not aware of the requirement. And not sure if the alarm was used during required fire drills, no documentation that the alarm was being tested or activated was also discovered. 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 Missouri Department of Health and Senior Services STATE FORM 6899 K78S11 (X2) MULTIPLE CONSTRUCTION PRINTED: 04/18/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/16/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE If continuation sheet 2 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22947C NAME OF PROVIDER OR SUPPLIER OZARK MANOR (X2) MULTIPLE CONSTRUCTION A. BUILDING: FREDERICKTOWN, MO 63645 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 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 April 16, 2025 the facility failed to provide a fire safe building for it's occupants. The facility census was 41. This deficiency affects 41 of 41 residents. Observation on April 16, 2025 at 1:04 P.M. showed the door to the Kitchen was being held open with a permantley mounted manual hold open device. The door had a self closure device attached. This would allow smoke and toxic gas to travel from the smoke compartment into the resident and occupied areas in the event of a fire. Obeservation on APril 16, 2025 at 1:04 P.M. also showed the rolll up serving window partition in the up position. the window was being attended to as this was during the lunch period and staff were present. However, the Owner/Director did not know if there was an auromatic closing device on the closure or if it was connected to the fire alarm system. During a interview on April 16, 2025 at 1:04 P.M. the Owner/Director said he would have this corrected. Missouri Department of Health and Senior Services STATE FORM 6899 K78S11 PRINTED: 04/18/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/16/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 22947C NAME OF PROVIDER OR SUPPLIER OZARK MANOR (X2) MULTIPLE CONSTRUCTION A. BUILDING: FREDERICKTOWN, MO 63645 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Protection from Hazards. (I) 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 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 II Based on observation and interview on April 16, 2025, the facility failed to ensure the required smoke separation doors fully close and latch. The facility census on April 16, 2022 was 41. This deficiency affects 41 out of 41 residents. Observation on April 16, 2025 at 1:09 PM. showed the smoke separation doors in the 100 Hall did not fully close and latch on three (3) of three (3) tries. Further observation showed the door was catching on the top of the frame. During an interview on April 16, 2025 at the time of discovery, the Owner/Director said he/she did not realize the doors were not latching properly and will have the doors repaired. Missouri Department of Health and Senior Services STATE FORM 6899 K78S11 PRINTED: 04/18/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/16/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 7 PRINTED: 04/18/2025 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 22947C —ESESE———————s 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 (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) OZARK MANOR Continued From page 4 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/II This regulation is not met as evidenced by: Class II Based on record review and interview on April 16, 2025, the facility failed to have fire sprinkler system inspections completed in accordance with NFPA 25, 1998 edition. The facility census on April 16, 2025, was 41. This deficiency affects 41 out of 41 residents. Record review on April 16, 2025, at 10:30 A.M., showed no documentation that an Annual Sprinkler Inspection had been completed for the current inspection period. Last Documented inspection report was for September 28, 2023. During an interview on April 16, 2025, at the time of discovery, the Owner/Director stated he would schedule the Annual Sprinkler Inspection. 