HARMONY GARDENS ASSISTED LIVING.

An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al 19 CSR 30-86.022(7)(A)(2) Exits/Stairways After 12/31/87 Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. Il 2. For a facility whose plans were approved after December 31, 1987, for more than twenty (20) beds, the required exits shall be doors leading directly outside, one- (1-) hour enclosed stairs or outside stairs or a two- (2-) hour rated horizontal exit as defined by paragraph 3.3.61 of 2000 edition NFPA 101. The one- (1-) hour enclosed stairs shall exit directly outside at grade. Access to these shall not be through a resident bedroom or a hazardous area. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on March 24, 2025, the facility failed to ensure the enclosed stairwell was a one (1) hour rated construction. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 1:26 P.M., showed a patch in the drywall not sealed with drywall tape and mud in the South stairwell. Observation at 1:42 P.M., showed a patch in the drywall not sealed with drywall tape and mud and a large rectangular hole in the ceiling of the North stairwell. At the times of discovery, the Maintenance Director said, "It is scheluded to be fixed." Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 HIHF11 If continuation sheet 1 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 1 During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "| make sure all of the issues are fixed." 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. Atwo- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing of the exit stairway, attendants ' work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states " AREA OF REFUGE IN CASE OF FIRE" and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable; 6. Asign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge; 7. Emergency lighting for the area of refuge; and Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 2 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 2 8. The total area of the areas of refuge on a floor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II This regulation is not met as evidenced by: Class II Based on observation and interview on March 24, 2025, the facility failed to ensure exit doors in the "Area of Refuge" had a smoke seal. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 1:49 P.M., showed an exit door in the East Wing Area of Refuge that will not close completely. At the time of discoveries, the Maintenance Director said, "I will get it fixed." During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "| make sure all of the issues are fixed." 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 observation and interview on March 24, Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 3 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 3 2025, the facility failed to maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 1:42 P.M., showed a small circular ring missing from the bottom of a smoke detector in the North stairwell's ceiling. At the time of discovery, the Maintenance Director said, "| have a spare detector and will get it switched out." During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "| make sure all of the issues are fixed." 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on March 24, 2025, the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 4 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 4 Observation at 1:34 P.M. showed a sprinkler head in the newly remodeled Area of Refuge in the North wing, that is approximately three (3") from the separation wall of the corridor. This creates an unprotected area on the opposite side of the wall measuring approximately three to four (3' to 4’). Observation at 2:56 P.M. showed no hydraulic nameplate attached to the sprinkler system. During an interview on March 24, 2025 at 4:07 P.M., the Maintenance Director said, "I'll look into this." * Record review of the Nation Fire Protection Association (NFPA) 13, 1999 Edition. 5-6.2.2 Maximum Protection Area of Coverage. The maximum allowable protection of area coverage for a sprinkler (As) shall be in accordance with the value indicated in Tables 5-6.2.2(a) through 5-6.2.2(d). In any case, the maximum area of coverage of a sprinkler shall not exceed 225 ft? (21 m?). Table 5-6.2.2(b) Protection Area and Maximum Spacing (Standard Spray Upright/ Standard Spray Pendent) for Ordinary Hazard Construction Type: All - System Type: All - Protection Area: 130 ft? - Spacing (maximum): 15 ft 5-6.3.4 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4" (102 mm) from a wall. 10-5* Hydraulic Design Information Sign. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 5 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 5 secured with corrosion-resistant wire, chain, or other approved means. Such sign shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. The sign shall include the following: (1) Location of the design area or areas. (2) Discharge densities over the design area and areas. (3) Required flow and residual pressure demand at the base of the riser. (4) Occupancy classification or commodity classification and maximum permitted storage height and configuration. (5) Hose stream demand included in addition to the sprinkler demand. 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 on March 24, 2025, the facility failed to maintain their sprinkler system in accordance with the National Fire Protection Association (NFPA) 25, 1998 edition. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 1:24 P.M., showed a blanket Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 6 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 6 stored within eighteen (18") of a sprinkler head in the closet of resident room 207. Observation at 1:37 P.M., showed a sprinkler head with a open space around the escutcheons ring at the ceiling, outside of resident room 224. Observation at 1:40 P.M., showed a sprinkler head with a open space around the escutcheons ring at the ceiling and objects stored within eighteen (18") of sprinkler head in the closet of resident room 221. Observation at 1:48 P.M., showed a sprinkler head with paint on it in the East stairwell. Observation at 1:40 P.M., showed objects stored within eighteen (18") of sprinkler head in the closet of resident room 217. Observation at 2:26 P.M., showed objects stored within eighteen (18") of sprinkler head in the closet and a sprinkler head with pain on it with the escutcheon ring penetrating the ceiling in resident room 209. Observation at 2:41 P.M., showed a sprinkler head with paint on it in resident room 103. Observation at 2:48 P.M., showed objects stored within eighteen (18") of sprinkler head in the closet of resident room 108. Observation at 2:51 P.M., showed a sprinkler head with paint on it in Assisted bathroom on the 1st floor.. Observation at 2:59 P.M., showed a sprinkler head in the kitchen with foreign material on it. Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 7 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 7 Record review at 3:05 P.M., showed an open corrective action and solution summary on the Semi-Annual Sprinkler Report dated, January 29, 2025 with a corrective actions of, "No upright sprinkler heads in head box." During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "I will look into this." *Phone call with the sprinkler company shows a quote was sent for review regarding the dry system heads replacement. 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 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.* Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 8 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 8 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). 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III Based on observation and interview on March 24, 2025, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 2:58 P.M., showed more than twelve (12) oxygen cylinders under the north stairwell. Three (3) oxygen cylinders were not in a storage rack and four (4) were stored in a cardboard container, laying on its side. During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "| don't understand why we have so many and I'll make arrangements for the rest to be picked up." Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 9 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 9 Review of the following chapters of the 1999 National Fire Protection Association (NFPA) 99, showed: 8-3.1.11 Storage Requirements 8-3.1.11.2 Storage for non-flammable gases less than 3000 ft3 (85 m3) (a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor. (c) Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either: 1. Aminimum distance of 20 ft (6.1 m), or 2. Aminimum distance of 5 ft (1.5m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or 3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage. 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 Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 10 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 10 This regulation is not met as evidenced by: Class III Based on observation and interview on May 24, 2025, the facility failed to maintain the building in good repair. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 12:21 P.M., showed a metal electrical outlet cover that was bent in Resident Room 2. Observation at 1:19 P.M., showed a crack above the door to resident room 206. Observation at 1:21 P.M., showed a crack in the window of resident room 205. (This room is vacant.) Observation at 1:25 P.M., showed a hole in the wall by the TV in resident room 207. Observation at 1:29 P.M., showed drywall tape coming lose in the bathroom ceiling and a corner by the front door damaged in resident room 218. Observation at 1:35 P.M., showed a crack in the ceiling next to the closet and a broken door with no door knob in resident room 220. Observation at 1:46 P.M., showed damage to a corner of the wall in the Assisted Bathing room on the second floor. Observation at 2:00 P.M., showed drywall tape coming lose in the bathroom ceiling of resident room 212. Observation at 2:04 P.M., showed a small hole in Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 11 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 11 the wall and water damage on the ceiling in the closet in resident room 215. Observation at 2:22 P.M., showed several holes and water damage in the ceiling of a mechanical room on the 1st floor. Observation at 2:23 P.M., showed a gap around the base of an exit sign on the ceiling of the East hall of the 1st floor. Observation at 2:24 P.M., showed a patch in the wall with no drywall tape and mud in resident room 109. Observation at 2:27 P.M., showed a crack in the drywall tape on the ceiling and a crack in the drywall above the door in resident room 112. Observation at 2:29 P.M., showed two (2) cracks in the drywall near two (2) different windows and a crack in the drywall tape on the ceiling in resident room 114. Observation at 2:00 P.M., showed a damaged area in the drywall on the ceiling of the bathroom in resident room 103. Observation at 2:53 P.M., showed drywall spackling peeling off the ceiling in the laundry room. Observation at 2:54 P.M., showed several holes in the ceiling of the sprinkler riser room. Observation at 2:59 P.M., showed a space around a junction box in the kitchen. At the time of discoveries, the Maintenance Director said, "I will get these fixed and some of Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 12 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 12 the items are already scheduled to be fixed." During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "| make sure all of the issues are fixed." 