SOUTH POINTE ASSISTED LIVING.

PRINTED: 09/29/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: i cei 13735¢ 8. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SOUTH POINTE-ASSISTED LIVING BY AMERICARE A2253 19 CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults Complete Fire Alarm Systems. | | (G) Upon discovery of a fault with the complete | fire alarm system, the facility shall correct the fault, Wl This regulation is not met as evidenced by: Class I! | Based on observation and interview during the | fire safety inspection process, the facility failed to correct a fault with the complete fire alarm | system. The facility census was 27. This | deficiency affects 27 of 27 residents. Observation revealed the fire alarm control panel | for the Arbors indicating a trouble signal. During the exit interview on September 22, 2025 at 12:30 PM, the maintenance man advised the trouble was due to a new outside alarm for the sprinkler system and that he would contact the alarm company for an update on repairs. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for | furnace or boiler rooms. Hazardous areas | equipped with a complete sprinkler system are | Not required to have this one- (1-) hour fire | Separation, Doors to hazardous areas shall be 0 [2]aoas, Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13735C NAME OF PROVIDER OR SUPPLIER SOUTH POINTE-ASSISTED LIVING BY AMERICARE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 09/29/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 09/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults Complete Fire Alarm Systems. (G) Upon discovery of a fault with the complete fire alarm system, the facility shall correct the fault. I/II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the facility failed to correct a fault with the complete fire alarm system. The facility census was 27. This deficiency affects 27 of 27 residents. Observation revealed the fire alarm control panel for the Arbors indicating a trouble signal. During the exit interview on September 22, 2025 at 12:30 PM, the maintenance man advised the trouble was due to a new outside alarm for the sprinkler system and that he would contact the alarm company for an update on repairs. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 8MQ711 If continuation sheet 1 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13735C NAME OF PROVIDER OR SUPPLIER SOUTH POINTE-ASSISTED LIVING BY AMERICARE (X2) MULTIPLE CONSTRUCTION A. BUILDING: WASHINGTON, MO 63090 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 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, the facility failed to maintain self closing smoke partition doors that separate hazardous areas from residential areas. The facility census was 27. This deficiency affects 27 of 27 residents. Observation revealed the Arbors kitchen smoke partition roll door was disconnected from the fire alarm activated closing device and was open. Observation revealed the South Pointe facility laundry smoke partition door was open and did not have a self closure device. Observation revealed a stove, for resident use, in South Pointe that did not have the power secured and is not enclosed in a 1 hour rated room. Facilities that have a residential use stove setup like this, must have an exception from DHSS. During an interview on September 22, 2025 at 12:35 PM, the maintenance man advised no one on staff knew how to reset the roll door release. He is going to have the installers come and do an inservice on resetting the roll door. He further Missouri Department of Health and Senior Services STATE FORM 6899 8MQ711 PRINTED: 09/29/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13735C NAME OF PROVIDER OR SUPPLIER SOUTH POINTE-ASSISTED LIVING BY AMERICARE (X2) MULTIPLE CONSTRUCTION A. BUILDING: WASHINGTON, MO 63090 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 advised he would install a self closer on the laundry room door. The facility will make a decision regarding the resident use stove, but will lock out the power with a padlock for the time being. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/Il This regulation is not met as evidenced by: Class Il Based on observation and interview during the fire safety inspection process, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was 27. This deficiency affects 27 of 27 residents. Observation revealed loose escutcheon rings in the central TV room (3), room 19 (1), and the dry pantry (1) of South Pointe. Observation revealed missing escutcheon rings in the central TV room (1) and room 9 of South Pointe. Observation revealed a missing escutcheon ring in the facility laundry of the Arbors. These penetrations could allow smoke, fire and toxic gases to travel to unaffected areas on the Missouri Department of Health and Senior Services STATE FORM 6899 8MQ711 PRINTED: 09/29/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13735C NAME OF PROVIDER OR SUPPLIER SOUTH POINTE-ASSISTED LIVING BY AMERICARE (X2) MULTIPLE CONSTRUCTION A. BUILDING: WASHINGTON, MO 63090 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 building During the exit interview on September, 2025 at 12:40 PM the maintenance man advised he would check all the sprinkler heads within the facility to ensure the escutcheon rings are properly aligned and replace the missing escutcheon rings. 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 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 27. This deficiency affects 27 of 27 residents. Observation revealed a large 2' X 4' ceiling drywall collapse in the beauty shop due to a pin leak of South Pointe's sprinkler. Observation revealed 4' X 3" penetration of the ceiling drywall, along a seam in room 20, due to another pin leak of South Pointe's sprinkler. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. During the exit interview on September 22, 2025 Missouri Department of Health and Senior Services STATE FORM 6899 8MQ711 PRINTED: 09/29/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 5 PRINTED: 09/29/2025 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 13735C —ESESE———————s 09/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 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) SOUTH POINTE-ASSISTED LIVING BY AMERICARE Continued From page 4 at 12:45 PM, the maintenance man stated they can't repair the drywall until the sprinkler company repairs the leaks. Missouri Department of Health and Senior Services STATE FORM 6899 8MQ711 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: Americare South Pointe and Americare South Pointe Memory Care 5125 and $129 Old Highway 100, Washington, MO 63090 Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIF ICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REF ERENCED aaa “s TO THE APPROPRIATE DEFICIENCY | This plan of correction (POC) is submitted as required under State law. The submission of the POC does not constitute an admission on the part of Americare South Pointe and Americare South Pointe Memory Care (the Facility) as to the accuracy of neither the inspector’s findings, nor the conclusions drawn there from. The Facility’s submission of the POC does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency, or the scope and severity regarding any deficiencies cited are correctly applied. This POC is intended to constitute the Facility’s credible letter alleging compliance. Loses | RS SR CT ee erreey The facility will contact the monitoring company and have them update the fire alarm system to ensure all areas are