MEADOW RIDGE SENIOR LIVING.

PRINTED: 02/48/2025 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 B.WING_ 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 521 MEADOW RIDGE LANE MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES i PROVIDER'S PLAN OF CORRECTION i (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL : (EACH CORRECTIVE ACTION SHOULD BE ; COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE j DATE DEFICIENCY) ; MEADOW RIDGE SENIOR LIVING A1225] 19 CSR 30-86.012(25) Elevator Requirements Residential care facilities and facilities formerly licensed as residential care facilities It whose plans were initially approved between December 31, 1987 and December 31, 1998, shall have at least one (1) hydraulic or electric motor-driven : elevator if there are more than twenty (20) | residents with bedrooms above the first floor. The elevator installation(s) shall comply with all local and state codes, American Society for Mechanical Engineers (ASME) A17.1, Safety Code for Elevators, Dumbwaiters, and ; Escalators, and the National Fire Protection i Association 's applicable codes. All facilities with plans approved on or after January 1, 1999, shall comply with all local and state codes, ASME A17.1, 1993 Safety Code for Elevators and : Escalators, and the 1996 National Electrical Code. These references are incorporated by reference in this rule and available at: American Society for Mechanical Engineers, Three Park Avenue, New York, NY 10016-5990; and The American National Standards Institute, 11 West 42nd Street, 13th Floor, New York, NY 10036. This rule does not incorporate any additional amendments or additions. II : This regulation is not met as evidenced by: Based on record review and interview on 2/13/2025, the facility failed to have a current approved elevator inspection certification from either the city or the state available. The facility : census was thirty-seven (37). This affected thirty-seven (37) of thirty-seven (37) residents. Record review showed the current posted state ; elevator inspection certificates for the elevator expiring on 8/6/2024 During an interview on 2/13/2025 at 3:00 P.M., Pia ministrator stated she just needed to pay penne SIGNATURE A TITLE & (x6) DATE Ly Upped dr VIX AF Sey If pontinuatiop’’Sheet 1 of 4 PRINTED: 02/18/2025 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 BWING 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 521 MEADOW RIDGE LANE MOBERLY, MO 65270 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) MEADOW RIDGE SENIOR LIVING | Continued From page 1 for the permit and would get that donequickly | 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: i Class II Based on observation and interview on 2/13/2025 the facility failed to use only metal or UL- or FM-fire-resistant rated wastebaskets. The facility census was thirty-seven (37). This affected thirty-seven (37) of thirty-seven (37) residents. Observations showed resident rooms 108, 201, 203,204, 206, and 209 with unapproved plastic trash cans. | During an interview on 2/13/2025 at 12:00 PM., : the maintenance director said he would get the trash cans replaced with correct ones. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with | NFPA 99, 7999 Edition. II/fll This regulation is not met as evidenced by: Class Ill. | Based on observation and interview on Missouri Department of Health and Senior Services STATE FORM 6293 B61111 If continuation sheet 2 of 4 PRINTED: 02/18/2025 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 BLWING 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 521 MEADOW RIDGE LANE MOBERLY, MO 65270 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) j CROSS-REFERENCED TO THE APPROPRIATE H DATE DEFICIENCY} MEADOW RIDGE SENIOR LIVING Continued From page 2 2/13/2025, facility fails to ensure oxygen storage shall be in accordance with NFPA 99, 1999 edition. The facility census is thirty-seven (37). This deficiency affects thirty-seven (37) of thirty-seven (37) residents. Observations showed resident rooms : 126,135,136,and 211 without proper signage. In an interview with the maintenance director at 12:00 P.M. he stated he would get those signs hung. ! 19 CSR 30-86.032(18) Extension Cords/Duplex : Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. IVIII This regulation is not met as evidenced by: Class ill Based on observation and interview on 2/13/2025, the facility failed to insure that extension cords comply with electrical appliance approved standards. The facility census was thirty-seven (37). This deficiency potentially affected thirty-seven (37) of thirty-seven (37) residents. Missouri Department of Health and Senior Services STATE FORM 6899 B61111 If continuation sheet 3 of 4 PRINTED: 02/18/2025 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 B.WING 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 521 MEADOW RIDGE LANE MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL i {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} MEADOW RIDGE SENIOR LIVING A3219 Continued From page 3 | Observations showed resident rooms 108 and 204 with multi plug electrical adapters ' During the exit interview on 2/13/2025 at 12:00 : P.M., the maintenance director stated he would $ i get those removed. t 3 i 3 Missouri Department of Health and Senior Services STATE FORM 689 B61111 If continuation sheet 4 of 4 Name: Street Address, City, Zip: Date of Survey: ID PREFIX TAG A1225 A2286 A2298 A3219 (cont. on p.2) PLAN OF CORRECTION Provider/Supplier | te adow Ridge Senior Living 521 Meadow Ridge Lane 02/13/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2091603 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Elevator inspection had been completed but we had not received our invoice for the operating certificate. I contacted the Div. of Fire Safety and our invoice had been emailed to the address of a previous employ. I verified our correct contact information with them and obtained the 02/20/25 invoice for our operating certificate and made the payment. We received our operating certificate on 02/20/2025. Going forward if we do not receive our invoice in a timely manner we will reach All unapproved items (plastic wastebaskets) have been removed from apartments 108, 201, 203, 204, 206 and 209. The maintenance director will continue with his regular apartment checks to ensure that all wastebaskets are metal or UL or FM fire-resistant rated. We also had a meeting and educated staff to report any items that are not in 02/14/25 compliance, so that they can be removed and replaced with ones that are appropriate. Residents and families will also be educated upon move in regarding appropriate receptacles. Appropriate signage for oxygen use is now posted on the doors of apartments 126,135, 136 and 211. All nursing staff have been educated on the need to properly display signs for oxygen storage. Administrator will be directly responsible for making sure signs are posted on apartments with oxygen stored and/or in use. 02/14/25 All unapproved multiplug adapters have been removed from apartments 108 and 204. Maintenance director will continue doing his regularly scheduled apartment checks to ensure that no inappropriate devices are in use. Staff have 02/14/25 also been educated as to what items are not appropriate and told to report them immediately so that they can be removed and replaced with ones that are in compliance. Residents and families will also be educated upon move in regarding appropriate receptacles. 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.

