ASPEN VALLEY .

2249 · 1

→2025-02-27

4751 · 2

→2024-04-15

No findings

→2024-01-31

No findings

→2023-11-27

View raw inspection records →

2249 · 3

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Tour Prep

Questions to ask before you visit.

A short pre-tour checklist tailored to ASPEN VALLEY's record and state requirements.

01 /

The facility has 6 deficiencies on file across all inspections — can you provide your corrective-action plans for each cited item, and show families any documentation of remediation steps taken?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

02 /

The March 12, 2025 inspection is the most recent visit on file — can you provide the deficiency notice from that inspection and walk through what was cited and how each item was addressed?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

03 /

The facility is licensed for 14 beds and advertises memory care — can you provide the written dementia-care program required by Title 22 §87705, and confirm it is actively implemented for all residents with cognitive impairment?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

Full Inspection Record

Every inspection visit, verbatim.

5 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.

reports on file

total deficiencies

2025-03-12

Annual Compliance Visit

2249 · 1 finding

224919 CSR §2249

Verbatim citation text · 19 CSR §2249

“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 seven. This deficiency affects seven of seven residents. Record review of the annual fire alarm testing and inspection report revealed deficiencies that have not been corrected. During the exit interview on March 12, 2025 at 4150, the Director of Nursing stated she would notify the director. DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE LABORATORY WIeE5 A rtd, tLatot fowte B/1t jes = If continuation sheet 1 of 1 Scanned with CamScanner PLAN OF CORRECTION Provider/Supplier Name: Aspen Valley City, Zip: 1888 East 9"* Street Washington, MO 63090 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER Roe ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE In order to ensure that the deficient practice does not recur, all Upon owners will read and sign the annual and semi-annual system completion of testing reports to ensure no action is needed or recommended inspections in action is completed. June and December of 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. Scanned with CamScanner”

Read raw inspector notes

PRINTED: 03/13/2025 . FORM APPROVED artment of Health and Senior Services (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: Missouri Dep STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: aad 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1888 EAST 9TH STREET ASPEN VALLEY WASHINGTON, MO 63090 (x4) 1D 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) 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: 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 seven. This deficiency affects seven of seven residents. Record review of the annual fire alarm testing and inspection report revealed deficiencies that have not been corrected. During the exit interview on March 12, 2025 at 4150, the Director of Nursing stated she would notify the director. Missouri Department of Health and Senior Services DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE LABORATORY WIeE5 A rtd, tLatot fowte B/1t jes = If continuation sheet 1 of 1 STATE FORM KSOU11 Scanned with CamScanner PLAN OF CORRECTION Provider/Supplier Name: Aspen Valley Street Address, ¥ ; City, Zip: 1888 East 9"* Street Washington, MO 63090 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER Roe ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE In order to ensure that the deficient practice does not recur, all Upon owners will read and sign the annual and semi-annual system completion of testing reports to ensure no action is needed or recommended inspections in action is completed. June and December of 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. Scanned with CamScanner

