TURNERS ROCK.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION (DENTIFICATION NUMBER: A BUILDING: B. WING PRINTED: 02/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D THENERS ROVE SPRINGFIELD, MO 66809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A2228) 19 CSR 30-86.022(7)}{D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An "area of refuge" shall have- 1. An area separated by one- (1-} hour rated smoke wails, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. A two- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing of the exit stairway, attendants’ work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states AREA OF REFUGE IN CASE OF FIRE” and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lackable; 6. Asign canspicuously posted at the bottom of the exit stairway with a diagram showing each lacation of the areas of refuge; 7. Emergency lighting for the area of refuge; and 8. The total area of the areas of refuge on a fioor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II Missouri Department of Health and Senior Services LABORATORY [ur STATE FORM PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 (X6) DATE 3-13-24 continuation sheet 1 of 13 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 TURNERS ROCK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 02/13/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. A two- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing of the exit stairway, attendants ' work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states AREA OF REFUGE IN CASE OF FIRE" and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable; 6. Asign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge; 7. Emergency lighting for the area of refuge; and 8. The total area of the areas of refuge on a floor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II " Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 055711 If continuation sheet 1 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 This regulation is not met as evidenced by: Class II Based on observation and interview on January 29, 2024, the facility failed to provide a two- (2-) way communication system between the area of refuge and a remote and monitored area. The facility census on January 29, 2024, was 62. This deficiency affects 62 out of 62 residents. Observation showed the communication system in the area of refuge on the south end of the fourth floor did not operate when the call button was pushed in six (6) of six (6) attempts. Not having two-way communication in the areas of refuge would delay the evacuation process in the event of an emergency. During an interview on January 29, 2024, at 11:59 A.M., a maintenance person said he/she did not know why the call system would not work. 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: Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Class II Based on observation, review and interview on January 29, 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 January 29, 2024, was 62. This deficiency affects 62 out of 62 residents. Observation of a delayed egress locked door, at the south end of the Memory Care unit showed no required delayed egress signage on the delayed egress door. Observation of a delayed egress locked door, at the south end of the Memory Care dining room showed no required delayed egress signage on the delayed egress door. Observation of a delayed egress locked gate, at the south end of the Memory Care outdoor courtyard, showed no required delayed egress signage on the delayed egress gate. Observation of the egress path from the Memory Care dining room to a public way (a public way is the surface of, and the space above and below, any public street, highway, freeway, bridge, land path, alley, court, boulevard, sidewalk, way, lane, public way, drive, circle, public right-of-way other land or waterway, dedicated or commonly used for pedestrian or vehicular traffic or other similar purposes) showed two (2) delayed egress locking devices in the egress pathway. One delayed egress door lock was at the exit door from the south end of the Memory Care dining room and Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 13 PRINTED: 02/13/2024 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 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 (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) TURNERS ROCK Continued From page 3 the second delayed egress door lock was on the gate at the south end of the outside courtyard of the Memory care unit. Further observation showed no other means of egress from the courtyard. 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 follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." During an interview on January 29, 2024, at 1:48 P.M., a maintenance person said he/she did not know the delayed egress signage needed to be on the doors and / or gate. The maintenance person said he/she also did not know about having two delayed egress locks in one path of egress. 