Vintage Gardens Assisted Living .

No findings

→2025-10-06

4776 · 1

→2025-05-13

3220 · 2

→2025-03-03

4797 · 1

→2025-02-19

4777 · 1

→2025-01-30

No findings

→2024-08-17

4776 · 1

→2024-05-24

No findings

→2024-05-23

7021 · 1

→2024-05-16

2238 · 2

→2023-08-31

View raw inspection records →

2257 · 7

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Full Inspection Record

Every inspection visit, verbatim.

11 inspections in the public record, most recent first. Plain-language summaries open first — click into any row for the full citation text.

reports on file

total deficiencies

2026-02-10

Annual Compliance Visit

No findings

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PRINTED: 02/26/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY (X2} MULTIPLE CONSTRUCTION COMPLETED A BUILDING: B, WING 22959 02/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64805 NAME OF PROVIDER OR SUPPLIER VINTAGE GARDENS ASSISTED LIVING PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x8) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4782, 19 CSR 30-86.047(41) Medication Storage/Accessibility All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. IVI This regulation is not met as evidenced by: Class Ill Based on observation, interview, and record review the facility failed to ensure all medications were kept in a secured location behind at least on locked door or cabinet when Level One Medication Aide (L1MA) A left the medication cart unlocked and unattended. The facility census was 34, Review of the facility undated policy titled, "Medication Administration”, showed all narcotics should have been kept behind two locks. 4. Observation on 02/10/26 at 10:35 A.M. the medication cart was observed in the hallway outside the Director of Nursing (DON's) office, unlocked and no staff around it. 2. Review of Resident #4's February 2026 Physician's Order Sheet (POS) showed: -Diagnoses included dementia (the loss of cognitive functioning). -Order dated 03/21/25 Buspirone (medication used for anxiety) 5 milligrams (mg) three times daily. Observation on 02/10/26 at 10:57 A.M. showed: -LiMAA brought the resident out of his/her room to the hallway, where he/she prepared and gave Missouri Department of Health and Senior Services (X6) DATE 4Cuytt tion sheet 1 of 6 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 VINTAGE GARDENS ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 02/26/2026 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 02/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4782 19 CSR 30-86.047(41) Medication Storage/Accessibility All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. I/II This regulation is not met as evidenced by: Class III Based on observation, interview, and record review the facility failed to ensure all medications were kept in a secured location behind at least on locked door or cabinet when Level One Medication Aide (L1MA) A left the medication cart unlocked and unattended. The facility census was 34. Review of the facility undated policy titled, "Medication Administration", showed all narcotics should have been kept behind two locks. 1. Observation on 02/10/26 at 10:35 A.M. the medication cart was observed in the hallway outside the Director of Nursing (DON's) office, unlocked and no staff around it. 2. Review of Resident #4's February 2026 Physician's Order Sheet (POS) showed: -Diagnoses included dementia (the loss of cognitive functioning). -Order dated 03/21/25 Buspirone (medication used for anxiety) 5 milligrams (mg) three times daily. Observation on 02/10/26 at 10:57 A.M. showed: -L1MAA brought the resident out of his/her room to the hallway, where he/she prepared and gave Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ACUY11 If continuation sheet 1 of 6 PRINTED: 02/26/2026 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 02/10/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 (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) VINTAGE GARDENS ASSISTED LIVING Continued From page 1 the resident his/her Buspirone; -L1MAA left the resident in the hallway next to the unlocked medication cart to reenter the resident's room to get water for him/her; -The resident took his/her medication, and handed his/her med cup and water cup back to L1MAA who returned to the resident's room to throw the cups away, while the medication cart remained unlocked and out of L1MAA's sight. During an interview on 02/10/26 at 1:37 P.M. L1MAA said: - He/She knew the medication cart was to remain locked at all times when left unattended. During an interview on 02/10/26 at 2:14 P.M. the Director of Nursing said: -He/She expected medication carts to be locked at all times when left unattended. During an interview on 02/10/26 at 2:47 P.M. the Administrator said: -He/She expected the medication cart to be locked at all times when left unattended and out of sight. 