MEADOWBROOK RESIDENTIAL CARE, INC.

-_ PRINTED: 11/14/2025 FORM APPROVED Missouri Department of Health and Senior Services . STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER‘CLIA M2} MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: a. BUILDING: (X3) DATE SURVEY COMPLETED 20513C 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 806 WEST MULBERRY PILOT KNOB, MO 63663 MEADOWBROOK RESIDENTIAL CARE, INC (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION ! (x5) 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) A3235 19 CSR 30-86.032(34) Hot Water 105-120 » A3235 Degrees F , Plumbing fixtures which are accessible to residents and which supply hot water shall be thermostatically controlled so that the water : temperature at the fixture does not exceed ane _ hundred twenty degrees Fahrenheit (120°F) : (49°C) and the water shall be ata temperature range between one hundred five degrees | Fahrenheit (105°F) (41°C) and one hundred ' twenty degrees Fahrenheit (120°F} (49°C). ill This regulation is not met as evidenced by: _ Class Il _ Based on observation and interview, the facility failed to ensure staff maintained hot water temperatures between 105 degrees Fahrenheit (°F) and 120 °F. The facility census was 33. | . The facility did not provide a policy, Observations of water temperatures on 11/06/25 from 11:20 A.M. through 12:10 P.M. taken with a digital stem type thermometer showed: - Raom #6 water temperature recorded at 137.5° | . at the sink: - Room #3 water temperature recorded at 135.6° "at the sink: _- Room #15 water temperature recorded at 124.8° at the sink; i - Room #8 water temperature recorded at 134.6° at the sink; - Room #11 water temperature recorded at 137.4° at the sink. _ Observation of the water temperature on 11/06/25 at 3:31 P.M. taken with a digital stem type thermometer for the shared shower room showed a water temperature of 125.6 degrees F. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE . TITLE {X6) DATE ae : Li2if2s lf continuation sheet 1 of 2 nM | STATE FORM sie 2GNI11 (X4) ID TAG A3235 om, Missouri Department of Health and Senior Services STATE FORM NAME OF PROVIDER OR SUPPLIER MEADOWBROOK RESIDENTIAL CARE, INC PREFIX Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X14) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 20513C SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 . During an interview on 11/06/25 at 12:15 P.M., the Director of Nursing (DON) said the tanks will be drained and a plumber called. During an interview on 11/06/25 at 12:28 P.M., , the Maintenance Director said he/she would need _ to get a new thermometer because his measured less than the temperatures taken with the digital _ Stem type thermometer. He/she said this had ' never happened in the past other than with the kitchen water heater, which had to be adjusted . higher, During an interview on 11/06/25 at 1:33 P.M., the DON said someone had come out to fix the water heater for the kitchen last week because it wasn't _ hot enough. He/she suspected they may have turned all the heaters up and would call the _ plumber to assure that did not happen again. _ A38235 6859 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 11/14/2025 FORM APPROVED ihe Ok Opprpsate lett Corectre STREET ADDRESS, CITY, STATE, ZIP CODE 806 WEST MULBERRY PILOT KNOB, MO 63663 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} | Facitty dnd tenis Pichu stead | Now Jrwineneder was (M il2i)2s Calt piaea + CoChld> ( yioktinn tm yy ale Cow Unie dyere SHA IE Noe te Vee ddjustivy Dev Water | Wienke Wil Carbnug Te ds mainly \WMuer Rinpeaiwe Cer OS pe weekly Chrecas her rexd Maares Nine Worle! — (X3) DATE SURVEY COMPLETED 11/06/2025 | Lhelzs- Pluapr Couiud “po “After DeecNagtel Cuirnedd He taut zits | ilu le Prohote | Are will ob ol (8) COMPLETE DATE od 2GNH1 Coie bsp If continuation sheet 2 of 2

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 20513C NAME OF PROVIDER OR SUPPLIER 806 WEST MULBERRY MEADOWBROOK RESIDENTIAL CARE, INC PILOT KNOB, MO 63663 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG 19 CSR 30-86.022(3)(B) Fire Extinguishers-Type Fire Extinguishers. (B) All new or replacement portable fire extinguishers shall be ABC-rated extinguishers, in accordance with the provisions of NFPA 10, 1998 edition. A K-rated extinguisher or its equivalent shall be used in lieu of an ABC-rated extinguisher in the kitchen cooking areas. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on November 2, 2023 the facility failed to ensure the provisions of NFPA 10 within the facility . The facility census November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight (28) residents. Observation on November 2, 2023 at 1055 revealed grease laden cooking cooking and no Class K fire extinguisher. During a telephone interview on November 2, 2023 at 1341 the D.O.N. stated she would order a Class K fire extinguisher for the kitchen. 19 CSR 30-86.032(2) Substantially Constructed & A3201 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE 6899 STATE FORM (X2) MULTIPLE CONSTRUCTION PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/02/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE TITLE (X6) DATE G18711 If continuation sheet 1 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 20513C NAME OF PROVIDER OR SUPPLIER 806 WEST MULBERRY MEADOWBROOK RESIDENTIAL CARE, INC PILOT KNOB, MO 63663 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG ID PREFIX TAG Continued From page 1 Based on observation and interview during the fire safety inspection process on November 2, 2023, the facility failed to maintain the structure in good repair by allowing penetrations of horizontal and vertical smoke partitions. The facility census November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight (28) residents. Observation on November 2, 2023 at 1003 revealed a two (2) inch round hole in the wall of the D.O.N's Office. Observation on November 2, 2023 at 1049 revealed a six (6) inch square hole in the ceiling of the basement. Observation on November 2, 2023 at 1051 revealed a three (3) foot square hole in the wall of the basement office. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the building During the exit interview on November 2, 2023 at 1110, the D.O.N. stated she would have the repairs made. 19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION G18711 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/02/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 20513C NAME OF PROVIDER OR SUPPLIER 806 WEST MULBERRY MEADOWBROOK RESIDENTIAL CARE, INC PILOT KNOB, MO 63663 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 2 heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. 1/II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on November 2, 2023 the facility failed to ensure only approved heating sources were used within the facility . The facility census November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight (28) residents. Observation on November 2, 2023 at 1054 revealed a portable space heater being used in the kitchen. During an interview on November 2, 2023 at 1105 the D.O.N. stated said she would remove the Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION G18711 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/02/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 20513C NAME OF PROVIDER OR SUPPLIER 806 WEST MULBERRY MEADOWBROOK RESIDENTIAL CARE, INC PILOT KNOB, MO 63663 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 3 heater. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire inspection process on November 2, 2023 the facility failed to ensure the facility's electric wiring was properly maintained. The facility census November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION G18711 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/02/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 4 of 5 PRINTED: 11/06/2023 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 20513C $$$ i$ 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 806 WEST MULBERRY PILOT KNOB, MO 63663 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY MEADOWBROOK RESIDENTIAL CARE, INC A3214 | Continued From page 4 (28) residents. Observation on November 2, 2023 at 1007 revealed a relocateable power tap plugged into an extension cord in the administrator's office. Extension cords are not permitted as permanent wiring and relocateable power taps must plug directly into a permanent outlet. Observation on November 2, 2023 at 1049 revealed an open breaker slot in the downstairs electrical panel. During an interview on November 2, 2023 at 1100 the D.O.N. stated she would have the extension cord removed and a blank inserted into the electrical panel. Missouri Department of Health and Senior Services STATE FORM oeee G18711 If continuation sheet 5 of 5 PRINTED: 11/06/2023 * ; 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 20513C B. WING 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 806 WEST MULBERRY MEADOWBROOK RESIDENTIAL CARE, INC PILOT KNOB, MO 63663 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | wee TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE | DEFICIENCY, 19 CSR 30-86.022(3}{B) Fire Extinguishers-Type | Fire Extinguishers. | (B) All new or replacement portable fire extinguishers shall be ABC-rated extinguishers, in | accordance with the provisions of NFPA 10, 1998 | edition. A K-rated extinguisher or its equivalent shall be used in lieu of an ABC-rated extinguisher in the kitchen cooking areas. II This regulation is not met as evidenced by: | Class II , Based on observation and interview during the fire | safety inspection process on November 2, 2023 | the facility failed to ensure the provisions of NFPA _ 10 within the facility . The facility census November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight (28) residents. Observation on November 2, 2023 at 1055 revealed grease laden cooking cooking and no Class K fire extinguisher. During a telephone interview on November 2, 2023 at 1341 the D.O.N. stated she would order a Class K fire extinguisher for the kitchen. | A3201 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. HAI | | This regulation is not met as evidenced by: | Class III Missouri Department of Health an nior Services (x6) DATE LABORATORY DIRECTOR'S OR PROVIQER/SUPPLIER REPRESENTATIVE'S SIGNATURE = . TITLE STATE FORM G18711 if continuation sheet 1 of 5 PRINTED: 11/06/2023 Pe 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 20513C B. WING 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 806 WEST MULBERRY PILOT KNOB, MO 63663 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE GOMCEETE ij Tac | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE | DEFICIENCY) MEADOWBROOK RESIDENTIAL CARE, INC A3201 Continued From page 1 | A3201 | | Based on observation and interview during the fire | | | safety inspection process on November 2, 2023, the facility failed to maintain the structure in good | | | repair by allowing penetrations of horizontal and | vertical smoke partitions. The facility census November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight (28) residents. Observation on November 2, 2023 at 1003 revealed _ a two (2) inch round hole in the wall of the D.O.N's Office. Observation on November 2, 2023 at 1049 revealed | a six (6) inch square hole in the ceiling of the } basement. | Observation on November 2, 2023 at 1051 revealed a three (3) foot square hole in the wall of the | basement affice. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the | building During the exit interview on November 2, 2023 at | 1110, the D.O.N. stated she would have the repairs | made. | A3211 19 CSR 30-86.032(10) Heaters-Approved Label, A821 | Venting. No Portable In newly licensed facilities or if a new heating | system is installed in an existing licensed facility, | the heating of the building shail be restricted to | | steam, hot water, permanenily installed electric | Missouri Department of Health and Senior Services STATE FORM 6899 G18711 If continuation sheet 2 of 5 PRINTED: 11/06/2023 " 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 20513C B. WING 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 806 WEST MULBERRY MEADOWBROOK RESIDENTIAL CARE, INC PILOT KNOB, MO 63663 (x4) 10 | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE rh TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE Continued From page 2 heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or | National Board of Fire Underwriters. The foregoing | requirements are applicable to residential care | facilities. In assisted living facilities, the heating of | the building shall be restricted to steam, hot | water, permanently installed electric heating | devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved | installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all | facilities, oil or gas heating appliances shall be | properly vented to the outside and the use of | portable heaters of any kind is prohibited. If | approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II | This regulation is not met as evidenced by: | Class II Based on observation and interview during the fire safety inspection process on November 2, 2023 the facility failed to ensure only approved heating sources were used within the facility . The facility census November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight (28) residents. Observation on November 2, 2023 at 1054 revealed | a portable space heater being used in the kitchen. | During an interview on November 2, 2023 at 1105 the D.O.N. stated said she would remove the Missouri Department of Health and Senior Services STATE FORM 6508 G18711 If continuation sheet 3 of 5 PRINTED: 11/06/2023 - 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 20513C BaWING 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 806 WEST MULBERRY MEADOWBROOK RESIDENTIAL CARE, INC PILOT KNOB, MO 63663 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION | (x5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE ee T TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE | A3211) Continued From page 3 | heater. A3214 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected | In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the | requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., | incorporated by reference, in this rule and available | by mail at One Batterymarch Park, Quincy, MA | 02269, and local codes. This rule does not | incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This | rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be | maintained in good repair and shall not present a | safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified | electrician. IV/III | This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire inspection process on November 2, 2023 the | facility failed to ensure the facility's electric wiring | was properly maintained. The facility census | November 2, 2023 was twenty-eight (28). This deficiency affects twenty-eight (28) of twenty-eight Missouri Department of Health and Senior Services STATE FORM rade G18711 If continuation sheet 4 of 5 PRINTED: 11/06/2023 » 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 20513C B. WING = 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 806 WEST MULBERRY PILOT KNOB, MO 63663 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID | PROVIDER'S PLAN OF CORRECTION | (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE | : DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE “ j j MEADOWBROOK RESIDENTIAL CARE, INC aii Continued From page 4 | (28) residents. Observation on November 2, 2023 at 1007 revealed a relocateable power tap plugged into an extension cord in the administrator's office. Extension cords | are not permitted as permanent wiring and relocateable power taps must plug directly into a permanent outlet. | Observation on November 2, 2023 at 1049 revealed an open breaker slot in the downstairs electrical panel. | During an interview on November 2, 2023 at 1100 the D.O.N. stated she would have the extension cord removed and a blank inserted into the electrical panel. Missouri Department of Health and Senior Services STATE FORM Be98 618711 If continuation sheet 5 of 5 | | PLAN OF CORRECTION Provider/Supplier Name: Wuedowbyrie RCP | Street Address, city, Zip Die W. Mulbe yy Pil ine Ms (23lo3 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE fo Te feans, Wi) be placed fy | UAL yes AM A iikp ee On Has LT 4, oo 7a Ura R a adi Vepniy ran = 6 wt m | srudued | | j alle hoe ee 7 Suduled +s lo? Can cuted on nWsday | 1i/a[eous | | Nisvembt- 941 26 p __IRAtbie Gir Cod fmerlhiakr his ben Yemset | iizfeos | ite FACity Che cave’ iiiefames St = | A322. -—_ectentien (rel (uriedel from vii ie Offecine |MTelenes.| fiefs | LCrictine DIAGA blank Mist nt eZ DIA mm (Vina M4 22-2 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.