19 CSR 30-86.022(9)(A)(1) Smoke Detectors-NFPA 13 Complete Fire Alarm Systems. (A) All facilities shall have a complete fire alarm system installed in accordance with NFPA 101, Section 18.3.4, 2000 edition. The complete fire alarm shall automatically transmit to the fire department, dispatching agency, or central monitoring company. The complete fire alarm system shall include visual signals and audible alarms that can be heard throughout the building and a main panel that interconnects all Missouri Department of Health and Senior Services STATE FORM 6899 055711 If continuation sheet 4 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 alarm-activating devices and audible signals. Manual pull stations shall be installed at or near each required attendant 's station and each required exit. I/II 1. For facilities with a sprinkler system in accordance with NFPA 13, 1999 edition, smoke detectors interconnected to the complete fire alarm system shall be installed in all corridors and spaces open to corridors. Smoke detectors shall be no more than thirty feet (30') apart with no point on the ceiling more than twenty-one feet (21') from a smoke detector. 1/Il This regulation is not met as evidenced by: Class II Based on observation and interview on January 29, 2024, the facility, with a sprinkler system installed in accordance with NFPA 13, 1999 edition, failed to ensure smoke detectors shall be installed no more than thirty feet (30') apart with no point on the ceiling more than twenty-one feet (21') from a smoke detector. The facility census on January 29, 2024, was 62. This deficiency affects 62 out of 62 residents. Observation of the corridor outside of resident room 403 and the fourth floor nurses station showed the distance between the smoke detectors to be thirty-four feet (34’). Observation of the corridor outside of resident rooms 308 and 312 showed the distance between the smoke detectors to be thirty-three feet (33'). During an interview on January 29, 2024, at 1:48 P.M., the maintenance person said he/she did not know the smoke detectors were not properly installed. Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain 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 regulation is not met as evidenced by: Class II Based on record review and interview on January 29, 2024, the facility failed to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. The facility census on January 29, 2024, was 62. This deficiency affects 62 out of 62 residents. National Fire Protection Association (NFPA) 72, 1999 edition, chapter 7-3.1 states "Visual Inspection. Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having Jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.". NFPA 72, 1999 edition, table 7-3.1 shows the following items that shall be visually inspected semiannually: ~ Nickel-Cadmium and Sealed Lead-Acid batteries ~ Transient Suppressors ~ Control Unit Trouble Signals ~ Emergency Voice / Alarm Communications Equipment ~ Remote Annunciators ~ Initiating Devices including air sampling devices, duct detectors, electromechanical Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 13 PRINTED: 02/13/2024 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 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 (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) TURNERS ROCK Continued From page 6 releasing devices, fire-extinguishing system(s) or suppression system(s) switches, fire alarm boxes, heat detectors, smoke detectors. ~ Guard's Tour Equipment ~ Interface Equipment ~ Alarm Notification Appliances - Supervised ~ Supervising Station Fire Alarm Systems - Transmitters including DACT, DART, McCulloh and RAT. ~ Special Procedures ~ Supervising Station Fire Alarm Systems - Receivers including DARR, McCulloch Systems, Two-Way RF Multiplex, RASSR, RARS, Private Microwave. NFPA 72, 1999 Edition, chapter 7-3.2 states "Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction.". NFPA 72, 1999 edition, table 7-3.2 shows the following fire alarm battery types that shall be tested semiannually: ~ Lead-Acid Type battery Discharge Test (30 minutes) Load Voltage Test Specific Gravity ~ Sealed Lead-Acid Type and Nickel-Cadmium Type batteries Load Voltage Test Record review showed no documentation that semi-annual fire alarm visual inspections had been completed as required by NFPA 72, 1999 edition, table 7-3.1. Record review showed no documentation that semi-annual fire alarm functional testing had been completed as required by NFPA 72, 1999 Missouri Department of Health and Senior Services STATE FORM 6899 055711 If continuation sheet 7 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 edition, table 7-3.2. During an interview on January 29, 2024, at 1:20 P.M., the maintenance person said the semi-annual fire alarm inspection should have been conducted in June of 2023, but did not know why it was not conducted. 