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of Missouri Department of Health and Senior Services STATE FORM 6899 ACUY11 If continuation sheet 2 of 6 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 VINTAGE GARDENS ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT JOSEPH, MO 64505 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. II This regulation is not met as evidenced by: Class II Based on observation, interview, and record review the facility failed to develop and implement a safe and effective system of medication administration when Level One Medication Aide (L1MA) A failed to watch two of six sampled residents (Resident #1 and Resident #2) consume the medications administered to them. In addition, L1MAA administered medication to one sampled resident (Resident #3) from his/her bare hand. The facility census was 34. Review of the undated facility policy titled, "Medication Administration," showed: -All residents were to be observed taking the medication administered to them; -Medication was to be placed directly into a medication cup and not handled. 1. Review of Resident #1's February 2026 Physician's Order Sheet (POS) showed: Missouri Department of Health and Senior Services STATE FORM 6899 4CUY11 PRINTED: 02/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/10/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 6 PRINTED: 02/26/2026 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 02/10/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 (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) VINTAGE GARDENS ASSISTED LIVING Continued From page 3 -Diagnoses included diabetes and high blood pressure; -Order dated 10/02/25 Hydralazine (medication used for high blood pressure) 50 milligrams (mg) three times daily. Observation on 02/10/26 at 10:45 A.M. showed L1MAA prepared the resident's Hydralazine into a med cup, gave the med cup to the resident, and L1MAA left the room before the resident ingested the medication. 2. Review of Resident #2's February 2026 POS showed: -Diagnoses included high blood pressure; -Order dated 09/25/25 Sodium Chloride (medication used to prevent muscle cramps) 1 gram (gm) three times daily. Observation on 02/10/26 at 11:13 A.M. showed L1MAA prepared the resident's Sodium Chloride into a med cup, gave the med cup to the resident, and L1MAA left the room before the resident ingested the medication. 3. Review of Resident #3's February 2026 POS showed: -Diagnoses included anxiety, cerebellar ataxia (inability to coordinate muscle movement), and heart disease; -Order dated 03/03/22 Hydroxyzine (medication used for anxiety) 50 mg three times daily; -Order dated 03/19/25 Vitamin B12 (gummy supplement) 2000 micrograms (mcg) once daily. Observation on 02/10/26 at 10:42 A.M. showed: -L1MAA prepared the resident's Hydroxyzine from its original container into a med cup, and his/her Vitamin B12 gummies from its original container into his/her bare hand; Missouri Department of Health and Senior Services STATE FORM 6899 ACUY11 If continuation sheet 4 of 6 PRINTED: 02/26/2026 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 02/10/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 (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) VINTAGE GARDENS ASSISTED LIVING Continued From page 4 -L1MAA then gave the med cup with Hydroxyzine to the resident to take while still holding the Vitamin B12 gummies in his/her bare hand; -Upon the resident finishing taking his/her Hydroxyzine, L1MAA, from his/her bare hand, handed the resident his/her Vitamin B12 gummies to take. During an interview on 02/10/26 at 1:37 P.M. L1MAA said: - He/She had been trained that as long as there were no issues with the resident taking their medication they did not need to watch them; -There were specific residents that were known for forgetting, or choking that they do watch take their medications; -Resident #3 did not want his/her gummies with his/her pills, so L1 MAA just held on to