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 Missouri Department of Health and Senior Services STATE FORM 6899 K78S11 If continuation sheet 5 of 7 PRINTED: 04/18/2025 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 22947C —ESESE———————s 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 (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) OZARK MANOR Continued From page 5 and one-half (1 1/2) hours. II This regulation is not met as evidenced by: Class II Based on observation and interview on APri;| 16, 2025, the facility failed to insure all battery powered emergency lighting was capable of operating the light for at least one and one-half (1-1/2) hours. The facility census on April 16, 2025, was 41. This deficiency affects 41 out of 41 residents. Observation on April 16, 2025 at 1:14 P.M., the emergency light in the 100 hallway, near room 112 showed the light failed to operate when the test button was pressed. During an interview on April 16, 2025 at 1:15 P.M, the Owner/Director stated he/she would get the light repaired. 19 CSR 30-86.032(2) Substantially Constructed & 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 III Based on observation and interview on April 16,2025 the facility failed to ensure the building 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 was 41 This deficiency affects 41 Missouri Department of Health and Senior Services STATE FORM 6899 K78S11 If continuation sheet 6 of 7 PRINTED: 04/18/2025 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 22947C ce -e 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 (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) OZARK MANOR Continued From page 6 of 41 residents. Observation on April 16, 2025 at 1:07 P.M. ., showed 2 pipe chase's through the ceiling in the Furnace Room, located in Storage Room that were not sealed with Fire Caulk or other approved materials. During an interview on April 16, 2025 at 1:07 P.M., the maintenance person said he was not aware of the hole and will get this corrected. And that he missed it after discussions from last years Fire Safety Inspection. Missouri Department of Health and Senior Services STATE FORM 6899 K78S11 If continuation sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier Name: Street Address, City, Zip: Date of Survey: PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE ieee ID PREFIX TAG COMPLETION |__PATE_ IAZZ\ ones (a dministrator signing and dating the first page of the CMS-2567/State F is indicati i = orm is ind an of correction being submitted on this form. oe tea ae lk PLAN OF CORRECTION Provider/Supplier Name: Street Address, City, Zip: Date of Survey: SPREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | AZZ [Emernects ARR SEI DIN : __ Iiiainterarce) rescccmilcle Loe Sica; risk | | ; 6A | Realed- Dennis KebstCMainienance Sa SN ye Giza! | r Wesponmide Sec Syira Kash erst to |) (ne Sure Ve cine “One VeOre.s cee ORE ATA| ast i i The Administrator signing and dating the first J M page of the CMS-2567/S is indicati i the p f correction being submitted on this form. Se Eero Mnclicating chelcappratal of 2:

PRINTED: 06/24/2025 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 22947C B. WING 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 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) OZARK MANOR A4817, 19 CSR 30-86.047(51)(A)(1) Schedule II Meds-Reconcile Each Shift, Record Records shall be maintained upon receipt and disposition of all controlled substances and shall be maintained separately from other records, for two (2) years. (A) Inventories of controlled substances shall be reconciled as follows: 1. Controlled Substance Schedule II medications shall be reconciled each shift; II This regulation is not met as evidenced by: Class II 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. The facility's census was 48. Review of the facility's Narcotic Count Reconciliation Policy showed all controlled substances (pills, liquids & patches) must be counted by staff at each shift change. Both the oncoming and outgoing staff should look at the card and the narcotic book to ensure accuracy. 1. Review of the Controlled Medication Count Sheet for 03/07/25 through 03/13/25 showed: - One staff signature for the narcotic shift count on 03/08/25 for the 7:00 A.M.-3:00 P.M./3:00 P.M.-11:00 P.M. and the 3:00 P.M.-11:00 P.M./11:00 P.M.-7:00 A.M.; - One staff signature for the narcotic shift count on 03/10/25 for the 3:00 P.M.-11:00 P.M./11:00 P.M.