19 CSR 30-86.022(10)(G) Door Devices - Self/Auto closing Protection from Hazards. (G) All doors providing separation between floors shall have a self-closing device attached. If the doors are to be held open, electromagnetic hold-open devices shall be used that are interconnected with either an individual smoke detector or a complete fire alarm system. Il This regulation is not met as evidenced by: Class II Based on observation and interview on January 29, 2024, the facility failed to ensure doors providing separation between floors shall be self-closing. The facility census on January 29, 2024, was 62. This deficiency affects 62 out of 62 residents. Observation showed the stairwell door providing separation between floors at the south end of the second floor hallway would not self-close when the door was opened 90 degrees from the closed position in six (6) of six (6) attempts. Separation doors failing to close will allow fire, smoke and toxic gases to spread to other areas of the building. Observation showed the stairwell door providing Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 separation between floors at the south end of the third floor hallway would not self-close when the door was opened 90 degrees from the closed position in six (6) of six (6) attempts. Observation showed the stairwell door providing separation between floors at the south end of the fourth floor hallway would not self-close when the door was opened 90 degrees from the closed position in six (6) of six (6) attempts. During an interview January 29, 2024, at 1:49 P.M., a maintenance person said he/she was not aware the doors would not close properly. 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 January 29, 2024, the facility, licensed after August 28, 2007, failed to ensure doors in a smoke partition Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 shall be self-closing. The facility census on January 29, 2024, was 62. This deficiency affects 62 out of 62 residents. Observation showed fire door 13, located at the north end of the second floor Assisted Living hallway, did not close completely in six (6) of six (6) attempts. Fire doors failing to close will allow smoke and toxic gases to spread to other areas of the building. Observation showed fire door 15, located at the north end of the fourth floor Assisted Living hallway, did not close completely in six (6) of six (6) attempts. During an interview January 29, 2024, at 1:49 P.M., a maintenance person said he/she was not aware the doors would not close properly. 19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. Sprinkler Systems. (F) All facilities shall have inspections and written certifications of the approved sprinkler system completed by an approved qualified service representative in accordance with NFPA 25, 1998 edition. The inspections shall be in accordance with the provisions of NFPA 25, 1998 edition, with certification at least annually by a qualified service representative. 1/Il This regulation is not met as evidenced by: Class II Based on observation, review and interview on January 29, 2024, the facility, which had a sprinkler system installed prior to August 28, Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 2007, failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census on January 29, 2024, was 62. This deficiency affects 62 out of 62 residents. Observation of the large closet of resident room 207 showed a sprinkler head covered with white paint. Further observation showed a concealed sprinkler head with no cover plate installed. Painted sprinkler heads may not operate as designed in the event of a fire. Observation of the furnace room of resident room 207 showed a sprinkler head with brown paint on the deflector plate of the sprinkler head. Observation of the furnace room of resident room 402 showed a sprinkler head with white drywall compound on the deflector plate of the sprinkler head. Drywall compound on the sprinkler head may not allow the sprinkler head to operate as designed in the event of a fire. 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 Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 13 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 TURNERS ROCK (X2) MULTIPLE CONSTRUCTION A. BUILDING: SPRINGFIELD, MO 65809 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 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 January 29, 2024, at 1:20 P.M., the maintenance person said the painted sprinkler heads should have been replaced when the building was built two years ago. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FIM-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 January 29, 2024, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. The facility census on January 29, 2024, was 62. This deficiency potentially affects 62 of 62 residents. Observation of the following resident rooms showed non-compliant wastebasket(s) being used for trash: ~ 101 ~ 103 ~ 105 ~ 106 ~ 107 (two (2) non-compliant wastebaskets) ~ 108 ~ 109 Missouri Department of Health and Senior Services STATE FORM 6899 055711 PRINTED: 02/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 13 PRINTED: 02/13/2024 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 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 (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) TURNERS ROCK Continued From page 12 ~ 115 ~ 116 (two (2) non-compliant wastebaskets) ~ 203 (two (2) non-compliant wastebaskets) ~ 205 (two (2) non-compliant wastebaskets) ~ 206 ~ 210 mi 212 ~ 213 (four (4) non-compliant wastebaskets) ~ 215 (two (2) non-compliant