those in his/her hand; - He/She was trained to use medication cups to administer all medications to residents; - He/She did not think to use a separate medication cup with Resident #3's vitamin gummies; - He/She was not supposed to place medication into his/her bare hands. During an interview on 02/10/26 at 2:14 P.M. the Director of Nursing said: -He/She expected all staff to prepare medications directly into med cups and not into their hands; -He/She expected all residents to be watched taking their medications. During an interview on 02/10/26 at 2:47 P.M. the Administrator said: -He/She expected all residents to be watched taking their medications, no exceptions; -He/She expected medication staff to utilize med cups and never handle them with their bare Missouri Department of Health and Senior Services STATE FORM 6899 ACUY11 If continuation sheet 5 of 6 PRINTED: 02/26/2026 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: ee COMPLETED 02/10/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 (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) VINTAGE GARDENS ASSISTED LIVING A4797 | Continued From page 5 hands. Missouri Department of Health and Senior Services STATE FORM 6899 ACUY11 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Name: Vintage Gardens Assisted Living Street Address, City, Zip: 3302 N Woodbine Rd, St. Joseph, MO 64505 Date of Survey: 2/10/26 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 22959 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE “This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission on the part of Vintage Gardens as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community’s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The Community submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies” 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. PLAN OF CORRECTION Provider/Supplier Name: Vintage Gardens Assisted Living Street Address, City, Zip: 3302 N Woodbine Rd, St. Joseph, MO 64505 Date of Survey: 2/10/26 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 22959 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE What corrective actions will be done to all residents affected by the deficient practice? - Ail Level One Medication Aid (LIMA) have been inserviced on proper medication storage procedure by the Wellness Director and Administrator, including ensuring medications are kept ina secure location behind at least one locked door or cabinet. A4782 2/24/26 How will you identify other residents with potential to be affected by the same deficient practice? - The Community reviewed each resident's record to determine which residents, if any, could be affected by the alleged deficient practice. 2/24/26 What measures are being put into place or systemic changes to prevent a reoccurrence? - The medication cart will be spot checked by the Wellness Director (WD) or designee at a minimum of 4 times weekly for 4 weeks. 3/2/26 How will they monitor to prevent reoccurrence? - Medication carts will be checked at a minimum weekly for 6 weeks following the 4x weekly checks for 6 weeks by the 3/22/26 Wellness Director (WD) or designee.. 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. PLAN OF CORRECTION Provider/Supplier Name: Vintage Gardens Assisted Living Street Address, City, Zip: 3302 N Woodbine Rd, St. Joseph, MO 64505 Date of Survey: 2/10/26 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 22959 COMPLETION DATE A4797 What corrective actions will be done to all residents affected by the deficient practice? - All L1MAs have been inserviced on proper medication handling procedure by the Wellness Director and Administrator, including a safe and effective system of medication administration. 2/24/26 How will you identify other residents with potential to be affected by the same deficient practice? - The Community reviewed each resident's record to determine which residents, if any, could be affected by the alleged deficient practice. 2/24/26 What measures are being put info place or systemic changes fo prevent a reoccurrence? - The medication pass will be spot checked for four residents, weekly for 4 weeks. 3/2/26 How will they monitor to prevent reoccurrence? - Medication pass will be spot checked by the Wellness Director (WD) or designee at a minimum weekly for a least 1 resident for 6 weeks following the initial 6 weeks. 3/22/26 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.

