SULLIVAN POINTE ASSISTED LIVING.

THE PLAN OF CORRECTION WAS REJECTED AND NEVER APPROVED, THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) 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 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 12/17/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(4)(B)(1)(2) Range Hood-After 7/11/80 & Before 10/1/00 Range Hood Extinguishing Systems. (B) In licensed facilities with a total of twenty-one (21) or more licensed beds and whose application was filed after July 11, 1980, and prior to October 1, 2000: 1. The kitchen shall be provided with a range hood and an approved automatic range hood extinguishing system unless the facility has an approved sprinkler system. Facilities with range hood systems shall continue to maintain and test these systems; and 2. The extinguishing system shall be installed, tested, and maintained in accordance with NFPA 96, 1998 edition. II/III This regulation is not met as evidenced by: Class III Based on record review and observation during the fire safety inspection process, the facility failed to maintain a hood extinguishing system in accordance with NFPA 96. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Observation revealed the kitchen hood suppression system with a red tag indicating deficiencies. Record review revealed the storage cylinder for suppression agent was out of hydrostat, according to the hood inspection report. During the exit interview on December 16, 2024 at 1300, the administrator stated she just received the report and didn't know there was a deficiency, but she would have it resolved. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 8Z0L11 If continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 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 during the fire safety inspection process, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Record review for the semi-annual fire alarm testing and inspection was not available. During the exit interview on December 16, 2024 at 1310, the administrator stated she had been off for surgery and would have to email the reports. 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 8ZOL11 PRINTED: 12/17/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD 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 6 PRINTED: 12/17/2024 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 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD 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) VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI Continued From page 2 Based on record review and interview during the fire safety inspection process, the facility failed to ensure 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. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Record review revealed the last annual fire alarm inspection and certification was not available for review. During the exit interview on December 16, 2024 at 1320, the administrator stated she had been off for surgery and would have to email the reports. 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 fourteen. This deficiency affects fourteen of fourteen residents. Observation revealed painted sprinkler heads in Missouri Department of Health and Senior Services STATE FORM 6899 8Z0OL11 If continuation sheet 3 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 rooms 1, 4, 10, 29, 30, 31, 33, 35, 37, 38, 40, 41, 43, 44, 45 and in hallway before exit 4. Observation revealed missing escutcheon rings in rooms 43 and 44. Observation revealed sprinkler heads have recessed into the ceiling of furnace room 4 and room 44 Observation revealed a sprinkler head that has dropped down from the ceiling in room 2. During the exit interview on December 16, 2024 at 1330, the administrator stated she would have the system worked on. 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/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process, the facility failed to maintain the building in good repair. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Observation revealed a ceiling penetration around a HVAC power supply in furnace room 9. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 8ZOL11 PRINTED: 12/17/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD 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 4 of 6 PRINTED: 12/17/2024 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 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD 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) VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI Continued From page 4 building. During the exit interview on December 16, 2024 at 1340, the maintenance man stated he would fill the gaps with fire foam. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process, the facility failed to ensure the facility's electric wiring was properly maintained. The facility census was fourteen. Missouri Department of Health and Senior Services STATE FORM 6899 8Z0OL11 If continuation sheet 5 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI SULLIVAN, MO 63080 PRINTED: 12/17/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE A3214| Continued From page 5 This deficiency affects fourteen of fourteen residents. Observation revealed an open slot within the maintenance breaker box. During the exit interview on December 16, 2024 at 1350, the maintenance man stated he would insert a blank in the breaker box. Missouri Department of Health and Senior Services STATE FORM 6899 8Z0OL11 DEFICIENCY) If continuation sheet 6 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PRINTED: 04/25/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 03/31/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A2212} 19 CSR 30-86.022(4)(B)(1)(2) Range Hood-After 7/11/80 & Before 10/1/00 Range Hood Extinguishing Systems. (B) In licensed facilities with a total of twenty-one (21) or more licensed beds and whose application was filed after July 11, 1980, and prior to October 1, 2000: 1. The kitchen shall be provided with a range hood and an approved automatic range hood extinguishing system unless the facility has an approved sprinkler system. Facilities with range hood systems shall continue to maintain and test these systems; and 2. The extinguishing system shall be installed, tested, and maintained in accordance with NFPA 96, 1998 edition. II/III This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated December 16, 2024. Class II* Based on observation, interview and record review, the facility failed to maintain a range hood extinguishing system in accordance with NFPA 96. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Observation on March 31, 2025 at 1:30 PM, showed the kitchen range hood suppression system was red tagged on May 29, 2024, indicating deficiencies from the range hood inspection company. Record review on March 31, 2025 at 1:55 PM, showed the storage cylinder for the suppression agent was out of date for hydrostatic pressure testing of the storage cylinder, according to the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM ease 8ZOL12 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A2212} TITLE (X6) DATE If continuation sheet 1 of 9 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 PRINTED: 04/25/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 03/31/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A2212}| Continued From page 1 range hood inspection report. Observation on March 31, 2025 at 1:31 PM, showed the range hood suppression system inspection tag issued on May 29, 2024 had exceeded it's 6 month life and was expired. Due to the red tag, the system cannot be serviced until the deficiencies are corrected. During an interview on March 31, 2025 at 2:27 PM, the regional maintenance director said the (former) facility maintenance man advised him there were no deficiencies during the annual fire inspection. NFPA Standard : Hydrostatic Test intervals for Extinguishers with a dry chemical with stainless steel shells should be completed in intervals of five years. Table 5-2 NFPA 10 5-1. NFPA Standard: Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a " Verification of Service " collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The " Verification of Service " collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch. 1998 NFPA 10 4-4.4.2 *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A2212} If continuation sheet 2 of 9 oes? 8ZOL12 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 PRINTED: 04/25/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 03/31/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A2249}| Continued From page 2 {A2249} 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: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated December 16, 2024. Class II Based on record review and interview, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Record review on March 31, 2025 at 2:00 PM, showed: -The semi-annual fire alarm testing and inspection was not available; -No documentation for the last annual fire alarm inspection. During an interview on March 31, 2025 at 2:05 PM, the regional maintenance director said the (former) facility maintenance person advised him there were no deficiencies during the fire alarm inspection. He would notify the facility administrator. Record review of NFPA 72 1999, 7-1.1.1: Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A2249} {A2249} If continuation sheet 3 of 9 oes? 8ZOL12 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 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG {A2249}| Continued From page 3 {A2249} recommendations, and shall verify correct operation of the fire alarm system. NFPA Standard: The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. 1999 NFPA 72, 7-1.2 Record review of NFPA 72, Chapter 14.3 showed: Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. - Batteries - Transient suppressors - Fire alarm control unit trouble signals - In-building fire emergency voice/alarm communications equipment - Remote annunciators - Initiating devices - Guard's tour equipment - Combination systems - Interface equipment - Alarm notification appliances - supervised - Exit marking audible notification appliances - Supervising station alarm systems - transmitters - Special procedures - Supervising station alarm systems - receivers* {A2269}, 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing {A2269} Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 8ZOL12 PRINTED: 04/25/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED R 03/31/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE If continuation sheet 4 of 9 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 PRINTED: 04/25/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 03/31/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A2269}| Continued From page 4 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: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated December 16, 2024. Class Il Based on observation record review, and interview, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Observations on March 31, 2025 between 12:30 PM and 1:50 PM, showed: -Painted sprinkler heads in rooms 1, 4, 10, 29, 30, 31, 33, 35, 37, 38, 40, 41, 43, 44, 45, and in the hallway before exit 4; -Missing escutcheon rings in rooms 43 and 44; -Sprinkler heads recessed into the ceiling of furnace room 4 and room 44; -A sprinkler head had dropped down from the ceiling in room 2. During an interview on March 31, 2025 at 2:27 PM, the regional maintenance director said the facility maintenance man (former) advised him there were no deficiencies during the annual fire inspection. He would notify the administrator. Record review of the National Fire Protection Association (NFPA) 25 1998, 2-2.1-1* showed: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A2269} If continuation sheet 5 of 9 oes? 8ZOL12 PRINTED: 04/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD 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) VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: {A2269}|} Continued From page 5 {A2269} shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Record review of the Nation Fire Protection Association (NFPA) 13, 1999 Edition.* 5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than eighteen (18") (457mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3. 5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be eighteen (18") (457 mm) or greater. Record review of the National Fire Protection Association (NFPA) 13, 1999 Edition.* 3-2.9.1 Asupply of spare sprinklers (never fewer than 6) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100° F (38° C). {A3201}} 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 Missouri Department of Health and Senior Services STATE FORM 6899 8ZOL12 If continuation sheet 6 of 9 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 PRINTED: 04/25/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 03/31/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A3201}| Continued From page 6 This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated December 16, 2024. Class III Based on observation and interview, the facility failed to maintain the building in good repair, by failing to seal ceiling penetrations. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. The facility census was fourteen. This deficiency affects fourteen of fourteen residents. Observation on March 31, 2025 at 12:50 PM, showed a ceiling penetration around a HVAC power supply in furnace room 9. During an interview on March 31, 2025 at 2:27 PM, the regional maintenance director said the facility maintenance man (former) advised him there were no deficiencies during the annual fire inspection. He would notify the administrator. State Statute This regulation is not met as evidenced by: Class II RsMO 198.026.2 The operator or administrator shall have five working days following receipt of a written report and correction order regarding a violation of a class | standard and ten working days following receipt of the report and correction order regarding violations of class II or class III Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A3201} If continuation sheet 7 of 9 oes? 8ZOL12 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 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 standards to request any conference and to submit a plan of correction for the departments approval which contains specific dates for achieving compliance. Within five working days after receiving a plan of correction regarding a violation of a class | standard and within ten working days after receiving a plan of correction regarding a violation of a class II or class III standard, the department shall give its written approval or rejection of the plan. If there was a violation of any class | standard, immediate corrective action shall be taken by the operator or administrator and a written plan of correction shall be submitted to the department. The department shall give its written approval or rejection of the plan and if the plan is acceptable, a reinspection shall be conducted within twenty calendar days of the exit interview to determine if deficiencies have been corrected. If there was a violation of any class II standard and the plan of correction is acceptable, an unannounced reinspection shall be conducted between forty and ninety calendar days from the date of the exit conference to determine the status of all previously cited deficiencies. If there was a violation of class III standards sufficient to establish that the facility was not in substantial compliance, an unannounced reinspection shall be conducted within one hundred twenty days of the exit interview to determine the status of previously identified deficiencies. Based on record review and interview, the facility failed to submit a Plan of Correction (POC) addressing deficiencies discovered during an inspection conducted on December 16, 2024. The census was fourteen. This deficiency potentially affects fourteen of fourteen residents . Record review on March 31, 2025 at 7:00 AM, Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 8ZOL12 PRINTED: 04/25/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED R 03/31/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD 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 8 of 9 PRINTED: 04/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD 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) VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: Continued From page 8 showed no record of a POC submitted to the Division of Fire Safety. During an interview on March 31, 2025 at 2:27 PM, the regional maintenance director said the (former) facility maintenance man advised him there were no deficiencies during the annual fire inspection. He would notify the administrator. Missouri Department of Health and Senior Services STATE FORM 6899 8ZOL12 If continuation sheet 9 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 26324 Be WING nt 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI! 18 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. [I/II 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 twenty-seven (27). This deficiency affects twenty-seven (27) of twenty-seven (27) residents. Observation on October 30, 2023 at 1213 revealed an exit sign with a directional arrow on exit sign four (4), indicating a turn that was not there. Observation on October 30, 2023 at 1219 revealed an exit sign with a directional arrow on exit sign five (5), indicating a turn that was not there. Observation on October 30, 2023 at 1228 revealed an exit sign with a directional arrow on exit sign three (3), indicating a turn that was not there. Observation on October 30, 2023 at 1236 revealed an exit sign with a directional arrow on the exit sign adjacent to room forty-eight (48), indicating a turn that was not there. Observation on October 30, 2023 at 1241 revealed an exit sign with a directional arrow on the exit sign at fire exit six (6), indicating a turn that was Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDE! IER REPRESETATIVE'S SIGNATURE 6) DATE STATE FORM UXG11 If continuation sheet 1 of 7 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 B.WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: Continued From page 1 not there. Observation on October 30, 2023 at 1249 revealed an exit sign with a directional arrow on the exit sign adjacent to room thirty-six (36), indicating a turn that was not there. Observation on October 30, 2023 at 1254 revealed an exit sign with a directional arrow on the exit sign at fire exit four (4), indicating a turn that was not there. During an interview on October 30, 2023 at 1310 the maintenance manager stated he would cover the misleading arrows. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-} hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are 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 Missouri Department of Health and Senior Services STATE FORM see VUXC11 If continuation sheet 2 of 7 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 26324 B.WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE One TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: Continued From page 2 automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this Tequirement. II 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 facility failed to maintain self closing smoke partition doors that separate the kitchen area from the dining area. The facility census October 30, 2023 was twenty-seven (27). This deficiency affects twenty-seven (27) of twenty-seven (27) residents. Observation on October 30, 2023 at 1233 revealed one of the kitchen smoke partition doors mechanically blocked open with a door chock and a door chock on the floor next to the other door. During an interview on October 30, 2023 at 1305 with the maintenance manager said he would remove the door chocks and see that the kitchen staff either keeps the door closed or they will install a magnetic hold on it that is tied into the fire alarm system. 