wastebaskets) ~ 216 ~ 306 ~ 309 ~ 310 (two (2) non-compliant wastebaskets) ~ 312 (three (3) non-compliant wastebaskets) ~ 314 (two (2) non-compliant wastebaskets) ~ 402 ~ 406 ~ 410 (two (2) non-compliant wastebaskets) ~ 413 ~415 Observation of the second floor nurses station showed two (2) non-compliant wastebasket being used for trash. Observation of the resident care director's office showed a non-compliant wastebasket being used for trash. Observation of the Memory Care sensory room showed a non-compliant wastebasket being used for trash. During an interview on January 29, 2024, at 1:20 P.M., the maintenance person said he/she did not know there were so many non-compliant wastebaskets in the facility. Missouri Department of Health and Senior Services STATE FORM 6899 055711 If continuation sheet 13 of 13 | PLAN OF CORRECTION Provider/Supplier Name: Turmers Rock Senior Living page 1 of 3 3911 East Highway D, Springfield, MO 65809 | Street Address, | City, Zip: Date of Survey: 01-29-2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 32441 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2228 | The communication system on the south end of the fourth floor 03-11-24 has been repaired and tested so that it operates correctly, to provide the necessary two-way communication with that area of refuge. The Maintenance Director will conduct Monthly tests on all the units. The Maintenance Director will schedule these monthly inspections on the communications systems in the areas of refuges to assure they are completed & working properly. These tests and results will be logged appropriately and kept for future verifications. ID PREFIX TAG A2229 | The community will have one(1) of the cited delayed egress 3-15-24 doors that were both locked, located at the south end of the memory care dining room, and the south end of the memory care courtyard, always unlocked, just leaving one(1) of them locked during the same times. This will assure one(1) of them unlocked, and one({1) always locked. Both egress doors will be monitored daily by on-site staff, with all staff being orientated and trained by the Maintenance Director, of the proper procedures of maintaining these doors properly. The staff will sign the training log, stating they have been trained and understand the proper locking & unlocking procedures. The required delayed egress signage will be placed at all the 3-20-24 doors that were cited, by the Maintenance Director, that have delayed egress. This signage will be monitored daily by all staff to assure that it remains in place. A2240 | The community had our licensed Fire equipment vendor relocate 3-11-24 the 2 smoke detectors in the cited locations, outside of room 403 and the fourth-floor nurse’s station; and outside of room 308 and room 312; and assured they are complying within the <30' apart regulation on the ceiling. 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 Name: Provider/Supplier Turners Rock Senior Living page 2 of 3 City, Zip: Street Address, Date of Survey: 3911 East Highway D, Springfield, MO 65809 01-29-2024 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 32441 COMPLETION DATE A2249 A2262 A2264 A2274 The community will schedule with our licensed vendor, the semi- annual visual inspection of the complete fire system, to include all components listed, including suppression systems, all detectors, supervising systems, battery systems, and all other functions, in accordance with the regulations specified on the report, to be completed immediately, and then scheduled subsequently every six(6) months thereafter, to maintain compliance with this regulation. Compliance will be verified through the completed inspection reports of the vendor contracted to perform these semi-annual inspections. The three(3) cited stairwell doors, on the south ends of 2", 314, 3 4'4 floors, have been repaired so that they self-close after opening, to provide the separation required to not allow fire, smoke, or toxic gases to spread to other areas of the building. The doors will be checked monthly by the Maintenance Director to assure proper closing and will be included in our overall monthly inspections of our egress doors, fire communications systems and other safety related procedures. The two(2) cited hallway fire doors, #13 & #15, have been repaired so that they will self-close upon release from the mag- lock system, to provide the separation required. The doors will be checked monthly by the Maintenance ‘Director to assure proper closing and will be included in our overall monthly | inspections of our egress doors, fire communications systems and other safety related procedures by Maintenance Staff. The three(3) cited sprinkler heads, in 207 & 402, with paint, have been replaced & repaired; the missing cover plate in 207 has been replaced; The sprinkler heads will be inspected annually by the Maintenance Director to insure no other foreign materials are present to not allow proper operation. 