WESTPORT ESTATES ASSISTED LIVING.

PRINTED: 10/29/2025 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 16202C B. WING 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 (x4) ID | SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL (EACH CORRECTIVE ACTION SHOULD BE ' COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TA CROSS-REFERENCED TO THE APPROPRIATE j DATE DEFICIENC WESTPORT ESTATES ASSISTED LIVING A4724. 19 CSR 30-86.047(19) TB Screen Residents & | A4724 : Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Ii This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility ' failed to ensure a two-step tuberculosis (TB - a : communicable disease that affects the lungs, : characterized by fever, cough and difficulty : breathing) test was completed as required upon hire for five of five sampled employees (Dietary ' Cook D, Life Enrichment Coordinator E, Personal : Care Attendant F, Certified Medication Aide ' (CMA)/Level 1 Medication Aide (LIMA) G and CMA H). The facility census was 29. Review of the facility policy, Tuberculosis Testing Policy, dated 05/24/24, showed the following: -lt is the policy that each facility will follow guidelines, specifically the Center for Disease Control (CDC) and Occupational Safety and | Health Administration (OSHA) standards, as well i as the "Tuberculosis Exposure Control Plan", to ' prevent transmission of tuberculosis; : -Staff screening: each employee and volunteer : shall receive a tuberculin skin test (TST) in the | two-step Manfoux method, consisting of five tuberculin units of purified protein derivative within 90 days prior to, or within seven to ten days, beginning employment; -Test can be initiated at the time of hire but results must be read prior to any employee or resident contact; -The policy did not address that the first step TB test must be administered and read before compensation. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROV! LIER_REP! NTATIVE'S SIGNATURE TITLE lf continyation sheét 1 of & PRINTED: 01/07/2026 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 16202C B. WING 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X6) 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) WESTPORT ESTATES ASSISTED LIVING 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure a two-step tuberculosis (TB - a communicable disease that affects the lungs, characterized by fever, cough and difficulty breathing) test was completed as required upon hire for five of five sampled employees (Dietary Cook D, Life Enrichment Coordinator E, Personal Care Attendant F, Certified Medication Aide (CMA)/Level 1 Medication Aide (LIMA) G and CMA H). The facility census was 29. Review of the facility policy, Tuberculosis Testing Policy, dated 05/24/24, showed the following: -It is the policy that each facility will follow guidelines, specifically the Center for Disease Control (CDC) and Occupational Safety and Health Administration (OSHA) standards, as well as the "Tuberculosis Exposure Control Plan", to prevent transmission of tuberculosis; -Staff screening: each employee and volunteer shall receive a tuberculin skin test (TST) in the two-step Mantoux method, consisting of five tuberculin units of purified protein derivative within 90 days prior to, or within seven to ten days, beginning employment; -Test can be initiated at the time of hire but results must be read prior to any employee or resident contact: -The policy did not address that the first step TB test must be administered and read before compensation. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 11/12/25 STATE FORM 8890 i¥S811 if continuation sheet 1 of 8 PRINTED: 01/07/2026 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 16202C B. WING 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 (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) WESTPORT ESTATES ASSISTED LIVING Continued From page 1 1. Review of Dietary Cook D's employee file showed the following: -Hire date of 04/29/25; -TB test #1 administered on 04/30/25; -TB test #1 read on 05/02/25 (three days after hire date). 2. Review of the Life Enrichment Coordinator E's employee file showed the following: -Hire date of 09/17/25; -TB test #tadministered on 09/22/25; -TB test #1 read on 09/24/25 (seven days after hire date). 3. Review of Personal Care Attendant F's employee file showed the following: -Hire date of 01/29/25; -TB test #1administered on 01/29/25; -TB test #1 read on 01/31/25 (two days after hire date). 4. Review of CMA/LIMA G's employee file showed the following: -Hire date of 02/25/25; -TB test #1 administered on 02/25/25; -TB test #1 read on 02/27/25 (two days after hire date). 5. Review of CMA H's employee file showed the following: -Hire date of 04/15/25; -TB test #1 administered on 04/15/25; -TB test #1 read on 04/17/25 (two days after hire date). During an interview on 10/23/25 at 5:02 P.M., the Director of Nursing (DON) said the following: -She is responsible for administering the TB test for all new employees; Missouri Department of Health and Senior Services STATE FORM Bee9 iYS811 if continuation sheet 2 of 8 PRINTED: 04/07/2026 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 16202C B.WING 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE WESTPORT ESTATES ASSISTED LIVING MARSHALL, MO 65340 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES fi 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} Continued From page 2 -The TB test is administered on the onboarding (orientation) day; -The new employee tours the facility including resident care areas on the day of onboarding. During an interview on 10/23/25 at 5:09 P.M., the administrator said the following: -The DON is responsible for administering the TB tests for new employees; -The TB test is administered during the onboarding process (orientation); -The onboarding date is the first day of compensation; -The new employee tours the facility including resident care areas on the day of onboarding. 