CORNERSTONE LIVING CENTER.

PRINTED: 09/22/2025 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 13926N 09/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER PROVIDER'S PLAN OF CORRECTION SUMMARY STATEMENT OF DEFICIENCIES (x5) (X4) ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EAGH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2238| 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. 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 ensure all exit signs were operational. The facility census was 37. This deficiency affects 37 of 37 residents. Observation revealed an exit sign unit was not illuminated and failed to illuminate while depressing the test button in the dining room. During the exit interview on September 17, 2025 at 2:00 PM, the maintenance man stated he would repair it. 19 CSR 30-86.022(9)(B)(1}(B) Alarm/Detectors- Correct Faults Complete Fire Alarm Systems. (B) Facilities that are required to install a sprinkler system in accordance with section (11) of this rule shall comply with the following requirements: 1. Until the required sprinkler system is installed, each resident room or any room designated for sleeping shall be equipped with at least one (1) battery-powered smoke alarm installed, tested, and maintained in accordance with manufacturer 's specifications. In addition, the facility shall be equipped with interconnected heat detectors installed, tested, and maintained in accordance with NFPA 72, 1999 edition, with detectors in all areas subject to nuisance alarms, including, but Missouri Department of Health and Senior Services LABORATORS RPR ER/B (X6) DATE 6808 5ZKI11 lf continuation sheet 1 of 3 PRINTED: 09/22/2025 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 13926N — 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 (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) CORNERSTONE LIVING CENTER 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III 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 ensure all exit signs were operational. The facility census was 37. This deficiency affects 37 of 37 residents. Observation revealed an exit sign unit was not illuminated and failed to illuminate while depressing the test button in the dining room. During the exit interview on September 17, 2025 at 2:00 PM, the maintenance man stated he would repair it. 19 CSR 30-86.022(9)(B)(1)(B) Alarm/Detectors- Correct Faults Complete Fire Alarm Systems. (B) Facilities that are required to install a sprinkler system in accordance with section (11) of this rule shall comply with the following requirements: 1. Until the required sprinkler system is installed, each resident room or any room designated for sleeping shall be equipped with at least one (1) battery-powered smoke alarm installed, tested, and maintained in accordance with manufacturer "s specifications. In addition, the facility shall be equipped with interconnected heat detectors installed, tested, and maintained in accordance with NFPA 72, 1999 edition, with detectors in all areas subject to nuisance alarms, including, but Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 5ZKI11 If continuation sheet 1 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. ii B. Upon discovery of a fault with any detector or alarm, the facility shall correct the fault. I/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 correct known faults of detection devices within the fire alarm system. The facility census was 37. This deficiency affects 37 of 37 residents. Observation revealed a smoke or heat detector wrapped in plastic and dangling by it's wires in the maintenance shop behind the kitchen. During the exit interview on September 17, 2025 at 2:05 PM, the maintenance man stated he would repair it. 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/Il This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5ZKI11 PRINTED: 09/22/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 PRINTED: 09/22/2025 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 13926N — 09/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 (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) CORNERSTONE LIVING CENTER Continued From page 2 Based on observation, record review, and interview during the fire safety inspection process, the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census was 37. This deficiency affects 37 of 37 residents. Record review revealed no current annual sprinkler inspection on file for review. The last annual report was from August of 2024. During a telephone interview on September 17, 2025 at 2:30 PM, the administrator stated she has it scheduled for later this month, as the contractor wasn't available sooner. Missouri Department of Health and Senior Services STATE FORM 6899 5ZKI11 If continuation sheet 3 of 3 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 07/18/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check Fire Extinguishers. (D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure check. II/III This regulation is not met as evidenced by: Class II Based on observation, document review, and interview during the fire safety inspection process, the facility failed to maintain fire extinguishers and failed to perform and document monthly pressure checks on all portable fire extinguishers according to NFPA (National Fire Protection Association) 10, 1998 edition. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed the facilities fire extinguishers last annual service was performed May 2023. Observation revealed no monthly pressure check had been recorded on any fire extinguisher tag, nor a monthly check list within the facility. During the exit interview on July 16, 2024 at 1410, the manager and owner stated they would begin monthly checks. 19 CSR 30-86.022(4)(C) Range Hood Certification Range Hood Extinguishing Systems. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 C3XB11 If continuation sheet 1 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 (C) The range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. II/III 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 certify 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 the kitchen hood suppression system was last inspected inspected in December of 2023. (Kitchen Hood Suppression Systems are required to be inspected twice a year, as directed by NFPA 96). During the exit interview on July 16, 2024 at 1405, the manager sated she would contact the company.. 19 CSR 30-86.022(5)(E) Fire Drill Records Fire Drills and Emergency Preparedness. (E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. Ill This regulation is not met as evidenced by: Class III Based on interview and record review during the fire safety inspection process, the facility failed to provide twelve (12) months of fire drills records Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 for review. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Record review revealed no fire drill records could be provided for review for the previous year. During the exit interview on July 16, 2024 at 1400, the owner stated she had all the records elsewhere for training. 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on November 7, 2023, the facility failed to ensure all emergency lighting/exit signs were operational. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed an exit sign failed to illuminate while depressing the test button at the smoke partition doors in hall 100. During the exit interview on July 16, 2024 at 1355, the owner stated he would repair the exit sign. 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 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 during the fire safety inspection process, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Record review revealed no semi-annual inspection had been performed on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. An annual fire inspection was performed in May of 2023 and the semi-annual was due in November. This would have been the facilities first semi-annual test, had it been performed. During the exit interview on July 16, 2024 at 1350, the manager stated she would get an inspection program started. 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 This regulation is not met as evidenced by: Class II Based on record review and interview during a fire safety inspection process, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed.. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Record review reveled no annual inspection had been performed on the fire alarm system. During the exit interview on July 16, 2024 at 1345, the manager stated she would begin an inspection program. 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 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 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 during the fire safety inspection process, the facility failed to maintain self-closing rolling fire doors that separate the kitchen and scullery areas from the dining area. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed that the kitchen serving window roll-up door and the scullery tray return window roll-up door had both been tied open due to mechanical failures both roll-up doors were equipped with magnets to hold open attached to the fire alarm and fusible links. Tying the roll-up doors open defeat all the fire protection properties of the doors. During the exit interview on July 16, 2024 at 1340 the owner stated the building owner told him that they aren't required to work for his type of facility. 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 This regulation is not met as evidenced by: Class II Based on record review and interview during the fire safety inspection process, the facility failed to ensure the sprinkler system was maintained in accordance with the provisions of National Fire Protection Association (NFPA) 13, 1999 edition; NFPA 13R, 1999 edition and NFPA 25, 1998 edition. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Record review revealed no documentation of the required monthly inspection of the sprinkler system being performed. During the exit interview on July 16, 2024 at 1335 the manager and owner stated they would make sure the monthly inspections were done. 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/Il This regulation is not met as evidenced by: Class II Based on observation, record review, and interview during the fire safety inspection Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 process, the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed the last inspection tags on the sprinkler system dated May 12, 2023. Record review revealed no current annual sprinkler inspection on file for review. During the exit interview on July 16, 2024 at 1330 the manager stated she would get the sprinkler company out to do an inspection. 19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/III This regulation is not met as evidenced by: Class III Based on observation, interview, and records review during the fire safety inspection process, the facility failed to identify in writing, the designated smoking areas. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. The facility census was thirty-eight. This deficiency affects thirty-eight Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 of thirty-eight residents. Records review found no documentation to clarify the rules and regulations for employee or residents smoking policies and/or marked designated smoking areas. During the exit interview on July 16, 2024 at 1325 the owner and director advised they would create a smoking policy. 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 III Based on observation and interview during the fire safety inspection process, the facility failed to ensure only metal or UL- or FI-fire-resistant rated wastebaskets were being used for trash. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed unapproved wire mesh wastebaskets in use in the beauty parlor (2), med prep, business office (2), administrator's office, lobby men's restroom, lobby women's restrooms, rooms 106, 103, 208, 202, 200 (2), 304, 400, and 404. Observation revealed unapproved plastic wastebaskets in use in the central nursing station and rooms 400, 402, 404, 406, 403, 401, 102, Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13926N NAME OF PROVIDER OR SUPPLIER CORNERSTONE LIVING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 104, 106, 103, 205 (2), 207, 206, and 202. Observation revealed unapproved metal and plastic wastebaskets in use in medical records, kitchen employees restroom, rooms 202 (3), and 303. During the exit interview on July 16, 2024 at 1320 the owner stated that Stephanie from the state told them wire mesh wastebaskets were okay to use. He now understands what are approved and will remove all the unapproved waste baskets as soon as they can get approved ones. 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 Ill 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 large wall penetration behind the dryer in the laundry room on 300 hall. This penetration could allow smoke, fire, and gases to travel to unaffected portions of the building. During the exit interview on July 16, 2024 at Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 C3XB11 PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 12 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: 13926N NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 CORNERSTONE LIVING CENTER PRINTED: 07/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/16/2024 (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 Continued From page 10 1315, the owner stated he would repair the hole. 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 Ill Based on observation and interview during the fire safety inspection process, the facility failed to ensure the facility's electric wiring was properly maintained. The facility census was thirty-eight. This deficiency affects thirty-eight of thirty-eight residents. Observation revealed a missing electrical outlet Missouri Department of Health and Senior Services STATE FORM 6899 C3XB11 DEFICIENCY) If continuation sheet 11 of 12 PRINTED: 07/18/2024 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 13926N — 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 533 E CANNAN RD GERALD, MO 63037 (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) CORNERSTONE LIVING CENTER A3214 | Continued From page 11 cover plate in the dirty laundry room water heater closet, on 300 hall. During the exit interview on July 16, 2024 at 1415, the owner stated he would replace missing cover plate. Missouri Department of Health and Senior Services STATE FORM 6899 C3XB11 If continuation sheet 12 of 12 AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. UNABLE TO LOCATE PLAN OF CORRECTION