03-25-24 02-26-24 02-26-24 03-08-24 = PLAN OF CORRECTION by either metal or UL- or FM fire resistant rated wastebaskets in the community, overseen by the Maintenance Director and the Administrator. The community staff, including Maintenance, Housekeeping, and Resident Care, who ail are continually visiting and observing the resident rooms, and common areas, will all monitor and inspect daily compliance of this regulation. All community staff will be advised and trained by the Maintenance Director on which wastebaskets are compliant, to meet this regulation. Also, upon a new resident moving into the community, the Maintenance Director will inspect & verify that only compliant wastebaskets are being brought in, with the new move in furnishings. If a non-compliant wastebasket is found to have been brought into the community, the Staff will be advised to notify the Administrator and Maintenance Director immediately, so the family/resident can be notified, and it can be removed and replaced with a compliant wastebasket immediately. The Administrater and Maintenance Director will do a complete visual inspection monthly as well, of all resident apartments and common areas to assure compliance of only metal and fire-resistant wastebaskets in the community. Bhonileys Supper Turners Rock Senior Living page 3 of 3 Name: Street Address, . sell ows 3911 East Highway D, Springfield, MO 65809 City, Zip: Date of Survey: 01-29-2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 32441 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2286 | All non-compliant wastebaskets will be discarded and replaced 03-11-24

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: PRINTED: 01/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/14/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 TURNERS ROCK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 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 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 on January 14, 2024, the facility failed to ensure the use of portable heaters of any kind is prohibited. Facility census on January 14, 2024, was 62. This deficiency affects 62 of 62 residents. Observation of resident room 216 showed a portable electric heater in use in the room. The Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM bae9 RKPQ11 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A3211 TITLE (X6) DATE If continuation sheet 1 of 2 PRINTED: 01/30/2024 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 Cc 01/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 (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) TURNERS ROCK Continued From page 1 Director of Maintenance removed the portable heater at the time of discovery. During an interview on January 14, 2024, at 11:30 A.M. the Director of Maintenance said he/she had removed the portable heater the day before, but a family member had brought in a portable heater that morning (Sunday, January 14, 2024). The Director of Maintenance also said the permanent heating units inside the residents room were unable to maintain a comfortable temperature in the room due to the extremely cold outside air. During an interview on January 14, 2024, at 12:35 P.M. the resident 202 said his/her room was cold and "they" (the facility) had put a portable heater in his/her room yesterday, but they took it out when the room warmed up. Missouri Department of Health and Senior Services STATE FORM 6899 RKPQ11 If continuation sheet 2 of 2 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).

PRINTED: 11/17/2023 . FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (A1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 32441 B. WING 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 35911 EAST HIGHWAY D SPRINGFIELD, MO 65809 (%4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X85) 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) TURNERS ROCK A4797 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 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. Hil This regulation is not met as evidenced by: Class |! Based on record review and interview, the facility failed to ensure a safe and effective medication system when a card (30 pills) of one resident's (Resident #1) medication went missing while in the possession of the facility. The facility census was 60. Review of the facility policy “Medication Missouri Department of Health and Senior Services LABORATORY DIRECT : TITLE (X6) DATE Adm tRATOR. J2-(-2 If continuation sheet 1 af 7 STATE FORM PRINTED: 11/17/2023 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 C 32441 B. WING 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 (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) TURNERS ROCK Continued From page 1 Management", revised 06/08/23, showed the following: -Schedule II medications are stored in a locked non-removable container; -The separately keyed locked storage area may be either a secure cabinet, drawer, or medication cabinet, each having different locks and keys from the original locked key container; -One team member per shift is responsible for the keys to the controlled medications storage area; -Schedule II medications are counted at change of shift by the off-going and on-coming designated team member; -If a discrepancy is noted in the count, the team member is questioned for possible failure to sign the medication out when delivering to the resident; -If the count is not reconciled, the Resident Care Director (RCD) is notified; -Documentation for controlled medications per this policy is in addition to routine documentation of medication services on the medication assistance record (MAR). 