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 on March 24, 2025, the facility failed to maintain the building electrical wiring in good repair in accordance with the requirements of the National Electrical Code, Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 13 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 13 1999 edition. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 1:21 P.M. showed a broken electrical outlet in resident room 205. Observation at 1:42 P.M., showed a light fixure hanging by the wires in the north stairwell. Observation at 2:33 P.M., showed a broken electrical outlet in resident room 115. During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "| make sure all of the issues are fixed." 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/III This regulation is not met as evidenced by: Class III Based on observation and interview on March 11, 2025, the facility failed prevent the improper use of power strips and the use of multi-plug adapters. The facility census was twenty-five Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 14 of 15 PRINTED: 09/12/2025 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 18615C B. WING 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY Al Continued From page 14 (25). This deficiency affected twenty-five (25) of twenty-five (25) residents. Observation at 1:40 P.M. showed a multi-plug adapter by the TV in resident room 221. Observation at 2:04 P.M., showed a six (6) way adapter in resident room 215. Observation at 2:04 P.M., showed an unapproved power strip behind the TV with two (2) power strips, daisey-chained and a microwave plugged into them in resident room 217. Observation at 2:32 P.M., showed a three (3) way adapter by the bed in resident room 115. Observation at 2:04 P.M., showed a six (6) way adapter with a power strip plugged into it in resident room 108. During an interview on March 24, 2025 at 4:07 P.M., the Administrator said, "| make sure all of the issues are fixed." Missouri Department of Health and Senior Services STATE FORM 6899 HIHF11 If continuation sheet 15 of 15 PRINTED: 08/13/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: {X2} MULTIPLE CONSTRUCTION A, BUILDING: {X3)} DATE SURVEY COMPLETED R 07/31/2025 8. WING 18615C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD HARMONY DENS-ASS LIVING MONY GARDENS-ASSISTED LIVING BY AMERIC; WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X4} 1D PREFIX TAG (x6) COMPLETE DATE {A2269}' 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/ Testing {A2269} Sprinkler Systems. (B) Facttities 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. Wli This regulation is not met as evidenced by: This defictency Is uncorrected, For prior examples, refer to the Statement of Deficiencies dated March 24, 2025. Class I! Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association (NFPA) 25, 1998 edition. The facility census was twenty-five (25). This deficiency affected twenty-five (25) of twenty-five (25) residents, Observation on 07/31/2025 at 11:00 A.M., showed three (3) sprinkler heads in the kitchen with foreign material on them. During an interview on 07/31/2025 at 11:05 A.M., the Administrator said the three sprinkler heads were missed and they would get the cleaning scheduled. 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. Sprinkters shall be free of corrosion, foreign material, paint, and physical damage and shall be installed In the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall Missouri Department of Health and Senior Services ORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE THLE {X6) DATE E HIHF12 lf continuation sheet 1 of 2 PRINTED: 08/13/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED R 48645C B. WING 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG GROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} HARMONY GARDENS-ASSISTED LIVING BY AMERIC, {A2269}| Continued From page 1 {A2269) be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Missourt Department of Health and Senior Services STATE FORM 6699 HIHF42 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier N Harmony Gardens-Assisted Living ame; Street Address, City, Zip: 503 Burkarth Rd Warrensburg, MO 64093 07/31/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 18615C iD PREFIX TAG PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Date of Survey: Corrected 08/05/2025 and monthly rounds initiated to prevent re-occurrence. To ensure that there is no recurrence A2269 maintenance director will add to monthly rounds to monitor for 08/05/2025 unapproved items that are installed and monitor integrity of buildi mpliance. Pe _ fp | | fF | | Pp a maa 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. aon Yaron, ED YN/AS