19 CSR 30-86.047(40) Self-Control of Medication Requirements Self-control of prescription medication by a resident may be allowed only if approved in writing by the resident's physician and included in the resident ‘ s individualized service plan. A resident may be permitted to control the storage and use of nonprescription medication unless there is a physician ' s written order or facility policy to the contrary. Written approval for self-control of prescription medication shall be rewritten as needed but at least annually and after any period of hospitalization. IAI This regulation is not met as evidenced by: Class {I* Based on observation, interview and record review, the facility failed to obtain a physician's order for three residents (Resident #1, Resident #2 and Resident #3) of five sampled residents to self-administer or keep medications at bedside. Missouri Department of Health and Senior Services STATE FORM 6699 1¥S8811 if continuation sheet 3 of & PRINTED: 01/07/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING; (X3) DATE SURVEY COMPLETED B. WING 16202C 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 WESTPORT ESTATES ASSISTED LIVING (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) Continued From page 3 The facility census was 29. Review of the facility's policy, Self-Administration of Medication, revised 05/25/21, showed the following: -In order for residents to self-administer their medications, a physician's order should be obtained, and the resident should successfully pass the Medication Self-Administration Evaluation; -All nurses, nurse aides and medication aides should report to the licensed nurse, any medications found at the bedside not authorized for bedside storage; -The electronic medication jog (EML) medication administration record (MAR) should reflect that the resident self-administers their medications. 1. Review of Resident #2's electronic health record showed the following: -Diagnosis of chronic obstructive pulmonary disease (COPD/a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe): -No evidence of an evaluation for self-administration of medications or for medications to be kept at bedside. Review of the resident's October 2025 POS showed the following: -Airsupra (Albuterol-budesonide/a rescue inhaled medication used to treat asthma or asthma-like symptoms including wheezing, coughing and shortness of breath) inhalation aerosol! 90-80 micrograms per actuation, inhale two puffs orally every eight hours as needed for shortness of air; -May not have OTC medications at bedside and/or self-administer ad lib; -No physician's order authorizing the self-administration of any prescription medication. Missouri Department of Health and Senior Services STATE FORM 6889 t¥S811 If continuation sheet 4 of 8 PRINTED: 01/07/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (x3) DATE SURVEY COMPLETED B. WING 16202C 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE WESTPORT ESTATES ASSISTED LIVING MARSHALL, MO 65340 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION X5 (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4781| Continued From page 4 During an interview on 10/23/25 at 12:20 P.M., Level | Medication Aide (LIMA) B said the resident keeps his/her Airsupra inhaler in his/her pocket to use as a rescue inhaler as needed. During an interview on 10/23/25, at 3:06 P.M., the resident said the following: -He/She uses inhalers to help treat breathing problems; -He/She keeps the Airsupra inhaler in his/her pocket but mainly uses it when showering; -When he/she uses it, he/she usually tells staff. Observation on 10/23/25 at 3:08 P.M., showed the resident took an Airsupra inhaler out of his pants pocket. 2. Review of Resident #3's electronic health record showed the following: -No specific diagnosis related to ophthalmic issues; -No evidence of an evaluation for self-administration of medications or for medications to be kept at bedside. Review of the resident's October 2025 POS showed the following: -May not have OTC medications at bedside and/or self-administer, -GenTeal tears night-time ophthalmic ointment (a lubricant eye gei that can relieve dry, irritated eyes) instill one application in both eyes at bedtime; -Refresh tears ophthalmic solution (lubricant eye drops that help combat dry and irritated eyes) instill one drop into both eyes four times a day for dry eyes. During an interview on 10/23/25 at 11:42 A.M., Missouri Department of Health and Senior Services ; STATE FORM 6890 18811 If continuation sheet 5 of & PRINTED: 01/07/2026 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 16202C B. WING 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 804 APACHE DRIVE MARSHALL, MO 65340 (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} WESTPORT ESTATES ASSISTED LIVING Continued From page 5 LIMA B said the resident instills his/her eye drops in his/her room. During an interview on 10/23/25 at 2:56 P.M., the resident said the following: -He/She has eye drops and eye ointment in his/her drawer; -He/She used the eye drops four times a day and the ointment at bedtime; -He/She kept the eye drops and ointment in his/her room. Observation on 10/23/25 at 2:58 P.M., showed a bottle of Refresh eye drops and tube of GenTeal eye ointment in the resident's nightstand. 