DUNSFORD COURT MEMORY CARE.

PRINTED: 03/41/2025 Missouri Department of Health and Senior Services POS Annee STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA e ! 2) MULTIPL AND PLAN OF CORRECTION IDENTIFICATION NUMBER —— aaa l tole Se POMP HETED 46094D B WING _——— NAME OF PROVIDER OR SUPPLIER STREETADDRESS CITY STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 (X4) 1D 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-REFERENGED TO THE APPROPRIATE DATE DEFICIENCY) ARBORS AT DUNSFORD COURT-MEM CARE ¢ A4504 19 CSR 30-86.045(3)(A)(4) More Than Minima! Assist - Staff, Awake General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 4. Have sufficient staff present and awake twenty-four (24) hours a day to assist in the evacuation of all residents; Hil This regulation is not met as evidenced by’ Class Il Based on observation, interview, and record review, facility staff failed to ensure sufficient staff , were present twenty-four hours a day to assist in the evacuation of 15 residents for a fire drill within the required five minute timeframe. The facility census was 15. 4. Review of the facility's Evacuation Relocation Pian policy, dated 09/2010, showed the purpose of the policy is to ensure safety of every resident in the event residents need relocated due to disaster. Review of the facility staffing sheets, dated February, 2025, showed on 02/01/25 through 02/25/25, facility census 15 Review of the facility census and condition sheet, dated 02/25/25, showed: -Four residents required staff assistance with transfer or ambulation, who used wheelchairs an and/or required physical assistance or the use of an assistive device in order to negotiate a Missouri Department of Health and Senior Services — LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ¢ | TITLE, | : F sd i 7 a Hes STATE FORM | | PRINTED: 03/11/2025 Missouri Department of Health and Senior Services roman’ STATEMENT OF DEFICIENCIES (X1) PROV IDER/SUPPLIER/CLIA STATEMENT OF DEFICIENCI PROVIDER/SUPPLIER/CLI (X2) MULTIPLE CONSTRUCTION A BUILDING {X3) DATE SURVEY COMPLETED Cc 02/25/2025 16094D B WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZiP CODE ARBORS AT DUNSFORD COURT-MEMCAREA 778 DUNSFORD ROAD SULLIVAN, MO 63080 ods umes of a STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION — ' A pie obey yl MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLE Te OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4504 Continued From page 1 pathway to safety Observation on, 2/25/25 at 3:20 P.M. to 3:31 P.M. showed it took two staff members eleven minutes and forty-six seconds to evacuate all the resident's. 2. During an interview on 02/25/25 at 12:37 PM. the DON said staff are directed to evacuate the ambulatory resident out of the building before residents who required staff assistance. He/She said the state guidelines for evacuating resident's from a building was five minutes. He/She said it was unacceptable to take over ten minutes for staff to evacuate the residents from the building, due to the potential of harm to staff or residents. He/She said some of the resident's have declined in transferring abilities and there was enough staff during the last fire drill. During an interview on 02/25/25 at 3:39 P.M., the administrator said the state regulation for evacuating all residents from a facility in five minutes. He/She said there are only two staff members overnight The administrator said he/she did not feel it was acceptable to take over ten minutes to evacuate resicents from the building. He/She said the concern with not getting residents out of the building within the timeframe, is the potential for resident harm During an interview on 02/25/25 at 3:57 P.M., Certified Medication Aid (CMA) B said he/she received an in-service on facility evacuation a few months ago. He/She was directed to evacuate resident's who were able to ambulate before resident's who required staff assistance, He/She said said the expectation is to have the building evacuated within five minutes He/She said evacuating the resident's from the building is too Missoun Department of Health and Senior Services STATE FORM Bes0 sTUQNI if continuation sneet 2 of 3 PRINTED: 03/11/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER {X3) DATE SURVEY COMPLETED A BUILDING Cc 16094D B WING ____ 02/25/2025 STREET ADORESS CITY, STATE. ZIP CODE 775 DUNSFORD ROAD ARBORS AT DUNSFORD COURT-MEM CARE 4 SULLIVAN, MO 63080 NAME OF PROVIDER OR SUPPLIER (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE snes TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS RE ERE EE Cn APPROPRIATE o F v¥) A4504 Continued From page 2 much for only two staff. He/She said the concern with not being able to evacuate all the resident in a timely manner, is the potential for resident harm Missoun Department of Health and Senior Services STATE FORM me 5TUQ11 iF conpnuation sheet J of 3 PLAN OF CORRECTION : ~ | Provider/Supplier | The Arbors at Dunsford Court- Memory Care Assisted Living by Americare Name: Streat Address: | 796 bunsfurd Rd’Sullivan, MO 63080 | | City, Zip: Date of Survey: (2/28/25 —t = ID PREFIX TAG | PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED __TO THE APPROPRIATE DEFICIENCY) | COMPLETION DATE SS — _ | This plan of correction (POC) is submitted as required under State law. The submission of the POC does not constitute an admission on the part of The Arbors at _ Dunsford Court- Memory Care Assisted Living by Americare (the Facility) as to the accuracy of neither the surveyors’ findings. nor the conclusions drawn there from. The Facility’s submission of the POC does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency. or the scope and severity regarding any deficiencies cited | are correctly applied. This POC is intended to constitute the Facility’s credible letter alleging compliance. Compliance has been and will be achieved by 04/11/2025. 