PRINTED: 05/24/2024. 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 18615C B.WING 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) 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 OEFICIENCY} HARMONY GARDENS-ASSISTED LIVING BY AMERIC, 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Protection from Hazards. (1) in facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be ai least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the facility, licensed after December 31, 1987 for more than twenty (20) beds, failed to ensure doors in a smoke partition shall be self-closing. The facility census was nineteen. This deficiency affects nineteen of nineteen residents. Observation of a smoke door next to room 110 revealed that the smoke door is damaged and non-functional. Smoke doors failing to clase will allow smoke and toxic gases to spread to other areas of the building. During the exit interview on May 20, 2024 at 1240, the maintenance man staied that they knew about the damaged door and have a replacement door ordered and he would have the Missouri Department of Health and Senior Services LABORATORY:DIRECTOR'S OR PROVIDER/SUPPLIER RERRESENTATIVE'S SIGNATURE 7 Bd é a "s, at : . STATE FORM ‘ (X6) DATE a i ctingnuatidn sheet 1 oF 3 PRINTED: 05/24/2024. 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 18615C B. WING 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION ; {X5} (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY AMERIC, Continued From page 1 door repaired as soon as it arrives. | 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 It Based on record review 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 nineteen. This deficiency | affects nineteen of nineteen residents. Record review revealed deficiencies in the Annual ; and Semi-Annual Sprinkler reports. There has been no documented corrections regarding the need for an accelerator and replacement sprinkler heads placed in the head box. During the exit interview on May 20, 2024 at 1235, the maintenance man called the sprinkler company and confirmed that these items still needed to be addressed. 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 Missouri Department of Health and Senior Services STATE FORM sao JNSO11 If continuation sheet 2 of 3 PRINTED: 05/24/2024 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 18615C B. WING na 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 503 BURKARTH ROAD WARRENSBURG, MO 64093 (x4)iD | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) HARMONY GARDENS-ASSISTED LIVING BY AMERIC; Continued From page 2 rules in effect at the time of initial licensing. II/il! | 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 nineteen. This deficiency affects nineteen of nineteen residents. Observation revealed two ceiling penetrations in fire sprinkler riser room. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. During the exit interview on May 20, 2024 at | 1230, the maintenance man stated he knew about the ceiling holes, caused by recent water leaks, and that he is in the process of repairing ; them. } Missouri Department of Health and Senior Services STATE FORM eaeg JNSOT1 (f continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Harmony Gardens Assisted Living by Americare Name: Street Address, 503 Burkarth Road City, Zip: Warrensburg, MO 64093 Date of Survey: 5/20/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 18615C ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The filing of this correction does not constitute any admissions by the facility regarding the alleged violation stated in the summary Statement of Deficiencies dated 5/20/2024 by the Missouri Department of Health and Senior Services. This plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. immediate Action: Smoke Section Partitions- Protection from 6/20/2024 Hazards The facility will ensure that all doors in a smoke partition are appropriately fire rated, self closing and in good repair to prevent smoke or toxic gasses spreading to other areas. A new door was ordered to replace the damaged door in front of room 110 and will be installed upon receipt. Delivery of replacement door is expected to be 4-8 weeks. Ongoing Compliance: To ensure that there is no recurrence, the Maintenance Director will check the doors monthly as part of routine maintenance checklist process to verify that doors are properly functioning and are in good repair. Staff has been inserviced to notify the Administrator if doors sustain damage or do not close properly. Compliance Date: 6/20/2024 Sprinkler System Maintenance/Testing 6/20/2024 Immediate Action: The facility will maintain, inspect and testa ‘| complete sprinkler system as required. The accelerator and replacement sprinkler head deficiencies cited in the Annual and Semi Annual Sprinkler reports will be corrected and facility will secure documentation of the corrections. Ongoing Compliance: To ensure that there is no recurrence, the Administrator will review results of all sprinkler inspection reports when inspections are completed and verify scheduling of necessary repairs are made.. Documentation of repairs will be maintained with inspection reports. Compliance Date: 6/20/2024 Immediate Action: Substantially Constructed and Maintained The facility will maintain the building in good repair and ensure that there are no ceiling penetrations. The 2 penetrations in the fire sprinkler riser room will be sealed to prevent smoke, fire or gasses to travel to unaffected portions of the building. 6/20/2024 Ongoing Compliance: To prevent reoccurrence the facility Maintenance Director will visually inspect ceiling areas as a part of the monthly maintenance checklist process and report any ceiling penetrations to the Administrator. Administrator will verify that any penetrations are sealed promptly to prevent smoke, fire or gasses to travel to unaffected portions of the building. All staff have been inserviced to report any ceiling penetrations they observe to the Administrator. Compliance Date: 6/20/2024 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.