CHURCHILL TERRACE 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: 20783C NAME OF PROVIDER OR SUPPLIER CHURCHILL TERRACE-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: 11/18/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 03/05/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 120 HOSPITAL DRIVE FULTON, MO 65251 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 5, 2024 the facility staff failed to keep the facility in a condition to not present a hazard. The census was 23. This deficiency affects 23 of 23 residents. Observation during the inspection of the facility showed the furnaces to be fueled by natural gas with no carbon monoxide detectors located in the building. During an interview at 4:10 P.M. the maintinace manager stated he was not aware the detectors were not located in the building. He then called a local fire alarm company and requested a bid be put together. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 517611 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: 20783C NAME OF PROVIDER OR SUPPLIER CHURCHILL TERRACE-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 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 inspection and interview on March 5, 2024, the facility, licensed for more than twelve (12) beds after November 15, 1994, failed to provide a one- (1-) hour fire separation for a furnace room. 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. The facility census was 23. This deficiency affects 23 out of 23 residents. Observation of the furnace room in hallway A at 2:12 P.M., showed the door did not have a self closing device attached and was not closing on its own. During an interview at 4:10 P.M., the maintinace manager stated he would get the self closing device placed on the door. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 517611 PRINTED: 11/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/05/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 120 HOSPITAL DRIVE FULTON, MO 65251 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: 11/18/2024 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 20783C — 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 120 HOSPITAL DRIVE FULTON, MO 65251 (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) CHURCHILL TERRACE-ASSISTED LIVING BY AMERIC Continued From page 2 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 on March 5, 2024 the facility failed to maintain the main emergency lighting in good repair. The facility census was 23. This deficiency affects 23 of the 23 residents. Observation at 2:26 P.M. showed an emergency light located in hallway E that failed to activate when the test button was depressed. During an interview at 4:10 P.M. the maintinance manager stated he would get the emergency light fixed as soon as possible. 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 wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on March 5, 2024 the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being Missouri Department of Health and Senior Services STATE FORM 6899 517611 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: 20783C NAME OF PROVIDER OR SUPPLIER CHURCHILL TERRACE-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 used for trash. The facility census was 23. These deficiencies affects 23 of the 23 residents. Observation at 1:36 P.M. showed two unapproved wicker baskets as well as an unapproved plastic trash can in use as trash cans in room G1. Observation at 1:39 P.M. showed an unapproved plastic wastebasket in use in room G2. Observation at 1:50 P.M. showed two unapproved plastic wastebaskets in use in room E5. Observation at 1:54 P.M. showed tree unapproved plastic wastebaskets in use in room E3. Observation at 1:56 P.M. showed two unapproved plastic wastebaskets in use in the activity directors office. Observation at 2:09 P.M. showed an unapproved plastic wastebasket in use in the bathroom near the dining room. Observation at 2:15 P.M. showed an unapproved metal trash can with holes, in the office of the director of nursing. Observation at 3:16 P.M. showed two unapproved large plastic trash cans in use in the kitchenette area off of hallway B. During an interview at 4:10 P.M. the maintenance manager stated he will advise the managers of the situation and get the trash cans replaced with approved cans. . Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 517611 PRINTED: 11/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/05/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 120 HOSPITAL DRIVE FULTON, MO 65251 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: 20783C NAME OF PROVIDER OR SUPPLIER CHURCHILL TERRACE-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 4 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 during the fire safety inspection process on March 5, 2024, 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 census was 23. This deficiency affects 23 of 23 residents. Observation at 2:10 P.M., showed a one inch hole in the ceiling, near the sprinkler head mounted in the spa room, down hallway A. During an interview at 4:10 P.M., the maintenance manager stated he would see that the hole was sealed up as soon as possible. 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 517611 PRINTED: 11/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/05/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 120 HOSPITAL DRIVE FULTON, MO 65251 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: 11/18/2024 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 20783C — 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 120 HOSPITAL DRIVE FULTON, MO 65251 (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) CHURCHILL TERRACE-ASSISTED LIVING BY AMERIC Continued From page 5 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 5, 2024 the facility failed to properly maintain the buildings electrical wiring and not cause a safety or fire hazard. The facility census was 23. This deficiency affects 23 of 23 residents. Observation 1:52 P.M. showed an open electrical wiring connection sticking out of the ceiling inside the storage closet in hallway E. During an interview at 4:10 P.M. the maintinance manager stated there previously was a ceiling light mounted at this location. He would see that a new light was purchased and remounted in this room. Missouri Department of Health and Senior Services STATE FORM 6899 517611 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)