2025-10-06

Complaint Investigation

4776 · 1 finding

477619 CSR §4776

Regulation cited · 19 CSR §4776

“Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident ' s departure, of the resident ' s estimated length of absence from the facility, and of the resident ' s whereabouts while on voluntary leave. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

2025-05-13

Annual Compliance Visit

3220 · 2 findings

322019 CSR §3220

Verbatim citation text · 19 CSR §3220

“Based on record review and interview on 5/13/2025, the facility failed to have a current approved elevator inspection certification from either the city or the state available. The facility census was thirty-one (31) This affected thirty-one (31 )of thirty-one (31) residents. Record review showed the current posted state elevator inspection certificates for the elevator expiring on 4/17/2023 During an interview on 5/13/2025 at 1:00 P. M with maintenance, he stated they had to have a part replaced and have contacted to company to reinspect it. PLAN OF CORRECTION Provider/Supplier Name: Vintage Gardens Assisted Living- SOUTH City, Zip: 3310 N Woodbine Rd. St. Joseph MO 64505 Date of Survey: 5/13/2024 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 229596 COMPLETION DATE A3219 What corrective actions will be done to all residents affected by the deficient practice? - The unapproved electrical adapters and extension cords have been removed from the resident’s rooms. The Community reminded residents that unapproved electrical adapters and extensions cords are prohibited. 5/14/25 How will you identify other residents with potential to be affected by the same deficient practice? - The Community reviewed each resident’s record to determine which residents, if any, could be affected by the alleged deficient practice. 9/30/25 What measures are being put into place or systemic changes to prevent a reoccurrence? - A notification will be sent out to all residents and families reminding them of unapproved electrical items. Following the notification, an inspection of all resident rooms will be conducted to ensure all unapproved items have been removed. 6/6/25 How will they monitor to prevent reoccurrence? - Resident rooms will be inspected quarterly to ensure any unapproved electrical adapters or extension cords have been brought in. All new residents will be given a list of unapproved items at move-in and will have their room inspected within 2 weeks of move-in to ensure compliance. 7/1/25 LLL 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. PLAN OF CORRECTION Provider/Supplier Vintage Gardens Assisted Living- NORTH Name: . . 3310 N Woodbine Rd. St. Joseph MO 64505 City, Zip: Date of Survey: 5/13/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 22959 ID PREFIX TAG COMPLETION DATE PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} What corrective actions will be done to all residents affected by the deficient practice? - The elevator has been inspected and all required repairs have A3220 f : been requested. Upon completion of the repairs, the new certificate will be issued and posted. 9/20/24 How will you identify other residents with potential to be affected by the same deficient practice? - The Community reviewed each resident’s record to determine which residents, if any, could be affected by the alleged deficient practice. 9/21/25 What measures are being put into place or systemic changes to prevent a reoccurrence? - Elevator inspection will be requested in January to ensure time for the company to complete the inspection, and all necessary repairs are completed. If the current maintenance company is 6/1/25 unable to meet the deadlines, a new elevator company will be acquired. How will they monitor to prevent reoccurrence? - Inspections will be scheduled in January to allow time to 6/1/25 complete any needed repairs and receive a valid certificate prior to the expiration of the current certificate. 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.”

321919 CSR §3219

Verbatim citation text · 19 CSR §3219

“Based on observation and interview on 5/14/25, the facility failed to insure that extension cords comply with electrical appliance approved standards. The facility census was thirty-one (31). This deficiency potentially affected thirty-one (31) of the thirty-one (31) residents Observations during the inspection found: resident rooms 202 and 207 with 6 way electrical adapters resident room 203 with a 3 way electrical adapter. During the exit interview on 5/14/25 at 1:00 P.M. with maintenance, he removed the items from room 203, and took photos of the other rooms to remember to go back and remove. A3220,”