3. Review of Resident #1's electronic health record showed the following: -Diagnosis of allergic rhinitis (an allergic reaction that caused sneezing, congestion and a sore throat); -An evaluation for self-administration of medications, dated 09/19/25, that showed the resident has the ability to administer ophthalmics (eye medications), understands as needed medication use, recalis if medications taken, expresses the interest in self-administration and has a physician order to self-administer,; -The evaluation did not address nasal medications. Review of the resident's October 2025 Physician ‘| Order Sheet (POS) showed the following: -Lubricating eye drops solution (an over-the-counter/OTC eye drop used to treat dry eyes), instill one drop in both eyes every eight hours as needed for dry eyes; -Saline nasal spray solution (an over-the-counter saline spray used to moisturize dry nose in cases of allergies) one spray in both nostrils every eight Missouri Department of Health and Senior Services STATE FORM 8600 {1YS811 If continuation sheet 6 of 8 PRINTED: 01/07/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 16202C 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 WESTPORT ESTATES ASSISTED LIVING (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) Continued From page 6 hours as needed for nasal congestion: -No physician's order authorizing the self-administration of any over-the-counter medications or that the medications could be kept at bedside. Observation on 10/23/25 at 3:15 P.M., showed a bottle of saline nasal spray and lubricating eye drops sitting on a table by the resident's recliner in his/her room. During and interview on 10/23/25 at 3:15 P.M., the resident said he/she uses the saline nasal spray for dry sinuses or congestion and the eye drops for dry eyes. During an interview on 10/23/25 at 2:39 P.M., LIMA B said all resident's that have medications in their room should have an order allowing them to keep medications at bedside and to self-administer. During an interview on 10/23/25 at 5:02 P.M., the Director of Nurses said the following: -Any resident that has medication in their room, prescribed or over the counter, should have an order to keep at bedside as well as an evaluation to self-administer those medications; -If a medication was kept at beside, there should be a physician order for at bedside and an order allowing to self-administer; -She was aware of Resident #3's eye drops and eye ointment and felt like there was an order for him/her to self-administer and for those to be kept at bedside; -Resident #2 should not have a rescue inhaler on his/her person; -She was unaware Resident #1 had over the counter medications at bedside. Missouri Department of Health and Senior Services STATE FORM 6ea8 tYS811 If continuation sheet 7 of 8 PRINTED: 01/07/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDING: COMPLETED 16202C B. WING 10/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 (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) WESTPORT ESTATES ASSISTED LIVING A4781| Continued From page 7 During an interview on 10/23/25 at 5:09 P.M., the administrator said any medication at a resident's bedside should have an order and the self-administration assessment completed. *The higher classification merited merited due to the extent of the violation. Missouri Department of Heaith and Senior Services STATE FORM 8808 YS811 lf continuation sheet 8 of 8 i oO N Westport Estates Assisted Living Street Address, City, Zip: | 904 Apache Drive, Marshail, MO 65340 16202C PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE ID PREFIX TAG | ID PREFICTAG | PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED 10 THE APPROPRIATE DEFICIENCY] in response to 19 CSR 30-86.047 (19) TB Screen Resident & Staff immediate Action: Administrator and Director of Nursing will be educated on TB Screening of Residents and Staff. Education will include but is not limited to the following: Review of 19 CSR 20-20.100 as it relates to: Long-Term Care Employees and Volunteers. e All new long-term care facility employees and volunteers who work ten (10) or more hours per week are required to obtain a Mantoux PPD two (2)-step tuberculin test within one (1) month prior to starting employment in the facility. If the initial test is zero to nine millimeters (O-9 mm), the second test should be given as soon as possible within three (3) weeks after employment 11/12/2025 begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two (2) years. ° TB Screening for Long Term Employees DHSS PDF Education will take place on or before 11/10/2025 and will be conducted by the Regional Operations Director. All employee current employee files will be reviewed to assure all TB testing has been completed and newly hired will have TB testing in accordance with 19 CSR 20-20.100. Ongoing Compliance: Administrator will assure ongoing compliance by reviewing alt new hire records to assure the initial Mantoux PPD test is read prior to starting work for compensation. No new hire will be Provider/Supplier Name: aliowed to start work without having the initial