UNION POINTE ASSISTED LIVING.

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: B. WING 7 NAME OF PROVIDERIOR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE : 4320 WEST MAIN RI LACE OF , ASSIST LIV BY AME VICTORIAN P UNION, ASSIST RI UNION, MO 63084 PRINTED: 09/05/2025 FORM APPROVED {X3) DATE SURVEY COMPLETED 09/04/2025 (X4) 1D | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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- (/-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (f-) 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. II This regulation is not met as evidenced by: Class ll Based on observation and interview during the fire safety inspection process, the facility failed to maintain self closing smoke partition doors that separate the kitchen area from the dining area. The facility census was 27. This deficiency affects 27 of 27. residents. Observation revealed one of the kitchen smoke partition doors mechanically blocked open with a bucket, This is a reoccurring violation at the facility, Missouri Department of |Health and Senior Services se LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE mefyecvt fe 8898 QV3E11 (X6) DATE STATE FORM if continuation sheet 1 of 2 PRINTED: 09/05/2025 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 09/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1320 WEST MAIN UNION, MO 63084 (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 UNION, ASSIST LIV BY AMERI 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 automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the facility failed to maintain self closing smoke partition doors that separate the kitchen area from the dining area. The facility census was 27. This deficiency affects 27 of 27 residents. Observation revealed one of the kitchen smoke partition doors mechanically blocked open with a bucket. This is a reoccurring violation at the facility. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM Seog QV3E11 If continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER VICTORIAN PLACE OF UNION, ASSIST LIV 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 During the exit interview on September 4, 2025 at 12:30 PM, the maintenance manager said he would 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 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/Il This regulation is not met as evidenced by: Class Il 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 27. This deficiency affects 27 of 27 residents. Observation revealed 2 escutcheon rings missing from sprinkler heads under the drive through canopy. During the exit interview on September 4, 2025 at 12:40 PM, the maintenance manager said he would attempt to but escutcheon rings on the sprinkler heads or call the sprinkler company. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 QV3E11 PRINTED: 09/05/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1320 WEST MAIN UNION, MO 63084 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: Union Pointe (formally Victorian Place) Assisted living by Americare Street Address, . . 1320 West Main St. Union, Missouri 63084 City, Zip: Date of Survey: 09/04/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION : SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Preparation and/or execution of this plan do not constitute. admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals \ who draft or may be discussed in this response and plan of . correction. This plan of correction is submitted as the facility's \ credible allegation of compliance. \ Immediately the bucket used to prop the door open was removed, A sign was hung stating that the door is to remain A2256 closed, Staff will monitor to ensure that all smoke partition doors 10/03/2025 remain unblock or propped open. Completed by the Director of Dining Services and/or Designee. Immediately a call was placed to our vendor who tends to our A2269 sprinkler systems and the vendors are scheduled to the replace 10/03/2025 the two escutcheon’s ASAP. oa Defpeer Witte NA EIT

PRINTED: 12/12/2023 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 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1320 WEST MAIN VICTORIAN PLACE OF UNION, ASSIST LIV BY AMERI UNION, MO 63084 (x4) 1D 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 DEFICIENCY A2256: 19 CSR 30-86.022(10)(A) Hazardous Area Requirements : Protection from Hazards. i {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 sprinkier system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shail 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 Jt, and existing prior to ' November 13, 1980, shall be exempt from this requirement. II - This regulation is not met as evidenced by: : Class It | Based on observation and interview during the fire safety inspection process on November 29, 2023 the facility failed to maintain self closing smoke | partition doors that separate the kitchen area from | the dining area. The facility census November 29, | 2023 was twenty-two (22). This deficiency affects i twenty-two (22) of twenty-two (22) residents. : Observation on November 29, 2023 at 1300 ' revealed both of the kitchen smoke partition doors Misso ponenent of Health and Senior Services LABO RY, DIRECTOR'S OR PROVIDER/SUPPHIER REPRESENTATIVE'S SIGNATURE Yeni STATE FORM (X6) DATE S899 EJ6411 If continuation sheet 1 of 2 PRINTED: 12/12/2023 ; 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 24408 B.WING 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1320 WEST MAIN UNION, MO 63084 (X%4) ID 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 COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) ! CROSS-REFERENCED TO THE APPROPRIATE VICTORIAN PLACE OF UNION, ASSIST LIV BY AMERI Continued From page 1 mechanically blocked open, one with a door chock and the other door with a trash can. : During an interview on November 29, 2023 at 1415 "with the maintenance manager said he would 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. Missouri Department of Health and Senior Services STATE FORM Sese E6411 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Victorian Place of Union Name: Street Address, . . 1320 West Main Street, Union, MO 63084 City, Zip: Date of Survey: November 29, 2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Facility will ensure kitchen doors remained closed ai all times A2256 unless entering or exiting the area. Doors have been closed, November and signage placed to instruct individuals to keep doors closed 29, 2023 unless entering or exiting. Staff to monitor closely for compliance Pf | en A Pd re a rere PT a ee a ee Re ee ee ee es es 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.