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PRINTED: 05/20/2025 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 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x6) {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) VINTAGE GARDENS ASSISTED LIVING A3219, 19 CSR 30-86.032(18) Extension Cords/Dupiex 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 shail not be placed under rugs, through doorways or located where they are subject to physical damage. II/IH This regulation is not met as evidenced by: Class It Based on observation and interview on 5/14/25, the facility failed to insure that extension cords comply with electrical appliance approved standards. The facility census was thirty-one (31). This deficiency potentially affected thirty-one (31) of the thirty-one (31) residents Observations during the inspection found: resident rooms 202 and 207 with 6 way electrical adapters resident room 203 with a 3 way electrical adapter. During the exit interview on 5/14/25 at 1:00 P.M. with maintenance, he removed the items from room 203, and took photos of the other rooms to remember to go back and remove. A3220, 19 CSR 30-86.032(19) Elevator Requirements if elevators are used, installation and maintenance shall comply with local and state codes and the National Electric Code. H/Il! Missouri Department of Health and Senior Services DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6} DATE UOO614 ifcontinuatidn 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 VINTAGE GARDENS ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 05/20/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 05/13/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A3219 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. II/IIl This regulation is not met as evidenced by: Class III Based on observation and interview on 5/14/25, the facility failed to insure that extension cords comply with electrical appliance approved standards. The facility census was thirty-one (31). This deficiency potentially affected thirty-one (31) of the thirty-one (31) residents Observations during the inspection found: resident rooms 202 and 207 with 6 way electrical adapters resident room 203 with a 3 way electrical adapter. During the exit interview on 5/14/25 at 1:00 P.M. with maintenance, he removed the items from room 203, and took photos of the other rooms to remember to go back and remove. 19 CSR 30-86.032(19) Elevator Requirements If elevators are used, installation and maintenance shall comply with local and state codes and the National Electric Code. II/IIl Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 UO00611 If continuation sheet 1 of 2 PRINTED: 05/20/2025 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 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 (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) VINTAGE GARDENS ASSISTED LIVING Continued From page 1 This regulation is not met as evidenced by: Class III Based on record review and interview on 5/13/2025, the facility failed to have a current approved elevator inspection certification from either the city or the state available. The facility census was thirty-one (31) This affected thirty-one (31 )of thirty-one (31) residents. Record review showed the current posted state elevator inspection certificates for the elevator expiring on 4/17/2023 During an interview on 5/13/2025 at 1:00 P. M with maintenance, he stated they had to have a part replaced and have contacted to company to reinspect it. Missouri Department of Health and Senior Services STATE FORM 6899 U00611 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: Vintage Gardens Assisted Living- SOUTH Street Address, City, Zip: 3310 N Woodbine Rd. St. Joseph MO 64505 Date of Survey: 5/13/2024 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 229596 COMPLETION DATE A3219 What corrective actions will be done to all residents affected by the deficient practice? - The unapproved electrical adapters and extension cords have been removed from the resident’s rooms. The Community reminded residents that unapproved electrical adapters and extensions cords are prohibited. 5/14/25 How will you identify other residents with potential to be affected by the same deficient practice? - The Community reviewed each resident’s record to determine which residents, if any, could be affected by the alleged deficient practice. 9/30/25 What measures are being put into place or systemic changes to prevent a reoccurrence? - A notification will be sent out to all residents and families reminding them of unapproved electrical items. Following the notification, an inspection of all resident rooms will be conducted to ensure all unapproved items have been removed. 6/6/25 How will they monitor to prevent reoccurrence? - Resident rooms will be inspected quarterly to ensure any unapproved electrical adapters or extension cords have been brought in. All new residents will be given a list of unapproved items at move-in and will have their room inspected within 2 weeks of move-in to ensure compliance. 7/1/25 LLL 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. PLAN OF CORRECTION Provider/Supplier Vintage Gardens Assisted Living- NORTH Name: Street Address, . . 3310 N Woodbine Rd. St. Joseph MO 64505 City, Zip: Date of Survey: 5/13/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 22959 ID PREFIX TAG COMPLETION DATE PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} What corrective actions will be done to all residents affected by the deficient practice? - The elevator has been inspected and all required repairs have A3220 f : been requested. Upon completion of the repairs, the new certificate will be issued and posted. 9/20/24 How will you identify other residents with potential to be affected by the same deficient practice? - The Community reviewed each resident’s record to determine which residents, if any, could be affected by the alleged deficient practice. 9/21/25 What measures are being put into place or systemic changes to prevent a reoccurrence? - Elevator inspection will be requested in January to ensure time for the company to complete the inspection, and all necessary repairs are completed. If the current maintenance company is 6/1/25 unable to meet the deadlines, a new elevator company will be acquired. How will they monitor to prevent reoccurrence? - Inspections will be scheduled in January to allow time to 6/1/25 complete any needed repairs and receive a valid certificate prior to the expiration of the current certificate. 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.

2025-03-03

Complaint Investigation

4797 · 1 finding

479719 CSR §4797

Regulation cited · 19 CSR §4797

“The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

2025-02-19

Complaint Investigation

4777 · 1 finding

477719 CSR §4777

Regulation cited · 19 CSR §4777

“Residents shall receive proper care as defined in the individualized service plan. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

2025-01-30

Annual Compliance Visit

No findings

2024-08-17

Complaint Investigation

4776 · 1 finding

477619 CSR §4776

Regulation cited · 19 CSR §4776

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

2024-05-24

Annual Compliance Visit

No findings

2024-05-23

Annual Compliance Visit

7021 · 1 finding

702119 CSR §7021

Regulation cited · 19 CSR §7021

“Potentially hazardous food requiring refrigeration after preparation shall be rapidly cooled to an internal temperature of forty-five degrees Fahrenheit (45��F) or below, utilizing such methods as shallow pans, agitation, quick chilling or water circulation external to the food container so that the cooling period shall not exceed four (4) hours. Potentially hazardous food to be transported shall be prechilled and held at a temperature of forty-five degrees Fahrenheit (45��F) or below. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