19 CSR 30-86.022(11)(B) Sprinkler Systern 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 Missouc Department of Health and Senior Services STATE FORM ease VUXC11 If continuation sheet 3 of 7 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 26324 B.WING 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: Continued From page 3 on August 27, 2007. VII 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 twenty-seven (27). This deficiency affects twenty-seven (27) of twenty-seven (27) residents. Observation on October 30, 2023 at 1256 revealed @ painted sprinkler head in the hallway adjacent to roorn twenty-eight (28). During the exit interview on October 30, 2023 at 1330 the maintenance manager advised that repairs would be made. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shail be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/Ill This regulation is not met as evidenced by: Class III 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 twenty-seven (27). This deficiency affects Missouri Department of Health and Senior Services STATE FORM s8s9 VUXC11 If continuation sheet 4 of 7 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 (DENTIFICATION NUMBER: A. BUILDING: COMPLETED 26324 Be WING ne 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENC VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMER! Continued From page 4 twenty-seven (27) of twenty-seven (27) residents. Observation on October 30, 2023 at 1259 revealed the protective collars around the pipes in furnace room two (2) had slid down the pipes leaving penetrations open. 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 1325, the maintenance man stated he would move the collars back into proper position. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a Missouri Department of Health and Senior Services STATE FORM sas9 VUXC11 If continuation sheet 5 of 7 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 26324 B. WING en 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY; VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI Continued From page 5 safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. I/II This regulation is not met as evidenced by: Class Ili Based on observation 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 twenty-seven (27). This deficiency affects twenty-seven (27) of twenty-seven (27) residents. Observation on October 30, 2023 at 1222 revealed an extension cord being used as permanent wiring in the first office in the left wing off the main lobby. During an interview on October 30, 2023 at 1320 the maintenance manager stated he would remove the extension cord. 19 CSR 30-87.020(25} Plumbing per Code Plumbing shall be sized, installed and maintained according to the National Plumbing Code. Ii/III This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire safety inspection process on October 30, 2023, the facility failed to maintain plumbing in accordance to the National Plumbing Code. The facility census October 30, 2023 was twenty-seven (27). This deficiency affects twenty-seven (27) of Missouri Department of Health and Senior Services STATE FORM 6300 VUXC11 {f continuation sheet 6 of 7 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 26324 BING ne ; 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1250 EAST SPRINGFIELD ROAD SULLIVAN, MO 63080 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS) 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 VICTORIAN PLACE OF SULLIVAN, ASSIST BY AMERI: Continued From page 6 twenty-seven (27) residents. Observation on October 30, 2023 at 1211 revealed a water heater in the mechanical room with a drip teg that over a foot above the floor. Drip legs should terminate no more than four (4) inches above the floor. Observation on October 30, 2023 at 1258 revealed a water heater in furnace room two (2) with a drip leg that ended over a foot above the floor. Drip legs should terminate no more than four (4) inches above the floor. During an interview on October 30, 2023 at 1315 the maintenance manager stated he would extend or replace the drip legs. Missouri Department of Health and Senior Services STATE FORM cee VUXC11 if continuation sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier Victorian Place of Sullivan Name: Street Address, City, Zip: Date of Survey: 10-30-2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26324 1250 East Springfield Road, Sullivan MO 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE All non-applicable exit sign directional arrows will be removed or covered to prevent confusion when exiting the building. Continued monitoring with be done quarterly by the A2237 administrator to insure compliance. Regional Director of Operations will monitor and insure compliance annually in the communities Scorecard. This includes repair to # 4 exit sign, #5 Exit sign, Exit sign 3, Exit sign 6, Exit sign adjacent to room 36 and also Exit sign by fire door 4. 12-15-2023 Kitchen doors will immediately be closed with the expectation of no longer being propped open. The door Chocks have been removed from these doors. These doors will remain closed A2256 except for entering or exiting the kitchen/ Dining Room area. Administrator will monitor these doors daily to insure compliance. The regional Director of Operations will monitor these doors for compliance as well as documenting these doors on their annual community scorecard. 10-30-2023 The sprinkler inspection was completed by Gateway Fire in April 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 Administration office. The painted sprinkler head adjacent to A2269 room 28 will be replaced. Maintenance will monitor these 42-15-2023 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 mspectons ong their commen scorecard. The protective collars in question in furnace room 2 will be repaired and ready for reinspection. Maintenance will monitor A3201 protective collars when replacing air filters in all Furnace units. 12-15-2023 Administrator will preform a quarterly inspection to insure compliance. ee Williams electric has Completed an bi annual Electrical inspection on 2-24-2023. Our next inspection du will be 2-24- 2025.Documentation of this inspection is filed in the administrator's office. Extension Cord in question in the first office in the left wing of the main lobby has been removed and the appliance has been A3214 directly plugged into the electrical outlet. Maintenance and Administrator will conduct quarterly inspection of all office area and resident Room to insure compliance. 10-30-2023 10-30-2023 The drip legs on the two water heaters cited in the Mechanical room and in furnace room 2 will eb extended so they will A6025 terminate less than 4 inches from the floor. Maintenance will 12-15-2023 monitor all repair and replacement of future water heaters to insure future 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.