04/1 1/2025 | required five-minute timeframe. The facility will ensure sufficient staff are present 24-hours per day to assist in the evacuation of residents within the 04/11/2025 practice. All residents are potentially at risk for this alleged deficient | Residents #1 and 3°s, who required staff assistance with | transfers or ambulation. who used wheelchairs and/or fee - required physical assistance or the use of an assistive device in order to neyotiate a pathway to safety, no longer reside in the facility. as both have expired (02/27/25 and | 03/05/2025, respectively) 7 | 03/06/2025 | | a DON or designee will re-evaluate all residents. including _ Tr 04/11/2025 | | me Resident #2. 10 determine tie les ci of staff assistance each oT | resident requires to negotiate a pathway to safety. ISPs will | | be updated to include the level of assistance each resident | requires. IEPs will be developed for residents identified as requiring more than minimal assistance. and/or allernauve | placement will be arranged for residents whose need for | assistance exceeds the facility's staffing level on any shift. Ifa resident is referred for alternative placement. additional | | stafling will be arranged as necessary to meet that resident's need for assistance until alternative placement is , made. Evaluations will be documented on an evaluation | form and reviewed with Administrator. C ompleted _ | evaluation forms will be kept in the Administrator's office. | | | i | ator S OUNCE fa —— tL a | Administrator or designee will oversee 4 fire drill on all | shifts. on or before 04/1 1/2025. to ensure staffing levels | are sufficient to evacuate all residents in the required five- | minute timeframe. Fire drills will be documented on a | facility fire drill form and will be kept in the Administrator s office. TT | | | 94/11/2025 i per = Administrator or designee will meet with DON or designee | weekly to discuss current and newly admitted residents potential need for more than minimal assistance to ensure IEPs are developed and incorporated into the ISP for any resident identified as requiring more than minimal assistance. and/or alternative placement is arranged for any resident whose need for assistance exceeds the facility's | staffing level on any shift. If a resident is referred for alternative placement. additional staffing will be arranged as necessary 10 meet that resident's need for assistance until alternative placement is made. Admin/DON meetings will be documented on an internal form kept in the | Administrator's office. Administrator will report weekly to | Regional Director of Operations (RDO) any residents ‘dentified in these mectings as needing IEP and/or | alternative placement. | - eee oe \ | \ | \ | 04/11/2025 \ lj — ccapmerguerg, 2% "RDO will in-service Administrator and DON regarding the | requirements of regulation A4504 as it pertains to having | sufficient staff present 24-hours per day to assist in the | evacuation of residents within the required five-minute | timeframe. | | | | | — Sl | | | 4/11/2025 | | The Administrator signing and dating the first page of the CMS-2567/State For the plan of correction being submitted on this form. mis indicating their approval of

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. PRINTED: 05/06/2024 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 16094D — 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 (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) ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L 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 II Based on observation and interview during the fire safety inspection process, the facility failed to ensure all exit signs were operational. The facility census was eight. This deficiency affects eight of eight residents. Observation revealed exit sign number 9 failed to illuminate while depressing the test button. During the exit interview on April 24, 2024 at 1010 the program manager stated that she would notify maintenance. 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 and interview during the fire safety inspection process, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was eight. This deficiency affects Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0EXG11 If continuation sheet 1 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 16094D NAME OF PROVIDER OR SUPPLIER ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 1 eight of eight residents. Observation revealed misaligned escutcheon rings in room B-1. Observation revealed misaligned escutcheon rings in room B-2. Observation revealed a missing escutcheon ring in room B-3. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the building During the exit interview on April 24, 2024 at 1020, the program manager stated she would notify maintenance. 19 CSR 30-86.032(2) Substantially Constructed & A3201 Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire safety inspection process, the facility failed to maintain the vertical smoke partitions. The facility census was eight. This deficiency affects eight of eight residents. Observation revealed the ceiling above the furnace in the mechanical room had 2 large Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: OEXG11 PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/24/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 PRINTED: 05/06/2024 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 16094D — 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 (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) ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L Continued From page 2 holes. Observation revealed a missing vent scuttle cover in the storage room next to room A-4. Observation revealed a vent scuttle cover askew in the storage room next to room E-7. Observation revealed a missing vent scuttle cover in the storage room next to room D-4. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the building During the exit interview on April 24, 2024 at 1015, the program manager stated she would notify maintenance. Missouri Department of Health and Senior Services STATE FORM 6899 OEXG11 If continuation sheet 3 of 3 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 11/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDERVSUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 16094D B. WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE iene TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L A22141 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall Tequest consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility 's entire plan shall be provided to the local jurisdiction ' s emergency management director. II/IlI This regulation is not met as evidenced by: Class III Based on record review and interview during the fire safety inspection process on October 30, 2023 the facility failed to request consultation and assistance annually or provide documentation the consultation had been scheduled from the local fire unit for review of fire and evacuation plans. The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Record review on October 30, 2023 at 1504 revealed the last Fire Department consultation on file for review was dated August 23, 2021. During an interview on October 30, 2023 at 1505 the maintenance manager stated he did have access to the all of the director's files and that they would request a consult if they don't already have a recent one. Missouri Department of Health and Senior Services LABORATORY DIRECTOR‘ ) | - TE ator (3 3 _ QR sees §1JU11 (f continuation sheet 1 of 9 STATE FORM PRINTED: 11/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED 16094D B. WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD T DUNSFO -! ITL ARBORS AT DU RD COURT-MEM CARE ASS' SULLIVAN, MO 63080 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE Oe TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE Continued From page 1 19 CSR 30-86.022(8)(B) Exit-Directional Indicators Exit Signs. (B) Directional indicators showing the direction of travel shall be placed in corridors, passageways, or other locations where the direction of travel to reach the nearest exit is not apparent. II/I! This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire inspection process on October 30, 2023, the facility had confusing exit signs which had illuminated directional arrows in inappropriate locations. The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Observation on October 30, 2023 at 1437 revealed an exit sign with a directional arrow on exit sign fifteen (15), that had been turned sideways and needs to be turned to point towards the exit. Observation on October 30, 2023 at 1438 revealed an exit sign which requires the left directional arrow knock-out removed on exit sign sixteen (16), indicating a turn to the left is required to exit. During an interview on October 30, 2023 at 1515 the maintenance manager stated he would turn the one sign and remove the knock-out on the other sign. 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Missouri Department of Health and Senior Services STATE FORM ass §1JU11 \f continuation sheet 2 of 9 PRINTED: 11/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: {X3) DATE SURVEY COMPLETED 16094D B. WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE con TAG CROSS-REFERENCED TO THE APPROPRIATE ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 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. {Il This reguiation is not met as evidenced by: Class I Based on record review and interview during the fire safety inspection process on October 30, 2023, the facility failed to ensure facilities shail 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. The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Record review on October 30, 2023 at 1508 showed the last annual fire alarm inspection and certification was completed September 28, 2020. During an interview on October 30, 2023 at 1510 the maintenance manager stated he believed the testing was performed, but that the administrator has the records. 