2025-02-27

Annual Compliance Visit

4751 · 2 findings

475119 CSR §4751

Verbatim citation text · 19 CSR §4751

“Based on interview and record review, facility Staff failed to update the community based assessment ((CBA) a required assessment tool completed by certified facility staff) for two (Resident #1 and #2) of three sampled residents, when the residents had a significant change in | condition. The facility census was 7. 1. The facility did not provide a policy in regards to CBA's.., 2. Review of Resident #1's mecical record showed the resident admitted to the facility on 1/27/2023, Review of the resident's nurses note, dated 2/13/2023, showed staff documented the resident admitted on hospice services. Review of the resident's CBA, dated 7/22/23, issouri Department of Health and Senior Services sii MW4X11 If continuation sheef 1 of 4 Scanned with CamScanner Missouri Department of Health and Senior Services 32779 {X2} MULTIPLE CONSTRUCTION 1888 EAST 9TH STREET ASPEN VALLEY AATS1 WASHINGTON, MO 63030 showed the CBA did not contain documentation of the resident's admission on hospice or hospice provider services. 3. Review of Resident #2's medical record showed the resident admitted to the facility on 4/3/2024. Review of the resident's nurses note, dated 7/22/2024, showed staff documented the resident admitted on hospice services. Review of the resident's CBA, dated 10/3/2024, showed the CBA did not contain documentation of the resident's admission on hospice or hospice provider services. 4. During an interview on 2/27/2025 at 3:37 P.M., the administrator said he/she is responsible to ensure the CBA's are completed with a change in a resident's condition. The administrator said we have three qualified staff who can complete the CBA’'s but there is one person in charge to complete and update the CBA's as needed. The administrator said he/she is to ensure the resident's CBA is documented.”

475519 CSR §4755

Verbatim citation text · 19 CSR §4755

“Based on interview and record review, facility staff failed to update a change in condition of the resident's Individual Service Plan (ISP) a required assessment tool identifying the individual needs of the residents and completed by qualified facility staff) who had significant changes in their condition which required additional services and treatment for two (Resident #1 and #2) out of three sampled residents. The facility census was 7. 1. The facility did not provide an ISP policy. 2. Review of Resident #1's medical record showed the resident admitted to the facility on 1/27/2023. Review of the resident’s nurses note, dated 2/13/2024, showed staff documented the resident admitted on hospice. Review of the resident's ISP, dated 1/15/2025, showed the ISP did not contain documenation he/she admitted to hospice. 3. Review of Resident #2's medical record showed the resident admitted to the facility on 4/3/2024. Review of the resident's nurses note, dated 7/22/2024, showed staff documented the resident's admitted on hospice. Review of the resident's ISP, dated 4/9/2024, showed the ISP did not contain documenation MW4X11 (X3} DATE SURVEY COMPLETED 02/27/2025 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} 32779 B.WING 02/27/2025 1888 EAST 9TH STREET WASHINGTON, MO 63090 DEFICIENCY} ASPEN VALLEY A4755 Continued From page 3 he/she admitted to hospice on 7/22/2024. 4. During an interview on 2/27/2025 at 3:37 P.M., the administrator said he/she is responsible to ensure the ISP's are updated and document the resident's change in condition. The administrator said he/she was unaware Resident #1 and Resident #2's ISP did not reflect the update on their change in condition. PLAN OF CORRECTION Provider/Supplier Name: Aspen Valley City, Zip: 1888 East 9" Street Date of Survey: 02/27/2025 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 A new policy titled Community Based Assessment and Individualized Service Plan-Significant Change developed, A4751 reviewed and signed by the person responsible for completion. 3/16/25 This includes the Administrator, Director, and Director of Nursing. Residents #1 and # 2 update CBA to identify changes in 3/16/25 condition for hospice services. The new written policy will carryover to all ISP and CBA to be completed in combination when there is a change in condition 3/16/25 which includes admission to hospice care. Aspen Valley will monitor its performance to make sure that initial audit solutions are sustained by completing quarterly audits of all completed by residents CBA. 3/16/25 A new policy titled Community Based Assessment and Individualized Service Plan-Significant Change developed, A4755 reviewed and signed by the person responsible for completion. 3/16/25 This includes the Administrator, Director, and Director of Nursing. Residents #1 and #2 update ISP to identify changes in condition : , 3/16/25 for hospice services. The new written policy will carryover to all ISP and CBA to be completed in combination when there is a change in condition 3/16/25 which includes admission to hospice. Aspen Valley will monitor its performance to make sure that initial audit solutions are sustained by completing quarterly audits of all completed by residents ISP. 3/16/25 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.”