-7:00 A.M.; - One staff signature for the narcotic shift count Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 04/21/25 STATE FORM 6899 STFL11 If continuation sheet 1 of 2 PRINTED: 06/24/2025 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 22947C B. WING 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 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) OZARK MANOR Continued From page 1 on 03/11/25 for the 7:00 A.M.-3:00 P.M./3:00 P.M.-11:00 P.M. and the 3:00 P.M.-11:00 P.M./11:00 P.M.-7:00 A.M.; - One staff signature for the narcotic shift count on 03/12/25 for the 7:00 A.M.-3:00 P.M./3:00 P.M.-11:00 P.M. and the 3:00 P.M.-11:00 P.M./11:00 P.M.-7:00 A.M. During an interview on 3/13/25 at 12:15 P.M., the Administrator said narcotics should be counted by the Level One Medication Aide (LIMA) or Certified Medication Aide (CMA) coming on shift and the LIMA or CMA going off shift. The Administrator said a review will need to be done with the staff who pass medications. Missouri Department of Health and Senior Services STATE FORM 6899 STFL11 If continuation sheet 2 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X4) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 22847C Pave ees, Ure ee FORM APPROVED (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A BUILDING 6 WING. 03/43/2025 STREET ADDRESS. CiTY. STATE. ZIP CONE 1013 HIGHWAY Z NAME OF PROVIDER OR SUPPLIER OZARK MANOR SUMMARY STATEMENT OF DEFICIENCIES (x4) 1D PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A48171 19 CSR 30-86.047(51)(A)(1) Schedule I! Meds-Reconcile Each Shift, Record Records shall be maintained upon receipt and disposition of all controlled substances and shall be maintained separately from other records, for two (2) years. (A) Inventories of controlled substances shail be reconciled as follows: 1. Controlled Substance Schedule || medications shail be reconciled each shift; II This regulation is not met as evidenced by: Class I! Based on interview and record review, the facility failed to ensure inventories of Schedule I! controlled substances (medications which have a high potential for abuse) were reconciled each shift. The facility's census was 48. Review of the facility's Narcotic Count | Reconciliation Policy showed all controlled stances (pilis, fiquids & patches) must be counted by staff at each shift change. Both the oncoming andioutgoing staff should look at the card and the niarcotic book to-ensure accuracy. welt ap Controlled Medication Count (28 through 03/18/25 showed: tise for the nardotic shift count Stal gnahure for the narcotic shift count {208 B5710/25 for the’ 3:00:P.M.-11:00 P.M./11:00 PMTOOAMS | . One soft | for the narcotic shift count : At a a NL PUER REP Rt SENTATIYASS SIGNATURE FREDERICKTOWN, MO 63645 ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Ennplouee intervice aiven by Adenin xo Med- dudes on keep) records accurate vot 2 Siqnabwes, Every med- Gide unders tards tnoak We Are TeAyiced AD COONnk Sche, Orgs. ase veo Sianed Poluay. Copy Enclosed. ” D (p\25) o3l al24 TMe pie) DATE = a SN O4 [2,taf STFL14 1 continuation shee: Ais ae wy PRINTED: 03/25/2025 FORM APPROVED STATEMENT OF DEFICIENCIES 00) PROVIDERSUPPLIER/CLIA (X2) MULT:PLE CONSTRUCTION (%3) DATE SURVEY COMPLETED AND PLAN OF CORRECTION IDENT: . ENTIFICATION NUMBER A. BUILDING B WANG 03/13/2025 22847C STREET ADORESS. CITY, STATE. ZIP CODE OZARK MANOR 1013 HIGHWAY Z FREDERICKTOWN, MO 63645 NAME OF PROVIDER OR SUPPLIER (R51 PROMIDER'S PLAN OF CORRECTION COMPLETE xo 10 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFIGIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDO TO THE APPROPRIATE PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) DEFICIENCY) 44817/ Continued From page 1 on 03/11/25 for the 7:00 A.M.-3:00 P.M./3:00 P.M.-11:00 P.M, and the 3:00 P.M.-11:00 dA stot Wnstalte P.M/11:00 P.M.-7:00 AgM.:: Wi V Mere in \ IM med COOM. ~ One staff signature forfthe narcotic shift count 03/12/25 for the 7:00 A.M.-3:00 P.M./3:00 . on 03 for the SMM PL Cra roe COUNTS P.M.-11:00 P.M. and the 3:00 P.M.-11:00 P.M./11:00 P.M.-7:00 A.M. °. are bei AQ Pronored During an interview on 3/13/25 at 12:15 P.M., the Administrator said narcotics should be counted by the Level One Medication Aide (LIMA) or Certified Ore Ensured, ON-Qding Medication Aide (CMA) coming on shift and the LIMA or CMA going off shift, The Administrator by owner And Assist Said a review will need to be done with the staff Ad . who pass medications. W- Missouri! Department of Health and Senior Services STATE FORM 6889 STFL11 If continuation sheet 2:

PRINTED: 03/01/2024 FORM APPROVED ith and Senior Services (X1) PROVIDERYSUPPLIER/CLIA (IDENTIFICATION NUMBER pariment of Hea EFICIENCIES ORRECTION Missouri De 7 (%3) DATE SURVEY COMPLETED (%2) MULTIPLE CONSTRUCTION A BUILDING 02/28/2024 22947C NAME OF PROVIDER OR SUPPLIER ! ALM WS ‘ 1043 HIGHWAY 7 ic siak ures FREDERICK TOWN, MO 63645 | PROVIDERS PLAN OF (ene, Tw SUMMARY STATEMENT OY ' Encl in (EACH COMREC Trvt A TiOM eae COMPLETE PO py a PREFIX TAG | CROSS-REFERENCED TO The APPR PPAATE OEP COEMC YT) RY ON LS De NTH YEN NH CMRIMATIOUNS Y23\D) Fire Extinguishers A2710 > Veal on Maintain’Check e Extinguishers AN fre extinguishers shall bear the label of the Underwriters ' Laboratones (UL) or the we or Pcriuse +n, Factory Mutual (FM) Laboratones and shali be . “stalled and maintained in accordance with | , ' - 10, 1998 edition. This includes the | An paenart' ‘Tp 4 umentation and dating of a monthly pressure I - ra Ase ced This regulation is not met as evidenced by mmnerS\arda Whe Por +0 Class YY moaAwornna" ar Based on observation and interview, the facility failed to maintain the documentation and dating Bar of monthly pressure checks for four of seven fire ais ‘ extinguishers. The facility's census was 48 Observation on 02/28/24 from 9:57.A.M. through ] 12:30 P.M. showed the following . - The fire extinguisher in the kitchen showed the ast monthly pressure check on 12/15/23, - The two fire extinguishers in hallway 400 showed the iast monthly pressure check on 12/15/23 - The fire extinguisher in hallway 200 showed the | ast monthly pressure check on 12/15/23 No policy on fire extinguishers was provided Durning an interview on 2/28/24 at 10:41 AM Mairtenance said he/she missed checking some of the fire exunguishers. Maintenance said he/she does not Keep 2 log of monthly pressure checks tor the fee exonguisners / AEZHS 1G CGP G4 05234) Hot Water 105-120 we ts “ol tha (he bet 9 di aed st ite bee STATE FORM th and Senior Service TOVIDER/SUPPLIERICLIA ENT LEICATION NUMIAE ft WANG 1013 HIGHWAY Z 1p PREFIX TAG . MENT OF DEF ENCIES EACH OEMCIENCY MUST BE PRECEDED BY FULL SC IDENTIFYING INFORMATION) A3235 Continued From page 1 Plumbing fixtures which are accessible to residents and which supply hot water shall be thermostatically controlied so that the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit (120°F) (49°C) and the water shall be at a temperature range between one hundred five degrees Fahrenheit ({05°F) (41°C) and one hundred twenty degrees Fahrenheit (120°F) (49°C). I/Il This regulation is not met as evidenced by Class I! Based on observation and interview, the facility failed to ensure staff maintained hot water temperatures between 105 degrees Fahrenheit (°F) and 120 °F. The facility's census was 48. Observation on 02/28/24 at 10:58 A.M., during two minute hot water test with a digital stem type thermometer, showed the bathroom in resident room #304 had a water temperature of 123.8°F. Observation on 02/28/24 at 11:01 A.M., during two minute hot water test with a digital stem type thermometer, showed the bathroom in resident room #301 had a water temperature of 125.4°F. No policy on hot water temperatures was provided Durning en interview on 02/28/24 at 11:06 A.M., Maintenance said he/she had turned the water | heater up in hallway 300 so the water would be hotter in the laundry room. Maintenance said he/she does not keep a log of the hot water temperatures 0G) MULTIELE CONSTRUCTION A BUILDING (HEL T ADDRESS. CITY, STATE, ZIP CODE FREDERICKTOWN, MO 63645 — PRINTED: 03/01/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/28/2024 LS) CAPAPLETE DATE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD Bie CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Water +emnpS will be Sabet and Comort of Mes, dents Moimenance and eupport Hafl w | will monitor | Ax ver week. Por cme | Molin to emsure woier enpo are sralnbted WHhiN TeQuiaton Lins, then once weekly co make sure are 1beandg MAIMXAUNES - LOgs are Seeing, Kept Ho @nsure moni cori and 40 See Any Ay ends VN worder 4emperakure Pruckuaton. Adenim strate will Monto make oe 4 (e) ore ature fee