Mantoux PPD being read. Compliance Date: 11/12/2025 © In response to A4781 19 CSR 30-86.047(40) Self-Conirol of Medication Requirements Immediate Action: Resident #1, #2, #3 medications have been removed from their rooms and placed back into the Medication Secure box for administration only by certified or licensed staff. All other resident rooms reviewed for medications at bedside without physician orders for OTC at bedside, orders for self- administration or Self Administration Evaluations completed by a licensed nurse. Residents found to have medications at bedside will be assessed by the licensed nurse using the Self Administration Evaluation have orders obtained from his/her physician to have medication at bedside if evaluated to be safe to self-administer all Self Administration Evaluations and physician orders to completed on or before 11/12/2025. Director of Nursing and all Nursing Staff will be in-serviced on Over the counter Medication and Self Administration of Medication policy and procedures. Director of Nursing will be in- serviced by Regional Operations Director on or before 41/5/2025 and Director of Nursing will in-service all nursing on or before 11/12/2025. 14/12/2025 Ongoing Compliance: Director of Nursing will assure ongoing compliance through conducting monthly audits of resident rooms, physician orders and resident records to assure all residents with medications at bedside have been evaluated for Self- Administration and have physician orders to have medications at bedside. Residents who are found to not be safe in self-administration or who do not have physician orders to self-administrate will have all medications both prescription and OTC secured in the locked medication cabinet or cart. Completion Date: 11/12/2025

PRINTED: 03/12/2024 . 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 IDE : IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 16202C B. WING tt 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) {EACH DEFICIENCY MUST BE PRECEDED BY FULL j i (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE ; DATE DEFICIENCY) WESTPORT ESTATES-ASSISTED LIVING BY AMERIC, A2257| 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class ll. Based on observation and interview on 03/4/2024, facility fails to prevent storage of excessive amounts of combustibles. Facility | census is twenty-one (21). Deficiencies affect twenty-one (21) of twenty-one (21) residents. Observations showed rooms A3, A4, B8, and 12 being used for the storage of combustible items. None of the rooms being used for storage have self closures, storage signs, and are left unlocked. interview with Administrator on 03/4/2024 at 12:30 P.M. stated he would get them locked and | labeled. 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. | WIN This regulation is not met as evidenced by: Class Ill | Based on observation and interview on 3/4/2024, the facility failed to ensure rooms were neat, clean, and orderly. The facility census was twenty-one (21). This affected twenty-one (21) of twenty-one (21) residents. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLI REPRESENTATIVE'S SIGNATURE TITLE STATE FORM RP68114 Iféontinuatjon sheet 1 of 2 PRINTED: 03/12/2024 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 16202C —$ 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 904 APACHE DRIVE MARSHALL, MO 65340 (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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTPORT ESTATES-ASSISTED LIVING BY AMERIC, Continued From page 1 Observation excessive clutter in room D5 causing a higher fuel load. During the exit interview on 3/4/2024 at 12:30 PM, the administrator stated he would work on getting it organized. Missouri Department of Health and Senior Services STATE FORM sees RP6S11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: A2257 Street Address, City, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Westport Estates 904 Apache Drive, Marshall, MO 65340 In response to 19 CSR 30-86.022 (10)(B) Combustible Materials, Unnecessary Storage of. Immediate Action: Rooms A4 and B8 will be organized and cleaned and a self closure will be installed on the door on or before 4/5/2024. Rooms A3 and 12 will be cleaned and organized and returned to resident rooms on or before 4/5/2023. All rooms will be evaluated on or before 4/5/2024 to assure there are no excessive amounts of combustibles stored without proper storage protocols being in place. 4/5/2024 Ongoing Compliance: All storage areas will be cleaned and organized with proper self-closures place on the doors, along with proper signage indicating “Storage Area” and will be locked at all times when not in use. The Maintenance Supervisor will assure ongoing compliance through completing weekly audits of all rooms to assure storage areas have self-closures, storage signs and are locked at all times when not in use. Compliance Date: 4/5/2024 In response to 19 CSR 30.86.032 (23) Rooms Neat, Orderly Cleaned Daily. Immediate action: Room D5 will be cleaned and organized on or before 4/5/24. All resident rooms will be evaluated on or before 4/5/24 to assure rooms are neat, clean and well organized. Staff have been inserviced on completing daily cleaning of all 4/5/2024 rooms and weekly deep cleaning of rooms. Ongoing Compliance: Administrator will assure ongoing compliance by conducting weekly rounds to assure all resident rooms are neat, clean and orderly. Compliance Date: 4/5/2024