Read raw inspector notes

PRINTED: 03/11/2025 FORMAPPROVED (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING: (X1) PROVIDER/SUPPLIER/CLIA STATEMENT OF DEFICIENCIES IDENTIFICATION NUMBER: AND PLAN OF CORRECTION B. WING 02/27/2025 32779 STREET ADORESS, CITY, STATE, ZIP CODE 4888 EAST 9TH STREET ASPEN VALLEY WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES NAME OF PROVIDER OR SUPPLIER PROVIDER'S PLAN OF CORRECTION erp OULD BE EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SH oo REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REF mg tg APPROPRIATE DATE A4751 19 CSR 30-86.047(28)(F)(1)(C) Community | Based Assessment-Significant Change The facility may admit or retain an individual for residency in an assisted living facility only if the | individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this | rule: 1. Time frame requirements for assessment shall be: C. Whenever a significant change has occurred in the resident's condition, which may require a change in services. Il This regulation is not met as evidenced by: Class II Based on interview and record review, facility Staff failed to update the community based assessment ((CBA) a required assessment tool completed by certified facility staff) for two (Resident #1 and #2) of three sampled residents, when the residents had a significant change in | condition. The facility census was 7. 1. The facility did not provide a policy in regards to CBA's.., 2. Review of Resident #1's mecical record showed the resident admitted to the facility on 1/27/2023, Review of the resident's nurses note, dated 2/13/2023, showed staff documented the resident admitted on hospice services. Review of the resident's CBA, dated 7/22/23, issouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM Lalor, = = a as sii MW4X11 If continuation sheef 1 of 4 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 32779 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING STREET ADDRESS, CITY, STATE, ZiP CODE 1888 EAST 9TH STREET ASPEN VALLEY AATS1 WASHINGTON, MO 63030 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 showed the CBA did not contain documentation of the resident's admission on hospice or hospice provider services. 3. Review of Resident #2's medical record showed the resident admitted to the facility on 4/3/2024. Review of the resident's nurses note, dated 7/22/2024, showed staff documented the resident admitted on hospice services. Review of the resident's CBA, dated 10/3/2024, showed the CBA did not contain documentation of the resident's admission on hospice or hospice provider services. 4. During an interview on 2/27/2025 at 3:37 P.M., the administrator said he/she is responsible to ensure the CBA's are completed with a change in a resident's condition. The administrator said we have three qualified staff who can complete the CBA’'s but there is one person in charge to complete and update the CBA's as needed. The administrator said he/she is to ensure the resident's CBA is documented. 19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: {H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident *s condition which may require a change in Missouri Department of Health and Senior Services STATE FORM PRINTED: 03/11/2025 FORM APPROVED (X3} DATE SURVEY COMPLETED 02/27/2025 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE ed MW4X11 if continuation sheet 2 of 4 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 32779 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING 1888 EAST 9TH STREET ASPEN VALLEY AATSS WASHINGTON, MO 63030 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 services: Il This regulation is not met as evidenced by: Class Il Based on interview and record review, facility staff failed to update a change in condition of the resident's Individual Service Plan (ISP) a required assessment tool identifying the individual needs of the residents and completed by qualified facility staff) who had significant changes in their condition which required additional services and treatment for two (Resident #1 and #2) out of three sampled residents. The facility census was 7. 1. The facility did not provide an ISP policy. 2. Review of Resident #1's medical record showed the resident admitted to the facility on 1/27/2023. Review of the resident’s nurses note, dated 2/13/2024, showed staff documented the resident admitted on hospice. Review of the resident's ISP, dated 1/15/2025, showed the ISP did not contain documenation he/she admitted to hospice. 3. Review of Resident #2's medical record showed the resident admitted to the facility on 4/3/2024. Review of the resident's nurses note, dated 7/22/2024, showed staff documented the resident's admitted on hospice. Review of the resident's ISP, dated 4/9/2024, showed the ISP did not contain documenation Missouri Department of Health and Senior Services STATE FORM CROSS-REFERENCED TO THE APPROPRIATE MW4X11 PRINTED: 03/11/2025 FORM APPROVED (X3} DATE SURVEY COMPLETED 02/27/2025 STREET ADDRESS, CITY, STATE, ZiP CODE PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} if continuation sheet 3 of 4 PRINTED: 03/11/2025 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 32779 B.WING 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1888 EAST 9TH STREET WASHINGTON, MO 63090 (X4) 1D 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 A4755 Continued From page 3 he/she admitted to hospice on 7/22/2024. 4. During an interview on 2/27/2025 at 3:37 P.M., the administrator said he/she is responsible to ensure the ISP's are updated and document the resident's change in condition. The administrator said he/she was unaware Resident #1 and Resident #2's ISP did not reflect the update on their change in condition. Missouri Department of Health and Senior Services STATE FORM 5899 MW4X11 if continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: Aspen Valley Street Address, th City, Zip: 1888 East 9" Street Date of Survey: 02/27/2025 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 A new policy titled Community Based Assessment and Individualized Service Plan-Significant Change developed, A4751 reviewed and signed by the person responsible for completion. 3/16/25 This includes the Administrator, Director, and Director of Nursing. Residents #1 and # 2 update CBA to identify changes in 3/16/25 condition for hospice services. The new written policy will carryover to all ISP and CBA to be completed in combination when there is a change in condition 3/16/25 which includes admission to hospice care. Aspen Valley will monitor its performance to make sure that initial audit solutions are sustained by completing quarterly audits of all completed by residents CBA. 3/16/25 A new policy titled Community Based Assessment and Individualized Service Plan-Significant Change developed, A4755 reviewed and signed by the person responsible for completion. 3/16/25 This includes the Administrator, Director, and Director of Nursing. Residents #1 and #2 update ISP to identify changes in condition : , 3/16/25 for hospice services. The new written policy will carryover to all ISP and CBA to be completed in combination when there is a change in condition 3/16/25 which includes admission to hospice. Aspen Valley will monitor its performance to make sure that initial audit solutions are sustained by completing quarterly audits of all completed by residents ISP. 3/16/25 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.