Read raw inspector notes

PRINTED: 05/29/2024 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 B. WING 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 (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) VINTAGE GARDENS ASSISTED LIVING A7067| 19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. 11] This regulation is not met as evidenced by: Class []] Based on observation and interview the facility failed to ensure all nonfood-contact surfaces were cleaned as often as necessary to keep the surfaces free from accumulation of dust, dirt, and other debris. The facility census was 39. The facility did not provide a policy regarding the cleaning of nonfood-contact surfaces. Observation on 05/23/24 at 11:26 A.M. of the kitchen showed: -The ceiling to the left of range hood, around the air filter, which should have been white, was stained brown; -Dust was hanging from the ceiling in this area just above the prep table and microwave; ~The exterior of the ice machine had white build up along the edge above the door to the interior, and in many crevices; ~The exterior of the ice machine had an approximately one inch spot that was green and fuzzy on the top left corner above the door to the interior holding the ice. During an interview on 05/23/24 at 11:30 A.M. the Dietary Supervisor said: -The dieatary staff clean and scrub the ice machine daily, but cannot get the white deposit or the green stuff to go away; -He/She felt the machine was malfunctioning, Missourl Department of Health and Senior Services ‘SOR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE {X6) DATE STATE FORM Q4L411 If continuation sheet 1 of 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 3302 NORTH WOODBINE ROAD VINTAGE GARDENS ASSISTED LIVING SAINT JOSEPH, MO 64505 PRINTED: 05/29/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/23/2024 (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 Continued From page 1 causing the build up; -He/She felt the facility just needed a new machine; -He/She was unsure of what was on the ceiling, if it was grease or dust, but knew whatever it was it did not come off when they scrub it; -The ceiling had been tagged previously by the health department but nothing was fixed. During an interview on 05/23/24 at 3:26 P.M. the Executive Director said: -She expected all nonfood-contact surfaces to be kept clean; -She was aware of the ceiling being brown, but unsure why it was discolored; -She was not aware of the white buildup or green fuzzy spot on the ice machine. Missouri Department of Health and Senior Services STATE FORM oeee Q4L411 DEFICIENCY) If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Vintage Gardens Assisted Living Name: city Zp 3302 N Woodbine Rd, St. Joseph, MO 64505 Date of Survey: 5/23/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 22959 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE “This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission on the part of Vintage Gardens as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community’s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The Community submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies” | The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the pian of correction being submitted on this form. } ! | | PLAN OF CORRECTION Provider/Supplier Name: Vintage Gardens Assisted Living Street Address, ot 3302 N Woodbine Rd, St. Joseph, MO 64505 City, Zip: Date of Survey: 6/4/2022 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 22959 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Whai corrective actions will be done to all residents affected by the deficient practice? -Tiles have been removed and repiaced. A7067 5/30/24 - The ice machine has been cleaned and service scheduled to find the leak causing the build-up and to determine if a new unit is needed. How will you identify other residents with potential to be affected by the same deficient practice? - Each resident's record was reviewed to determine which residents, if any, could have been affected by the alleged 6/1/24 deficient practice. What measures are being put into place or systemic changes to prevent a reoccurrence? ~ Ceiling tiles will be checked on a monthly basis by the Dining Services Manager ("DSM") or designee to ensure they are still in good condition. If a tile can not be cleaned, the dining services manager will report the need to a new tile to the maintenance department. Ceiling tiles by the hood will be replaced annually when cleaning will no longer remove the discoloration. 6/1/24 The ice machine will be cleaned, inside and out, monthly How will they monitor to prevent reoccurrence? - The Executive Director or designee will audit the DSM’s ceiling checks monthly for 4 months to ensure that the systemic changes are preventing reoccurrence. 6/1/24 Monthly cleaning ice machine cleaning will be checked by the DSM or designee each month for four months 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.