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 Missouri Department of Health and Senior Services STATE FORM S899 51JU11 \f continuation sheet 3 of 9 PRINTED: 11/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED 16094D B. WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE aati TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENC ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 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 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. I] This regulation is not met as evidenced by: Class Il Based on observation and interview during the fire safety inspection process on October 30, 2023, the sprinklered facility, licensed for more than twelve (12) beds on February 7, 1991, failed to provide separation from a hazardous area with self-closing, smoke-resistant doors on a furnace room The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Observation of the main floor furnace room on October 30, 2023, at 1419 revealed the doors to the furnace room in the main corridor between C wing and D wing are a set of double bi-fold doors. These doors are not self-closing and by the nature of how bi-fold doors are installed, there are Missouri Department of Health and Senior Services STATE FORM sa99 51JU11 {f continuation sheet 4 of 9 PRINTED: 11/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 16094D B. WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION XS) PREFIX (EACH DEFICIENCY MUST 8& PRECEDED BY FULL PREEIX (EACH CORRECTIVE ACTION SHOULD BE asin TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L Continued From page 4 significant gaps around the doors, so they do not provide the required separation between the furnace room and a resident corridor. During an interview on October 30, 2023, at 1535 the maintenance manager stated they had always been that way. 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. Ill This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on October 30, 2023, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Observation on October 30, 2023 between 1400 and 1415 revealed multipie misaligned escutcheon rings in the closets on the A wing and B wing. Observation on October 30, 2023 at 1430 revealed a missing escutcheon ring in the closet of room D3. Missouri Department of Health and Senior Services STATE FORM 8899 51JU14 If continuation sheet 5 of 9 PRINTED: 11/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDERYSUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION A. BUILDING: {X3) DATE SURVEY COMPLETED B. WING 16094D 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE etedia TAG CROSS-REFERENCED TO THE APPROPRIATE DA DEFICIENC ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4} 1D PREFIX TAG Continued From page 5 Observation on October 30, 2023 at 1509 revealed a missing escutcheon ring in the main foyer. These penetrations would allow smoke, fire and toxic gases to trave! to unaffected areas on the building During the exit interview on October 30, 2023 at 1530 the maintenance manager advised he would check all closets within the facility to assure the escutcheon rings are properly aligned and replace the missing escutcheon rings. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shal! be in accordance with NFPA 99, 1999 Edition. II/Il} This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire safety inspection process on October 25, 2023 the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Observation on October 25, 2023 at 1443 revealed no "Oxygen Storage” sign on the door of the oxygen storage closet. Missouri Department of Health and Senior Services STATE FORM 6899 S1JU11 If continuation sheet 6 of 9 PRINTED: 14/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 16094D 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD ARBORS AT IRT- DUNSFORD COURT-MEM CARE ASSIT L SULLIVAN, MO 63080 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE aie TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENG Continued From page 6 During an interview on October 25, 2023 at 1520 the maintenance manager said he would make sure to have a sign placed on the oxygen storage room door. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/Iil This regulation is not met as evidenced by: Class ll Based on observation and interview during the fire safety inspection process on October 30, 2023, the facility failed to maintain the vertical smoke partitions. The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (41) residents. Observation on October 30, 2023 at 1401 revealed the ceiling above the furnace in the mechanical room had collapsed exposing ceiling joists. Observation on October 30, 2023 at 1401 revealed a missing vent fan cover in the mechanical room. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the building During the exit interview on October 30, 2023 at 4525, the maintenance man stated he was awaiting materials to make the repairs. Missouri Department of Health and Senior Services STATE FORM 6899 §1JU14 {f continuation sheet 7 of 9 PRINTED: 11/02/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 16094D 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 ID PROVIDER'S PLAN OF CORRECTION (5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE coe TAG CROSS-REFERENCED TO THE APPROPRIATE ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L (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(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, !nc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorperated by reference. Facilities built between September 28, 4979 and July 1, 2005 shall be maintained in accordance with the requiremenis of the National Etectrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shalt not present a safety hazard. Ali facilities shall have wiring inspected every two (2) years by a qualified electrician. F/I! This regulation is not met as evidenced by: Class Ill Based on observation, record review, and interview during the fire inspection process on October 30, 2023 the facility failed to ensure the facility's electric wiring was properly maintained. The facility census October 30, 2023 was eleven (11). This deficiency affects eleven (11) of eleven (11) residents. Observation on October 30, 2023 at 1406 revealed a missing electrical outlet cover plate in room A1. Missouri Department of Health and Senior Services STATE FORM 6689 §1JU11 If continuation sheet 8 of 9 PRINTED: 11/02/2023 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 16094D B. WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 775 DUNSFORD ROAD SULLIVAN, MO 63080 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE ean TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE ARBORS AT DUNSFORD COURT-MEM CARE ASSIT L Continued From page 8 Observation on October 30, 2023 at 1417 revealed an extension cord being used as permanent wiring in the office on A wing. Record review on October 30, 2023 at 1455 revealed no current certificate of electrical wiring. the last certificate expired July 7, 2023. During an interview on October 30, 2023 at 1500 the maintenance manager stated he would remove the extension cord, install a cover plate, and believes there is a new electrical certificate, but he doesn't have access to it. Missouri Department of Health and Senior Services STATE FORM eee8 §1J3U11 if continuation sheet 9 of 9 PLAN OF CORRECTION Provider/Supplier Arbors at Dunsford Court Name: a Street Address, | 775 Dunsford Road, Sullivan MO 63080 City, Zip: Date of Survey: 10-30-2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 16094D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | The administrator stated the Local Fire Consult was completed | in November 2023. Documentation for this is stored in the A2214 administrator's office at Dunsford Court. Administrator will monitor for compliance with a quarterly review of Inspections completion for the community. Regional Director of Operations will review these documents on annual conn scorecard. Exit signs directional Arrows cited will be repaired or replaced to allow only the appropriate directional arrows to remain lit. A2237 Maintenance will monitor exit signs on their monthly checks. Administrator will monitor on Quarterly checks with maintenance . Regional director of operations will monitor exit signs on anuual inspection in their community scorecard. 42-1-2023 12-15-2023 The sprinkler/fire alarm inspection was completed by Gateway Fire in May 2023. Documentation of this inspection is located in the Administrators office. The second inspection of Fire system was completed in November 2023. Evidence of this is in the A2250 Administration office. Maintenance will monitor these inspections and sprinkler heads on their monthly reports. Administrator will conduct quarterly inspections for proper documentation of inspections and visual compliance of Sprinkler Heads. Regional director of operations will include annual inspections during their community scorecard. 42-1-2023 The Bifold doors that were cited in this report in the main corridor between Hail C and D will be replaced with a door that A2256 is self-closing and will not allow for significant gaps so it will 12-15-2023 provide the required separation between the furnace room and the corridor. The escutcheon rings cited in this report will be repaired or replaced as needed by maintenance. Maintenance will review monthly and replace or repair equipment as necessary to remain A2269 : : . compliant. Administrator and maintenance will perform quarterly walkthroughs to inspect all closet and general areas for compliance. 12-15-2023 An Oxygen Storage sign has been place in the location of A2298 oxygen Storage closet. 12-3-2023 Drywall above Furnace in the Mechanical room will be replaced and repaired as to allow for vertical smoke partitions. Missing A3201 Vent cover cited in this report will be replaced. Administrator will perform quarterly walkthroughs with maintenance personnel to monitor compliance in these areas. Regional Director of operations will perform an annual walkthrough. 12-15-2023 Electrical Plate cited in this inspection will be replaced. The extension Cord has been removed and and appliance directly plugged into the outlet. Williams Electric performed an Electrical A3214 Inspection in March of 2023. Our next due inspection would be 42-15-2023 March 2025. Documentation of this inspection if filed in the Administrator’s office. Administrator to monitor up to date inspections on a monthly compliance. 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.