2024-04-15

Annual Compliance Visit

No findings

2024-01-31

Annual Compliance Visit

No findings

2023-11-27

Annual Compliance Visit

2249 · 3 findings

224919 CSR §2249

Verbatim citation text · 19 CSR §2249

“Based on record review and interview during the | fire safety inspection process on November 27, | 2023 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 November 27, 2023 was twelve (12). This deficiency affects twelve (12) of twelve (12) residents. | Record review on November 27, 2023 at 1100 | reveled no semi-annual inspection had been | performed on the fire alarm system. | During an interview on November 27, 2023 at 1105 the administrator stated she thought they had a contract with the alarm company, but no | inspections had been performed. She was going to | contact the company and find out why. As they needed an annual inspection, they would do that first and schedule a semiannual 6 months later. A2250|”

225019 CSR §2250

Verbatim citation text · 19 CSR §2250

“Based on review and interview during the fire safety inspection process on November 27, 2023 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 November 27, 2023 was twelve (12). This deficiency affects twelve (12) of twelve (12) residents. Record review on November 27, 2023 at 1110 revealed the last annual fire alarm inspection and certification was completed June 22, 2022, during the acceptance test. During an interview on November 27, 2023 at 1115 the administrator stated she thought they had a contract with the alarm company, but no inspections had been performed. She was going to contact the company and find out why. They will schedule an annual inspection immediately and schedule a semiannual 6 months later.”

