ASPEN VALLEY FOX CREST.

THE PLAN OF CORRECTION WAS REJECTED AND NEVER APPROVED, THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) PRINTED: 08/20/2025 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 33537 B. WING 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2694 FOX CREST DRIVE WASHINGTON, MO 63090 (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) ASPEN VALLEY FOX CREST 19 CSR 30-86.022(10)(J) Smoke Section Partitions < than 20 beds Protection from Hazards. (J) In all facilities that were initially licensed on or prior to December 31, 1987, and all facilities licensed for twenty (20) or fewer beds prior to August 28, 2007, each smoke section shall be separated by a one- (1-) hour fire-rated smoke partition that extends from the inside portion of an exterior wall to the inside portion of an exterior wall and from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces. Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspending ceiling system where the following conditions are met: The ceiling system forms a continuous membrane, a smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling and the space above the ceiling is not used as a plenum. Smoke partition doors shall be at 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 Il Based on observation and interview during the fire safety inspection process, the facility failed to ensure the smoke stop partition doors would properly close during fire alarm activation. The facility census was seven. This deficiency affects seven of seven residents. Observation of the operation of the double smoke partition doors revealed that the lower latching Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 GF6311 If continuation sheet 1 of 2 PRINTED: 08/20/2025 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 33537 B. WING 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2694 FOX CREST DRIVE WASHINGTON, MO 63090 (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) ASPEN VALLEY FOX CREST Continued From page 1 mechanism was dragging and preventing the doors from fully closing. During the exit interview on February 6, 2025 at 1145, the administrator advised she would have maintenance repair the doors to ensure they will close properly. Missouri Department of Health and Senior Services STATE FORM Sens GF6311 If continuation sheet 2 of 2 PRINTED: 06/09/2025 Missouri Department of Health and Senior Services FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: COMPLETED 33537 R B. WING 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASPEN VALLEY FOX CREST 2604 FOX CREST ORIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL PROVIDER'S PLAN OF CORRECTION REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 19 CSR 30-86.022(10)(J) Smoke Section Partitions < than 20 beds Protection from Hazards. (J) In all facilities that were initially licensed on or prior to December 31, 1987, and all facilities licensed for twenty (20) or fewer beds prior to August 28, 2007, each smoke section shall be separated by a one- (1-) hour fire-rated smoke partition that extends from the inside portion of an exterior wall to the inside portion of an exterior wall and from the floor to the underside of the floor or roof deck above, through any concealed Spaces, such as those above suspended ceilings, and through interstitial structural and mechanical Spaces. Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspending ceiling system where the following conditions are met: The ceiling system forms a continuous membrane, a smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling and the space above the ceiling is not used as a plenum. Smoke partition doors shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door clases automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated February 6, 2025. Based on observation and interview, the facility failed ta ensure the smoke stop partition doors properly closed during a manual door closure test. This deficiency has the potential to affect all residents. The facility census was ten. Observation on 06/05/2025 at 12:05 PM, during Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (%6) DATE STATE FORM = GF6312 \f continuation sheet 1 of 3 Scanned with CamScanner 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: 06/09/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 06/05/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2694 FOX CREST DRIVE WASHINGTON, MO 63090 ASPEN VALLEY FOX CREST (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A2265}| Continued From page 1 the operation of the double smoke partition doors closing showed the door was dragging on the floor and preventing the doors from fully closing. During interview on 06/5/2025 at 12:20 PM, the administrator said the owner's were out of town and would repair the doors upon their return. Review of 2000 NFPA 101 8.2.4 Smoke Partitions showed the following: 8.2.4.1 Where required elsewhere in this Code, smoke partitions shall be provided to limit the transfer of smoke. 8.2.4.2 Smoke partitions shall extend from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces. 8.2.4.3 Doors. 8.2.4.3.1 Doors in smoke partitions shall comply with 8.2.4.3.2 through 8.2.4.3.5. 8.2.4.3.2 Doors shall comply with the provisions of 7.2.1. 8.2.4.3.3 Doors shall not include louvers. 8.2.4.3.4* Door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. (NFPA 80) 6.1.4.2.1 Self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened. 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) {A2265} If continuation sheet 2 of 3 oes? GF6312 PRINTED: 06/09/2025 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. SU LURiRee COMPLETED R 06/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2694 FOX CREST DRIVE WASHINGTON, MO 63090 (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) ASPEN VALLEY FOX CREST {A2265}| Continued From page 2 {A2265} 8.2.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. Missouri Department of Health and Senior Services STATE FORM 6899 GF6312 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Suppl Aspen Valley Fox Crest ier Name: Street Address, 2694 Fox Crest Drive Washington, MO 63090 City, Zip: ~ PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETI ON DATE ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Maintenance/Owners adjusted the door in order for 6/10/25 smoke partition doors to latch completely by tightening the tension screws on the door closer. Maintain an Emergency Preparedness binder which 6/10/25 includes monthly fire drills. During each fire drill the double smoke partition doors will be assessed for proper functioning. If they are not functioning properly, maintenance/owners will be notified. The building task that was added to the electronic charting 6/18/25 system of Aspen Valley Fox Crest for staff to close fire doors 1x/week and document completion and outcome in order to ensure double smoke partition doors are functioning properly between monthly fire drills following the 2/6/25 deficiency HAS BEEN UPDATED TO A DAILY TASK. Any malfunction noticed will be reported to maintenance/owners at that time. Educate current staff to improve accuracy of identifying 6/27/25 complete door closure in order to report observed malfunction as needed. Include how to check fire door closure and report problems in 6/18/25 the new staff orientation. Brad Brewer, owner, is contacting the door company for an 7/03/25 appointment to review corrective changes that have been made and will evaluate if additional replacement parts are needed. 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.