WILLOW BROOKE ASSISTED LIVING.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. PRINTED: 07/24/2024 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 13596C — 07/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE #1 NORTH POTOMAC COURT 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) WILLOW BROOKE-ASSISTED LIVING BY AMERICARE 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 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 twelve. This deficiency affects twelve of twelve residents. Record review revealed the last annual fire alarm inspection and certification was completed in February of 2023 During the exit interview on July 23, 2024 at 1100 the maintenance manager stated he believed the testing was performed and would have the administrator email the report. Follow up email with the administrator on July 23, 2024 at 1319 and she was unable to produce a report. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MF1Q11 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: 13596C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: #1 NORTH POTOMAC COURT WILLOW BROOKE-ASSISTED LIVING BY AMERICARE UNION, MO 63084 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 (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 sprinklered facility, licensed for more than twelve (12) beds on November 6, 1987, failed to provide separation from a hazardous area with self-closing, smoke-resistant doors on a mechanical room. The facility census was twelve. This deficiency affects twelve of twelve residents. Observation revealed that the door to the center hallway mechanical room was a sliding wood door that was less than 1-3/4 inches thick. The door is not self-closing and by the nature of how sliding doors are installed, there are significant Missouri Department of Health and Senior Services STATE FORM 6899 MF1Q11 PRINTED: 07/24/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/23/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 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: 13596C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE #1 NORTH POTOMAC COURT WILLOW BROOKE-ASSISTED LIVING BY AMERICARE UNION, MO 63084 PRINTED: 07/24/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/23/2024 (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 A2256 | Continued From page 2 gaps around the doors, so they do not provide the required separation between the mechanical room and a resident corridor. During the exit interview on July 23, 2024 at 1105, the maintenance manager stated they had always been that way, but he would change it. Missouri Department of Health and Senior Services STATE FORM oeee MF1Q11 DEFICIENCY) If continuation sheet 3 of 3 UNABLE TO LOCATE PLAN OF CORRECTION