PRINTED: 02/15/2024 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: 8. WING 02/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 521 MEADOW RIDGE LANE MOBERLY, MO 65270 MEADOW RIDGE SENIOR LIVING (x4) ID: SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX j (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) 19 CSR 30-86.022(5)(D) Fire Drill Requirements, _ Evacuation Fire Drills and Emergency Preparedness. ; (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every : three (3) months on each shift. At least four (4) of | the required fire drills must be unannounced to | residents and staff, excluding staff who are ; assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a | resident evacuation at least once a year. II/ll This regulation is not met as evidenced by: Class fll | Based on record review and interview on 2/5/2024 the facility failed to conduct a minimum | of twelve (12) fire drilis per year with at least one - drill every three (3) months on each shift. The i facility census was twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine | : ; (29) residents. Record review on 2/5/24 showed fire drills being : only done at 10:00 A.M and 2:00 PM through the | year. » During an interview on 2/5/24 at 1:00 PM with the | Administrator, she states she would start making sure fire drills were being conducted at different : times on different shifts. 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 hall be separated by cdnstruction of at least a Bepartment of Health a - Missouri LABORA ij q SENTATIVE'S SIGNATURS ° TITLE (6) DATE LA TCU LE Ma B ad S STATE RORM . i bese 7ZH911 Fconfnuationdheet 1 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER MEADOW RIDGE SENIOR LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 02/15/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 02/05/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 521 MEADOW RIDGE LANE MOBERLY, MO 65270 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)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/IIl This regulation is not met as evidenced by: Class III Based on record review and interview on 2/5/2024 the facility failed to conduct a minimum of twelve (12) fire drills per year with at least one drill every three (3) months on each shift. The facility census was twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine (29) residents. Record review on 2/5/24 showed fire drills being only done at 10:00 A.M and 2:00 PM through the year. During an interview on 2/5/24 at 1:00 PM with the Administrator, she states she would start making sure fire drills were being conducted at different times on different shifts. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7ZH911 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 521 MEADOW RIDGE LANE MEADOW RIDGE SENIOR LIVING MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 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 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 Il. Based on observation and interview on 2/5/24, this facility fails to ensure hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. Facility census is twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine (29) residents. Observation on on 2/5/24 showed both mechanical rooms outisde of room 108 Hallwayand the sprinkler room needing holes in the ceiling sealed with fire caulk. During the interview on 2/5/24 at 1:00 P.M, the maintinance manager, he stated the holes would all be sealed off as soon as possible. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles Missouri Department of Health and Senior Services STATE FORM 6899 7ZH911 PRINTED: 02/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/05/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 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 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 521 MEADOW RIDGE LANE MEADOW RIDGE SENIOR LIVING MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/Ill This regulation is not met as evidenced by: Class III Based on observation and interview on 2/5/24, the facility failed to insure that extension cords comply with electrical appliance approved standards. The facility census was twenty-nine (29). This deficiency potentially affected twenty-nine (29) of twenty-nine (29) residents. Observations on 2/5/24 showed extension cords being used in rooms 228,235, and the front office. Observations on 2/5/24 showed the front office having an extension cord plugged into a power strip. Observations on 2/5/24 showed multiple power strips plugged into the same outlet in rooms 235,236, and 121. During the exit interview on 2/5/24 at 1:00 P.M., the maitenance director said he would get those taken care of and replaced. Missouri Department of Health and Senior Services STATE FORM 6899 7ZH911 PRINTED: 02/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/05/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 3 Provider/Supplier Name: Street Address, City, Zip: Date of Survey: ID PREFIX TAG A2217 A2256 A3219 PLAN OF CORRECTION Meadow Ridge Senior Living 521 Meadow Ridge Lane, Moberly, MO 65270 02/05/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Fire drills will be scheduled monthly at appropriate times to satisfy the requirement of alternating through the 3 shifts, also paying attention to times and making sure it is staggered in order to ensure emergency preparedness during all hours of the day. An annual schedule has been made indicating dates and times for upcoming fire drills. We will continue to make annual schedules so that there is no question of when fire drills are to be performed. Maintenance staff have all been educated on the correct process for future drills and have a copy of the schedule to follow. The areas of concern noted in mechanical rooms have been addressed. The open areas surrounding pipes have been properly closed in with drywall and have been fire caulked in any remaining gaps. All areas in the building are now in compliance with requirements for hazardous areas. Going forward, if any modifications need to be made to existing pipes, we will be sure that the areas have a final inspection and will not be considered complete until all holes are closed in and caulked where needed. All unapproved items (extension cords) have been removed from apartment 228, 235 and the business office. The extension cord plugged into a power strip in the business office has been unplugged and equipment properly plugged directly into the power strip only. Multiple power strips plugged into the same outlet in apartments 235, 236, and 121 have been removed and no more than 1 power strip will be allowed in an outlet. We are now in compliance with requirements regarding extension cords/duplex receptacles. Going forward we will have monthly inspections on apartments to ensure we do not have these issues again. We will also keep residents and staff educated on the proper use of receptacles and power strips so that apartments and offices remain in compliance. 26D2091603 COMPLETION DATE 02/09/2024 02/27/2024 02/21/2024