2024-05-16

Annual Compliance Visit

2238 · 2 findings

223819 CSR §2238

Verbatim citation text · 19 CSR §2238

“Based on observation and interview on 5/16/24, facility fails to ensure exit lights shall be lighted. The facility census is thirty-eight (38). This deficiency affects thirty-eight (38) of thirty-eight (38) residents. Observation at 2:56 p.m. showed the exit light by Room 214 is not lighting when tested. Observation at 3:09 p.m. showed the exit light by Room 208 is not lighting when tested. Observation at 3:42 p.m. showed the exit light by Room 105 is not lighting when tested. During an interview with the Administrator at 5:15 p.m., she/he said the facility will fix the exit lights.”

225619 CSR §2256

Verbatim citation text · 19 CSR §2256

“Based on observation and interview on 5/16/24, facility fails to ensure 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. The facility census is thirty-eight (38). This deficiency affects thirty-eight (38) of thirty-eight (38) residents. Observation at 2:13 p.m. found the laundry room door to be standing open, with the self-closing hinges no longer working properly to keep the door closed. During an interview with the Administrator at 5:15 p.m., she/he made a list of repairs to be made. 6899 YPJW11 COMPLETED 05/16/2024 3302 NORTH WOODBINE ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)”

Read raw inspector notes

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. 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 VINTAGE GARDENS ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 05/21/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 05/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD SAINT JOSEPH, MO 64505 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III This regulation is not met as evidenced by: Class III. Based on observation and interview on 5/16/24, facility fails to ensure exit lights shall be lighted. The facility census is thirty-eight (38). This deficiency affects thirty-eight (38) of thirty-eight (38) residents. Observation at 2:56 p.m. showed the exit light by Room 214 is not lighting when tested. Observation at 3:09 p.m. showed the exit light by Room 208 is not lighting when tested. Observation at 3:42 p.m. showed the exit light by Room 105 is not lighting when tested. During an interview with the Administrator at 5:15 p.m., she/he said the facility will fix the exit lights. 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 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YPJW11 If continuation 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 VINTAGE GARDENS ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT JOSEPH, MO 64505 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 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 5/16/24, facility fails to ensure 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. The facility census is thirty-eight (38). This deficiency affects thirty-eight (38) of thirty-eight (38) residents. Observation at 2:13 p.m. found the laundry room door to be standing open, with the self-closing hinges no longer working properly to keep the door closed. During an interview with the Administrator at 5:15 p.m., she/he made a list of repairs to be made. Missouri Department of Health and Senior Services STATE FORM 6899 YPJW11 PRINTED: 05/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3302 NORTH WOODBINE ROAD 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 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

2023-08-31

Annual Compliance Visit

2257 · 7 findings

225719 CSR §2257

Regulation cited · 19 CSR §2257

“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

224819 CSR §2248

Regulation cited · 19 CSR §2248

“Complete Fire Alarm Systems. (B) Facilities that are required to install a sprinkler system in accordance with section (11) of this rule shall comply with the following requirements: 1. Until the required sprinkler system is installed, each resident room or any room designated for sleeping shall be equipped with at least one (1) battery-powered smoke alarm installed, tested, and maintained in accordance with manufacturer ' s specifications. In addition, the facility shall be equipped with interconnected heat detectors installed, tested, and maintained in accordance with NFPA 72, 1999 edition, with detectors in all areas subject to nuisance alarms, including, but not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. I/II B. Upon discovery of a fault with any detector or alarm, the facility shall correct the fault. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

224919 CSR §2249

Regulation cited · 19 CSR §2249

“Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

225019 CSR §2250

Regulation cited · 19 CSR §2250

“Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

228619 CSR §2286

Regulation cited · 19 CSR §2286

“Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

229819 CSR §2298

Regulation cited · 19 CSR §2298

“Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

220219 CSR §2202

Regulation cited · 19 CSR §2202

“General Requirements. (D) The department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two- (2-) hour fire-resistant construction. No section of the building shall present a fire hazard. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.