1. Review of Resident #1's medical record showed the following: -Admission date of 05/05/22; -Diagnoses included cancer, anxiety disorder, depression, and essential tremors (a nervous disorder that causes rhythmic shaking). Review of the resident's current physician orders an order, dated 07/14/23, for clonazepam (used to treat seizures, panic disorder, and anxiety), 0.5 milligrams (mg), three times daily. Review of the the resident's Medication Missouri Department of Health and Senior Services STATE FORM 6899 C9PD11 If continuation sheet 2 of 7 PRINTED: 11/17/2023 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 C 32441 B. WING 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TURNERS ROCK Continued From page 2 Administration Record (MAR), dated 10/01/23 to 10/20/23, showed staff documented administration of the clonazepam to the resident three times a day as prescribed. Review of the resident’ "Narcotic Count Sheet," undated, for clonazepam showed the following: -On 10/17/23, at 10:30 P.M., Level One Medication Aide (LIMA) C signed in three cards (30 pills in each card) of clonazapam for resident; -Staff noted three new cards under the "explanation"; -Starting count was two cards and ending count was five cards. Review of facility's "Investigation Report-Turners Rock Senior Living" dated 10/19/23, showed the following: -The general manager was notified of missing narcotics (clonazepam) for the resident on 10/19/23 at 7:10 A.M.; -Four certified medication aide (CMA)/team members were identified as being responsible for the narcotics at various shift changes since 10:30 P.M. on 10/17/23; -The general manager began an investigation and reported the allegation to the Department of Health and Senior Services. During an interview on 10/20/23, at 10:34 A.M., the Senior Caregiver said the following: -He/She arrived for his/her shift at 7:00 A.M. on 10/19/23 and completed a narcotics count with LIMA D of the second floor medication cart; -The shift change narcotic count sheet indicated there should be five cards of the resident's clonazepam in the locked container; Missouri Department of Health and Senior Services STATE FORM 6899 C9PD11 If continuation sheet 3 of 7 PRINTED: 11/17/2023 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 C 32441 B. WING 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TURNERS ROCK Continued From page 3 -He/She only observed four cards in the locked container; -According to the narcotic count sheet, LIMA C signed in three cards with 30 pills in each card of clonazepam at 10:30 P.M. on 10/17/23 for the resident; -There should have been four cards for the resident and a partial one for another resident; -He/She called the pharmacy to verify the medication for the resident was delivered on 10/17/23; -The pharmacy verified the medication was delivered; -He/She gave the keys back to LIMA D and called the Resident Care Director (RCD); -The RCD contacted the General Manager; -He/She reviewed the signatures on the shift change narcotic count sheet; -LIMAA did not sign the book on 10/18/23 in the morning; -He/She is responsible for checking the signatures on the shift change narcotic count sheet and does this every few weeks. During an interview on 10/20/23, at 11:03 A.M., LIMA B said the following: -He/She was late for work on 10/18/23 and came in about 8:15 A.M.; -He/She counted the narcotics with LIMAA, who took the keys at 7 A.M. from LIMA C; -There were five narcotic cards of the resident's clonazepam in the container and nothing was missing; -He/She left work at 1:00 P.M. and did another count with LIMAA, who was taking the keys at that time; -The same five cards were in the container; -He/She came in on 10/19/23 at 7:00 A.M.; -At that time, the Senior Caregiver discovered Missouri Department of Health and Senior Services STATE FORM 6899 C9PD11 If continuation sheet 4 of 7 PRINTED: 11/17/2023 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 C 32441 B. WING 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TURNERS ROCK Continued From page 4 that one of the narcotic cards was missing for the resident; -If there is a discrepancy during shift change they are to call the RCD. During an interview on 10/20/23, at 10:05 A.M., Level One Medication Aide (LIMA) A said the following: -He/She worked 7:00 A.M. to 7:00 P.M. on 10/18/23 and took the second floor medication cart keys from LIMA C, who was going off duty; -He/She did a narcotics count with LIMA C, but did not sign the shift change narcotic count sheet; -He/She did not sign the sheet as he/she was only taking the keys until 8:30 A.M. when LIMA B was supposed to arrive for work; -He/She was not sure if LIMA C signed the book; -He/She could not remember how many cards of the resident's clonazepam were in the narcotic container; -He/She was trained by the facility that the sheet