SILVER CREEK ASSISTED LIVING.

PRINTED: 04/28/2025 FORM APPROVED 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: (X3) DATE SURVEY COMPLETED | ! B.WING 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE IVING BY AMERICARE 3325 S AVENUE SILVER CREEK-ASSISTED LIVIN JOPLIN, MO 64804 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS) ; PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL : PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE i i | REGULATORY OR LSC IDENTIFYING INFORMATION) : TAG CROSS-REFERENCED TO THE APPROPRIATE DATE AS . f DEFICIENCY) | 1208 19 CSR 30-86.012(8) Bedroom Window A1208 j | Requirements Facilities shall provide bedrooms with at least one (1) functional outside window with screen. i i | Window size shall be not less than one-twentieth ; | (1/20) or five percent (5%) of the required floor ! area. Il i : This regulation is not met as evidenced by: : Class | Based on observation and interview during the : | fire safety inspection process, the facility failed to , ensure all bedrooms featured at feast one (1) i | functional outside window with screen. Window : size shall be not less than one-twentieth (1/20) or i | five percent (5%) of the required floor area. The facility census was 33. This deficiency affects 33 i i of 33 residents. ' Observation on April 21, 2025 at 2:59 PM, revealed the window in roam 20 of Silver Creek t | could not be opened.. During the exit interview on April 21, 2025 at 4:15 | PM, the Administrator stated she would have | maintenance repair the window. i ‘ A2256| 19 CSR 30-86.022(10)(A) Hazardous Area | A2256 | Requirements _ Protection from Hazards. i | (A) In assisted living facilities and residential care | } | facilities licensed on or after November 13, 1980, ; ; | for more than twelve (12) beds, hazardous areas ; i | shall be separated by construction of at least a i i ; one- (1-) hour fire-resistant rating. In facilities : equipped with a cornplete fire alarm system, the I ; | one- (1-) hour fire separation is required only for | furnace or boiler rooms. Hazardous areas i ‘isseuri Department of Heaith and Senior Services \ OXre DIRECTOR'S OR PRQ R (X6) DATE STATE FORM 6s99 FSQQ11 ox coninuatiin, sheet 1 of g SWAVIS PRINTED: 08/20/2025 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 20541D B. WING 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3325 TEXAS AVENUE JOPLIN, MO 64804 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) SILVER CREEK-ASSISTED LIVING BY AMERIC A1208 19 CSR 30-86.012(8) Bedroom Window Requirements Facilities shall provide bedrooms with at least one (1) functional outside window with screen. Window size shall be not less than one-twentieth (1/20) or five percent (5%) of the required floor area. 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 bedrooms featured at least one (1) functional outside window with screen. Window size shall be not less than one-twentieth (1/20) or five percent (5%) of the required floor area. The facility census was 33. This deficiency affects 33 of 33 residents. Observation on April 21, 2025 at 2:59 PM, revealed the window in room 20 of Silver Creek could not be opened.. During the exit interview on April 21, 2025 at 4:15 PM, the Administrator stated she would have maintenance repair the window. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 05/14/25 STATE FORM 6899 FSQQ11 If continuation sheet 1 of 3 PRINTED: 08/20/2025 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 20541D B. WING 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3325 TEXAS AVENUE JOPLIN, MO 64804 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) SILVER CREEK-ASSISTED LIVING BY AMERIC Continued From page 1 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. || 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 install and/or properly maintain self-closing smoke partition doors to hazardous areas that separate them from the residential spaces. The facility census was 33. This deficiency affected 33 of 33 residents. Observation on April 21, 2025 at 3:30 PM, revealed no self-closure device on the mechanical room door, across from room 11 in the Arbors. Observation on April 21, 2025 at 3:45 PM, reveled the Arbors kitchen window was 2 shutter style doors that were not self-closing, nor attached to the fire alarm, and are not adequate as smoke partitions. During the exit interview on April 21 at 4:20 PM, the administrator advised they would look into a solution for the kitchen window and maintenance would install a self-closure device on the Missouri Department of Health and Senior Services STATE FORM 6899 FSQQ11 If continuation sheet 2 of 3 PRINTED: 08/20/2025 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 20541D B. WING 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3325 TEXAS AVENUE JOPLIN, MO 64804 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) SILVER CREEK-ASSISTED LIVING BY AMERIC Continued From page 2 mechanical room door. 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. 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 33. This deficiency affects 33 of 33 residents. Observation on April 21, 2025 at 3:12 PM, revealed an emergency light that failed to illuminate while depressing the test button in the med room at Silver Creek. During the exit interview on April 21, 2025 at 4:30 PM, the Administrator stated she would have maintenance repair the light. Missouri Department of Health and Senior Services STATE FORM 6899 FSQQ11 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Silver Creek Assisted Living and The Arbors at Silver Creek Name: Street Address, | 3395 Texas Ave Joplin MO 64804 City, Zip: Date of Survey: 4/21/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACT ION SHOULD | COMPLETION BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE In Response to 19 CSR 30-86.012(8) Bedroom Window A1208 Requirements ALF RM 21 Immediate Action: On 4/25/25, ALF Bedroom window, RM 21, was repaired by replacing spring. Ongoing Compliance: Functioning Window checks will be added preventive maintenance checks completed by Maintenance as a quarterly check. Completion Date: 4/30/25 In Response to 19 CSR 30-86.022(10)(A) Hazardous Area A2256 Requirements Arbors Mechanical Room Door Immediate Action: On 4/25/25, mechanical closet door in Arbors was installed with a self-closing mechanism. Ongoing Compliance: Ail hazardous area doors have self-closing mechanisms or sprinkler system within, per monthly preventive maintenance checks performed by Maintenance. A2256 In Response to 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Arbors Kitchen Service Window Immediate Action: On 5/2/25, Overhead Door company, in for measuremenis to gain a quote. Jeff Begley, Overhead Door Ongoing Action: Quote received 5/7/25, and equipment ordered. 4 to 6 week turn around time for delivery and install. Ongoing Compliance: Monthly Preventive checks of Fusible Link by Maintenance. Po Completion Date: On or before 7/3/25 A2278 In Response to 19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs- ALF med room Immediate Action: On 4/25/25, battery replacement to emergency light by maintenance. P| Ongoing Compliance: Monthly preventive testing of all emergency lights per Monthiy preventive checks by Maintenance. Completion Date: 4/25/25 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.