HOPEDALE COTTAGE ASSISTED LIVING THE.

PRINTED: 05/29/2025 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 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1314 W SCHOOL STREET 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) HOPEDALE COTTAGE ASSISTED LIVING, THE 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. Il This regulation is not met as evidenced by: Class II Based on observation and interview on May 27, 2025, 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 six (6). This deficiency affects six (6) of six (6) residents. Observation of the delayed egress exit door at end of the west hallway on May 27, 2025, at 12:51 P.M., showed a magnetically locked exit door that failed to open or set off any audible signal in six (6) out of six (6) attempts of pushing, with greater than 15 pound-force (Ibf), on the fire exit hardware 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 WYYK11 If continuation sheet 1 of 2 PRINTED: 05/29/2025 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 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1314 W SCHOOL STREET 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) HOPEDALE COTTAGE ASSISTED LIVING, THE Continued From page 1 building in the event of an emergency. During an interview on May 27, 2025, at 12:55 P.M., the Administrator said he/she would have a door company repair the door. 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 6899 WYYK11 If continuation sheet 2 of 2 UNABLE TO LOCATE PLAN OF CORRECTION

PRINTED: 08/07/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY MPLETED AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING: sa B.WING 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1314 W SCHOOL STREET 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) HOPEDALE COTTAGE ASSISTED LIVING, THE A2264, 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-} hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class II Based on observation and interview on August 5, 2024, the facility, licensed after August 28, 2007, failed to ensure doors in a smoke partition shall be self-closing. The facility census was nine (9). | This deficiency affects nine (9) out of nine (9) residents. Observation on August 5, 2024, at 12:30 A.M., showed a required smoke door located in the corridor outside of resident room nine (9) that did not close completely in six (6) of six (6) attempts when the door was released from the electro-magnetic hold-open device (a device that releases the door from the open position upon activation of the fire alarm). Smoke doors failing | to close will allow smoke and toxic gases to spread to other areas of the building in the event of a fire. During an interview August 5, 2024, at 1:41 P.M., Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE ST ) eheaaee ne KEAL Admmgstrnter 8 /15, | 02 STATE FORM PQ7311 If continuation sheet 1 of 4 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: 1314 W SCHOOL STREET HOPEDALE COTTAGE ASSISTED LIVING, THE OZARK, MO 65721 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 the Administrator said he/she was not aware the door would not close properly. 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: Class II Based on observation and interview on August 5, 2024, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. The facility census was nine (9). This deficiency affects nine (9) out of nine (9) residents. Observation of resident room four (4) on August 5, 2024, at 12:26 P.M., showed in the living room a non-compliant wastebasket being used for trash. Observation of resident room four (4) on August 5, 2024, at 12:26 P.M., showed in the bathroom a non-compliant wastebasket being used for trash. Observation of resident room 10 on August 5, 2024, at 12:31 P.M., showed in the living room a non-compliant wastebasket being used for trash. Observation of resident room 12 on August 5, 2024, at 12:32 P.M., showed in the living room two (2) non-compliant wastebaskets being used for trash. Observation of resident room two (2) on August 5, Missouri Department of Health and Senior Services STATE FORM 6899 PQ7311 PRINTED: 08/07/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/05/2024 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 4 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: 1314 W SCHOOL STREET HOPEDALE COTTAGE ASSISTED LIVING, THE OZARK, MO 65721 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 2024, at 12:37 P.M., showed in the living room a non-compliant wastebasket being used for trash. During an interview August 5, 2024, at 1:44 P.M., the Administrator said he/she train the staff to look for and remove non-compliant wastebaskets. 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 III Based on observation and interview on August 5, 2024, the facility failed to ensure the building shall be maintained in good repair. The facility census was nine (9). This deficiency affects nine (9) out of nine (9) residents. Observation of the west wall of the sprinkler room on August 5, 2024, at 12:43 P.M., showed a sixteen-inch (16") by eighteen-inch (18") section of sheetrock that had been removed from the wall. This open section of the wall will allow smoke and toxic gasses to spread to other parts of the building in the event of a fire. Observation of the west wall of the sprinkler room on August 5, 2024, at 12:43 P.M., showed behind the mop drain a six-inch (6") by six-inch (6") section of sheetrock missing from the wall. Further observation showed in the same area a thirty-six-inch (36") by eighteen-inch (18") section of the wall that had been damaged from a water Missouri Department of Health and Senior Services STATE FORM 6899 PQ7311 PRINTED: 08/07/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/05/2024 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 4 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: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1314 W SCHOOL STREET HOPEDALE COTTAGE ASSISTED LIVING, THE OZARK, MO 65721 PRINTED: 08/07/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/05/2024 (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 A3201 | Continued From page 3 leak. During an interview August 5, 2024, at 1:48 P.M., the Administrator said he/she would have maintenance repair the water leak and the sheetrock. Missouri Department of Health and Senior Services STATE FORM oeee PQ7311 DEFICIENCY) If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Hopedale Cottage Name: Street Address, | 4314 School Street Ozark, MO 65721 City, Zip: Date of Survey: August 5, 2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The required smoke door in the smoke partition was fixed by our maintenance team and now is self-closing. Hopedale staff has been educated to monitor the self-closing door during monthly A2264 fire drills and to notify the Owner or Administrator in the event 8/12/2024 the door does not self-close or fully close when released from the electro-magnetic hold open device. Completed by maintenance on 8/12/2024. hr an All waste baskets that don’t meet the regulation requirements have been removed from the community. Staff have been re- educated on the state regulations regarding waste baskets and A2286 the required specifications. Staff have been advised to notify 8/12/2024 family and residents that new wastebaskets cannot be brought into the community unless they are metal or UL or FM fire resistant rated. Completed by 8/12/2024 es ee West wall of sprinkler room will be cut out and wet/rot area will be replaced with new dry wall as to meet state regulations to prevent smoke and toxic gases from spreading to other parts of A3201 the building in the event of a fire. Hopedale Cottage maintenance team will monitor sprinkler room monthly, make iaicinata any repairs and report concerns to Administration staff. The maintenance team will do the wall repair which will be completed by 8/31/2024. | Pp | | a | bien ene at gee ae en ee a le ee ee eae men ree iain Ged 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.