227419 CSR §2274

Verbatim citation text · 19 CSR §2274

“Based on record review and interview during the fire safety inspection process on November 27, 2023 the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census November 27, 2023 was twelve (12). This deficiency affects twelve (12) of twelve (12) residents. Record review on November 27, 2023 at 1120 revealed no current annual sprinkler inspection. An acceptance test in June of 2022 was the last test. During an interview on November 27, 2023 at 1125 the administrator stated she thought they had a contract with the sprinkler company, but no inspections had been performed. She was going to contact the company and find out why. They will schedule an annual inspection immediately. 6899 9R12Z11 COMPLETED 11/27/2023 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE DEFICIENCY COMPLETE DATE PLAN OF CORRECTION Provider/Supplier Name: City, Zip: Date of Survey: A2250 Aspen Valley 1888 East 9th Street Washington, MO 63090 11/27/23 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY A2249 Semi-Annual inspection will be scheduled at the annual fire alarm inspection. Currently scheduled for June 5, 2024. Contract with Tech Electronics includes communication to Aspen Valley for scheduled semi-annual inspections. Maintain a maintenance calendar with a semi-annual inspection date recorded. Monthly, during Aspen Valley owners meeting, review scheduled maintenance program with follow up calls made as needed to confirm appointment for semi-annual fire alarm system inspection. Annual fire alarm inspection completed 12/7/23 and 12/11/23. Annual fire alarm inspection will be scheduled for December at time of semi annual fire alarm inspection. Contract with Tech Electronics includes communication to Aspen Valley for scheduled annual inspections. Maintain a maintenance calendar with an annual inspection date recorded. Monthly, during Aspen Valley owners meeting, review scheduled maintenance program with follow up calls made as needed to confirm appointment for annual fire alarm system inspection. Annual sprinkler inspection completed November 28, 2023. Schedule the next annual inspection at the time of the current annual inspection. Currently scheduled for November 18, 2024. Contract with Ozark Fire Sprinkler includes communication to Aspen Valley to schedule the annual inspection. Maintain a maintenance calendar with an annual inspection due date recorded. Monthly, during Aspen Valley owners meeting, review scheduled maintenance program with follow up calls made as needed to confirm an appointment for annual sprinkler system inspection. COMPLETION DATE 12/12/23 12/12/23 12/12/23 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.”

