RAVENWOOD ASSISTED LIVING.

PRINTED: 03/07/2024 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 20791C — 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1950 EAST REPUBLIC ROAD SPRINGFIELD, MO 65804 (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) RAVENWOOD-ASSISTED LIVING BY AMERICARE 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, review and interview on February 26, 2024, the facility failed to ensure delayed egress locks were installed in accordance with section 7.2.1.6.1 of the 2000 edition National Fire Protection Association (NFPA) 101, Life Safety Code. The facility also failed to ensure not more than one (1) such device is located in any egress path. The facility census on February 26, 2024, was 35. This deficiency affects 14 out of 35 residents. Observation of a delayed egress locked door, at the west end of the Arbors resident hallway, showed no required delayed egress signage on the delayed egress door. Review of NFPA 101, 2000 edition, Section 7.2.1.6.1 (d) states: "On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OYCF11 If continuation sheet 1 of 3 PRINTED: 03/07/2024 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 20791C — 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1950 EAST REPUBLIC ROAD SPRINGFIELD, MO 65804 (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) RAVENWOOD-ASSISTED LIVING BY AMERICARE Continued From page 1 follows: "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." *Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted. The Missouri Division of Fire Safety will approve the delay on delayed egress doors to be increased from 15 to 30 seconds provided the signage reflects the time required to open the door. During an interview on February 26, 2024, at 1:10 P.M., the Administrator said he/she did not know the proper signage was not on the door. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on observation, review and interview on February 26, 2024, the facility, which had a sprinkler system installed prior to August 28, 2007, failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 Missouri Department of Health and Senior Services STATE FORM 6899 OYCF11 If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20791C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 1950 EAST REPUBLIC ROAD SPRINGFIELD, MO 65804 RAVENWOOD-ASSISTED LIVING BY AMERICARE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 edition. The facility census on February 26, 2024, was 35. This deficiency affects 14 out of 35 residents. Observation of the Arbors kitchen on showed a sprinkler head with green corrosion, a greasy substance, cobwebs, dust and/or other foreign materials. Corroded sprinkler heads and dirty sprinkler heads may not operate as designed in the event of a fire and shall be replaced. Review of National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 1999 edition, chapter 12-1 states "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.". Review of National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition, chapter 2-2.1.1 states "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.". During an interview on February 26, 2024, at 1:10 P.M., the Administrator said he/she did not know about the corroded sprinkler head. Missouri Department of Health and Senior Services STATE FORM 6899 OYCF11 PRINTED: 03/07/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/26/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 3 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).