COTTAGE AT CENTURY PINES, THE.

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER COTTAGE AT CENTURY PINES, THE (X4) ID PREFIX TAG A4749 Missouri Department of Health and Senior Services LABORATORY DIREC 8 STATE FORM {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 30579 707 EMCCRACKEN OZARK, MO 65721 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day A4749 The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: A. Within five (5) calendar days of admission; II This regulation is not met as evidenced by: | Based on interview and record review the facility staff failed to complete a community based assessment (CBA - a required assessment describing an individual's abilities and needs in activities of daily living) for one resident (Resident #1) within five calendar days of admission. The facility census was 10. Review showed the facility did not provide a policy regarding timelines for completing CBA's. 1. Review of Resident #1's medical record _ showed the following: -Admission date of 04/09/25; -Diagnoses included cognitive impairment (persistent brain function deficits that can impact a person's ability to think, learn, and remember), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and high blood pressure; -Staff did not document an admission CBA was completed within five calendar days of admission; -The first CBA was completed on 06/01/25 (almost two months after admission). R'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 07/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 06/24/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Administrator reviewed with Director of Nursing the time frame that residents CBA, ISP must be completed and in respective chart. The CBA, ISP's for both residents were completed. See attached. D.O.N was instructed to discontinue handwriting CBA, ISP prior to entering into the computer to ensure they are electronically in resident's charts. o/®) 1G The Manager of Nursing and the Director of Nursing are responsible to verify monthly that the CBA, ISP's are completed for new residents, as well as, any updates needed for existing residents. This is the plan of correction for A4749, and A4754. (X6) DATE If continuation’sheef 1 of 4 PRINTED: 07/07/2025 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 30579 B. WING 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 707 E MCCRACKEN OZARK, MO 65721 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) COTTAGE AT CENTURY PINES, THE Continued From page 1 During an interview on 06/24/25, at 2:16 P.M., the Director of Nursing (DON) said the following: -He/She was certified to complete CBA's for the facility; -He/She was aware CBA's need to be completed within five calendar days of admission; -The resident was having behavior issues upon admission and it was unclear if he/she was going to remain in the facility. This may be why the CBA was not completed with in the time frame. During an interview on 06/24/25, at 2:26 P.M., the Administrator said the following: -He/She was aware that CBA's needed to be completed within five calendar days of admission; -He/She was unaware that the resident's CBA was not completed in a timely manner; -The DON was responsible for completing CBA's. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident "s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II This regulation is not met as evidenced by: Based on interviews and record review, the facility staff failed to develop a complete Missouri Department of Health and Senior Services STATE FORM 6899 OAXA11 If continuation sheet 2 of 4 PRINTED: 07/07/2025 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 30579 B. WING 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 707 E MCCRACKEN OZARK, MO 65721 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) COTTAGE AT CENTURY PINES, THE Continued From page 2 individualized service plan (ISP - a document outlining a resident's needs and preferences, services to be provided, and goals expected by the resident or resident's legal representative in partnership with the facility) in a timely manner for one resident (Resident #2). The facility census was 10. Review showed the facility did not provide a policy regarding ISP's. 1. Review of Resident #2's medical record showed the following: -Admission date of 04/10/25; -Diagnoses included history of stroke, chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and high blood pressure; -Staff did not complete an ISP until 05/28/25 (over six weeks after admission) During an interview on 06/24/25, at 2:16 P.M., the Director of Nursing (DON) said the following: -He/She was responsible for completing the ISP's for residents; -He/She was aware the ISP's need to be completed in a timely manner; -He/She did not realize six weeks had passed between the resident's admission date and the completion of the ISP; -He/She strives to complete the ISP's within five days after a resident's admission to the facility. During an interview on 06/24/25, at 2:26 P.M., the said Administrator said the following: -He/She was unaware that the resident did not have an ISP completed for six weeks after admission; -ISP's should be completed as soon as possible after a resident admits to the facility; Missouri Department of Health and Senior Services STATE FORM 6899 OAXA11 If continuation sheet 3 of 4 PRINTED: 07/07/2025 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 30579 B. WING 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 707 E MCCRACKEN OZARK, MO 65721 (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) COTTAGE AT CENTURY PINES, THE Continued From page 3 -The DON was responsible for completing ISP's. Missouri Department of Health and Senior Services STATE FORM 6899 OAXA11 If continuation sheet 4 of 4

PRINTED: 05/28/2025 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 By WING 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 707 E MCCRACKEN OZARK, MO 657214 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COTTAGE AT CENTURY PINES, THE A2229| 19 CSR 30-86.022(7)(E) Locked Exit Doors Exits, Stairways, and Fire Escapes. (E) If it is necessary to lock exit doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the building. Only one (1) lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA 101 shall be permitted, provided that not more than one (1) such device is located in any egress path. Self-locking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. Wl This regulation is not met as evidenced by: Class II Based on observation and interview on May 27, 20285, the facility failed to provide delayed egress locks in compliance with National Fire Protection Association (NFPA) 101, Section 7.2.1.6.1, 2000 edition. The facility also failed to ensure locks on exit doors shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the building. The facility census on May 27, 2025 was nine (9). This deficiency affects nine (9) of nine (9) residents. Observation of the delayed egress exit door at the main entrance on May 27, 2025, at 10:51 A.M., showed a magnetically locked exit door that failed to open or set off any any audible signal in six (6) out of six (6) attempts of pushing, with greater than 15 pound-force (bf), on the handle of the door for more than three seconds. Further observation showed a door code needed to be entered on a keypad before the exit door would open. This special knowledge of the door code would delay an egress from the building in the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE L p/) 06/03/25— STATE FORM agg ICER11 If contindation sheet 1 of 2 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 COTTAGE AT CENTURY PINES, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 event of an emergency. Observation of the delayed egress exit door at the north side of the dining room on May 27, 2025, at 10:55 A.M., showed a magnetically locked exit door that failed to open or set off any any audible signal in six (6) out of six (6) attempts of pushing, with greater than 15 pound-force (Ibf), on the handle of the door for more than three seconds. Further observation showed a door code needed to be entered on a keypad before the exit door would open During an interview on May 27, 2025, at 11:45 A.M., CMA 1 said he/she would let maintenance know. NFPA 101, 2000 edition, Section 7.2.1.6.1 (c) states: "An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 Ibf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only." Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 ICER11 PRINTED: 05/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/27/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 707 EMCCRACKEN OZARK, MO 65721 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 2 STATE PLAN OF CORRECTION Agency : Mame The Cottage at Century Pines STREET ADDRESS, 707 E McCracken Rd, Ozark, MO 65721 CITY, ZIP: Provider ; Number &p| 20579 Exit Date I> May 27,2025 The doors affected were inspected by the maintenance department of the facility. Adjustments were made to ensure the doors operated as intended and in accordance with the regulation. The operation of the delayed egress doors of the facility was placed on the monthly maintenance inspection/report to be tested to ensure that the doors operate as required. The supervisor of maintenance will be responsible for the monthly inspections and adjustments or repairs to doors as required.