Read raw inspector notes

Neen PRINTED: 12/04/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONST RUCTION A. BUILDING: me 11/27/2023 B. WING 32779 STREET ADDRESS. CITY. STATE, ZIP CODE 4688 EAST 9TH STREET WASHINGTON, MO 63090 I PROVIDER'S PLAN OF CORRECTION { 5) NAME OF PROVIDER OR SUPPLIER ASPEN VALLEY x4 MAR FICIENCIES | 1D coMPLETE ae I ipl sor elm | pReFIx | (EACH CORRECTIVE ACTION SHOULD BE | ate PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL oe oa enitmenaracroie TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG | DEFICIENCY —_ 19 CSR 30-86.022(9)(C) Fire Alarm | A2249 | 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/Il j | This regulation is not met as evidenced by: Class II { | Based on record review and interview during the | fire safety inspection process on November 27, | 2023 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 November 27, 2023 was twelve (12). This deficiency affects twelve (12) of twelve (12) residents. | Record review on November 27, 2023 at 1100 | reveled no semi-annual inspection had been | performed on the fire alarm system. | During an interview on November 27, 2023 at 1105 the administrator stated she thought they had a contract with the alarm company, but no | inspections had been performed. She was going to | contact the company and find out why. As they needed an annual inspection, they would do that first and schedule a semiannual 6 months later. A2250| 19 CSR 30-86.022(9)(D) Fire Alarm System A2250 Inspections/Certifications | | Complete Fire Alarm Systems. | (D) All facilities shall have inspections and written | certifications of the complete fire alarm system Missourj Department of Health and Senior Services -ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Le A. bess. (6) DATE STATE FORM = eee wat Sr aror it 22/223 If continuation sheet 1 of 3 Scanned with CamScanner PRINTED: 12/04/2023 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 32779 $$$ i$ 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1888 EAST 9TH STREET WASHINGTON, MO 63090 (X4) 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 DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY ASPEN VALLEY 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 on November 27, 2023 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 November 27, 2023 was twelve (12). This deficiency affects twelve (12) of twelve (12) residents. Record review on November 27, 2023 at 1100 reveled no semi-annual inspection had been performed on the fire alarm system. During an interview on November 27, 2023 at 1105 the administrator stated she thought they had a contract with the alarm company, but no inspections had been performed. She was going to contact the company and find out why. As they needed an annual inspection, they would do that first and schedule a semiannual 6 months later. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 9R1Z11 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: A. BUILDING: 32779 NAME OF PROVIDER OR SUPPLIER 1888 EAST 9TH STREET ASPEN VALLEY WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 1 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 review and interview during the fire safety inspection process on November 27, 2023 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 November 27, 2023 was twelve (12). This deficiency affects twelve (12) of twelve (12) residents. Record review on November 27, 2023 at 1110 revealed the last annual fire alarm inspection and certification was completed June 22, 2022, during the acceptance test. During an interview on November 27, 2023 at 1115 the administrator stated she thought they had a contract with the alarm company, but no inspections had been performed. She was going to contact the company and find out why. They will schedule an annual inspection immediately and schedule a semiannual 6 months later. 19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. Sprinkler Systems. (F) All facilities shall have inspections and written certifications of the approved sprinkler system Missouri Department of Health and Senior Services STATE FORM 6899 9R12Z11 (X2) MULTIPLE CONSTRUCTION PRINTED: 12/04/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/27/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 32779 NAME OF PROVIDER OR SUPPLIER 1888 EAST 9TH STREET ASPEN VALLEY WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 2 completed by an approved qualified service representative in accordance with NFPA 25, 1998 edition. The inspections shall be in accordance with the provisions of NFPA 25, 1998 edition, with certification at least annually by a qualified service representative. I/II This regulation is not met as evidenced by: Class II Based on record review and interview during the fire safety inspection process on November 27, 2023 the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census November 27, 2023 was twelve (12). This deficiency affects twelve (12) of twelve (12) residents. Record review on November 27, 2023 at 1120 revealed no current annual sprinkler inspection. An acceptance test in June of 2022 was the last test. During an interview on November 27, 2023 at 1125 the administrator stated she thought they had a contract with the sprinkler company, but no inspections had been performed. She was going to contact the company and find out why. They will schedule an annual inspection immediately. Missouri Department of Health and Senior Services STATE FORM 6899 9R12Z11 (X2) MULTIPLE CONSTRUCTION PRINTED: 12/04/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/27/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: Street Address, City, Zip: Date of Survey: A2250 Aspen Valley 1888 East 9th Street Washington, MO 63090 11/27/23 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY A2249 Semi-Annual inspection will be scheduled at the annual fire alarm inspection. Currently scheduled for June 5, 2024. Contract with Tech Electronics includes communication to Aspen Valley for scheduled semi-annual inspections. Maintain a maintenance calendar with a semi-annual inspection date recorded. Monthly, during Aspen Valley owners meeting, review scheduled maintenance program with follow up calls made as needed to confirm appointment for semi-annual fire alarm system inspection. Annual fire alarm inspection completed 12/7/23 and 12/11/23. Annual fire alarm inspection will be scheduled for December at time of semi annual fire alarm inspection. Contract with Tech Electronics includes communication to Aspen Valley for scheduled annual inspections. Maintain a maintenance calendar with an annual inspection date recorded. Monthly, during Aspen Valley owners meeting, review scheduled maintenance program with follow up calls made as needed to confirm appointment for annual fire alarm system inspection. Annual sprinkler inspection completed November 28, 2023. Schedule the next annual inspection at the time of the current annual inspection. Currently scheduled for November 18, 2024. Contract with Ozark Fire Sprinkler includes communication to Aspen Valley to schedule the annual inspection. Maintain a maintenance calendar with an annual inspection due date recorded. Monthly, during Aspen Valley owners meeting, review scheduled maintenance program with follow up calls made as needed to confirm an appointment for annual sprinkler system inspection. COMPLETION DATE 12/12/23 12/12/23 12/12/23 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.