needs to be signed at shift change. During an interview on 10/20/23, at 1:14 P.M. LIMA C said the following: -He/She worked from 7:00 P.M. on 10/17/23 to 7:00 A.M. on 10/18/23; -The pharmacy delivered three cards with 30 pills each of clonazepam for the resident at 10:30 P.M.; -He/She signed that the medications were delivered on the narcotic count sheet; -He/she rubber banded the three cards and put them in the container with the other cards; -He/She has been trained by the facility to reconcile and sign the shift change narcotic count sheet; -If there is a discrepancy, staff does a recount; Missouri Department of Health and Senior Services STATE FORM 6899 C9PD11 If continuation sheet 5 of 7 PRINTED: 11/17/2023 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 C 32441 B. WING 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TURNERS ROCK Continued From page 5 -If there is still a discrepancy, staff cannot leave work and the RCD is notified. During an interview on 10/20/23, at 1:47 P.M., LIMA D said the following: -He/She came on duty at 7:00 P.M. on 10/18/23; -LIMAA had the keys to the second floor medication cart; -LIMAA said he/she was in a hurry to leave; -LIMAA gave him/her a resident report; -LIMA D did sign the shift change narcotic count sheet, but did not do a proper count; -He/She remembers seeing only four cards of the resident's clonazepam in the narcotic box; -The senior caregiver came in at 7:00 A.M. and they did a count together; -They discovered that there were only four cards in the container, but there were supposed to be five; -The senior caregiver checked the other three medication carts in the building, but the card was not found; -He/She has been trained by the facility to count and sign the shift change narcotic count sheet; -If a discrepancy is found the RCD is notified. During an interview on 10/20/23, at 9:20 A.M., the General Manager said the following: -The missing card of narcotics for the resident on the second floor medication cart was discovered on 10/19/23 at 7 A.M.; -He/She was notified of the missing medication shortly after this time and began an investigation; -The RCD has been out all week; -The medication was delivered and signed in by LIMA C at 10:30 P.M. on 10/17/23; -The medication went missing sometime between delivery on 10/17/23 and 10/19/23 at 7:00 A.M.; Missouri Department of Health and Senior Services STATE FORM 6899 C9PD11 If continuation sheet 6 of 7 PRINTED: 11/17/2023 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 C 32441 B. WING 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3911 EAST HIGHWAY D SPRINGFIELD, MO 65809 (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) TURNERS ROCK Continued From page 6 -LIMAA did not sign the shift change narcotic sheet on 10/18/23 when he/she came on duty; -LIMA C signed the book on 10/18/23 indicating there were five cards in the box; -There were four different LIMA's working in the time period when the medication went missing; -The other three medication carts were searched for the missing card and it was not found; -The shift change narcotic count sheets on the other three carts were audited and no other narcotics were missing; -LIMA's are trained by the facility regarding management of narcotic medication; -It is the RCD's responsibility to audit the medication carts and the narcotic sign in and out processes; -He/She does not know how often the RCD does these audits. M0O00226197 Missouri Department of Health and Senior Services STATE FORM 6899 C9PD11 If continuation sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier Name: Turners Rock Senior Living Street Address, City, Zip: 3911 East Sunshine, Springfield, MO 65809 Date of Survey: 10-20-2023 page 1 of 1 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION _ SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) | 32441 COMPLETION DATE A4797 | The Resident Care Director and the Administrator will implement and start using the Narcotics Tracking Bind Book to record and monitor all future narcotic medications given throughout the community. There will be 1 book located at every Med Cart/Narcotics lock box in the building, for a total of 4 Tracking books. No pages can be added or subtracted from these books, without evidence of inaccuracy or incompleteness. The Resident Care Director, Administrator, or designee will Audit all (4) Narcotics Count sheets, within the Tracking Bind book each week, to assure the accuracy & completeness of every sheet for a period of 3 months. The Resident Care Director, Administrator, or designee will do unannounced spot checks each week within the Count sheets as well, on an ongoing basis. The Resident Care Director and the Administrator will jointly audit all (4) of the Narcotics Count sheets together once every month, to assure the accuracy & completeness of all sheets on an ongoing basis. All Certified Med Aides or Med Techs will be trained on medication administration and the use of the Narcotics Tracking Bind Book system by 12-15-23. Brad biedpe7, ta rinist 11-15-23 Dec, Jan, Feb Ongoing Procedures Ongoing Procedures 12-15-23 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.