included and that the trouble signal for the Memory Care is corrected. To identify other areas at risk of similar issues, the maintenance department will conduct a complete inspection of all fire alarm panels throughout the facility to verify proper operation and documentation. To ensure this deficient practice does not recur, the maintenance team 10/28/2025 will perform and document scheduled checks of the alarm panels, in addition to responding promptly to any panel trouble signals when they arise. All staff will be in-serviced on the requirement to immediately report and escalate any trouble indicators. The Executive Director will review the documented alarm panel checks will be completed by October 28", 2025, to confirm ongoing compliance. All corrective action for this deficiency Loewen Weenie once pemmecenmemem ee The facility will have the alarm vendor reconnect the Arbors kitchen smoke partition roll door to the fire alarm system and will provide an in- service for staff on how to reset the roll door release. A self-closer will be installed on the South Pointe ALF laundry room door to ensure it remains compliant, and the resident-use stove will have the power Jocked out with a padlock until a final determination is made to either remove the stove or obtain an exception from DHSS, To identify other areas with similar risk, the maintenance department will conduct a full inspection of all smoke partition doors, hazardous areas, and resident-use appliances throughout the facility to ensure the 10/28/2025 are properly enclosed, self-closing, and regulations. To prevent recurrence, the facility will include a scheduled hazardous- area door and equipment check to the preventive maintenance program, and all staff will be in-serviced on the requirement to keep hazardous area doors closed and report any malfunctions. All corrective actions for this deficiency will be completed by October 28", 2025. ae The facility will inspect all sprinkler heads in both South Pointe and the Memory Care to ensure that escutcheon rings are present, properly aligned, and secured. All missing and loose escutcheon rings identified during the inspection will be replaced or corrected to prevent the spread of smoke, fire, or toxic gases into unaffected areas. To identify other potential deficiencies, the maintenance team will complete a full walkthrough of the building to check every sprinkler component and document the condition of all escutcheon rings. To ensure this deficient practice does not recur, the facility will incorporate checking escutcheon rings in documented sprinkler and escutcheon inspection into the preventive maintenance schedule. The Executive Director will review the monthly logs and verify compliance during monthly safety committee meetings. All corrective actions for this deficiency will be completed by October 28", 2025. The facility will coordinate with the sprinkler company/vendor to repair the identified pin leaks in the system so that the affected areas in the beauty shop and resident rooms can be fully restored. Once the sprinkler repairs are completed, licensed contractors will repair and seal the ceiling drywall to restore the one-hour fire resistance and eliminate penetrations that could allow smoke, fire, or gases to travel to unaffected portions of the building. To identify other potential areas at risk, the maintenance department will perform a building-wide inspection of ceilings and walls for any water damage or penetrations related to sprinkler leaks and will document the results. To prevent recurrence, the facility will add a visual ceiling inspection to the maintenance walkthrough and require that any signs of water damage or structural compromise be reported and addressed within 24 hours. The Executive Director will review the maintenance logs weekly and discuss any findings during safety committee meetings to ensure continued compliance. All corrective actions for this deficiency will be mpleted by October 28", 2025. compliant with fire safety 10/28/2025 A2269 10/28/25 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.

PRINTED: 04/17/2025 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 13735C B.WING 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 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} SOUTH POINTE-ASSISTED LIVING BY AMERIC A2238 19 CSR 30-86.022(8)(C) Exit Sign-lllumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. IVIH This regulation is not met as evidenced by: Class Hil Based on observation and interview during the fire safety inspection process, the facility failed to ensure all exit signs were operational. The facility census was twenty-eight. This deficiency affects twenty-eight of twenty-eight residents. Observation revealed an exit sign failed to illuminate while depressing the test button at the rear center exit of the Arbor's. During the exit interview on September 3, 2024 at 1540, the Administrator stated she would have the exit sign repaired. 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. VII This regulation is not met as evidenced by: Class fi 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, Missouri Department of Health arid Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 12/18/24 STATE FORM 6899 6I7V11 if continuation sheet 1 of 6 PRINTED: 04/17/2025 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 13735C B.WING 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 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} SOUTH POINTE-ASSISTED LIVING BY AMERIC A2249 Continued From page 1 1999 ed. The facility census was twenty-eight. This deficiency affects twenty-eight of twenty-eight residents. Record review revealed no semi-annual inspection had been performed on the fire alarm system since April of 2023. During the exit interview on September 3, 2024 at 1545 the Administrator stated she had been on out for an extended period, due to a family health crisis, and that the person replacing her should have had this done, but she could not find the reports. 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/ll This regulation is not met as evidenced by: Class Il 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 twenty-eight. This deficiency affects twenty-eight of twenty-eight residents. Record review revealed the last annual fire alarm Missouri Department of Health arid Senior Services STATE FORM B99 6I7V11 if continuation sheet 2 of 6 PRINTED: 04/17/2025 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 13735C B.WING 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 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} SOUTH POINTE-ASSISTED LIVING BY AMERIC A2250 Continued From page 2 inspection and certification was completed in February of 2023 During the exit interview on September 3, 2024 at 1550 the Administrator stated she had been on out for an extended period, due to a family health crisis, and that the person replacing her should have had this done, but she could not find the reports. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. {A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. 11 This regulation is not met as evidenced by: Class Il Missouri Department of Health arid Senior Services STATE FORM B99 6I7V11 if continuation sheet 3 of 6 PRINTED: 04/17/2025 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 13735C B.WING 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 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} SOUTH POINTE-ASSISTED LIVING BY AMERIC A2256 Continued From page 3 Based on observation and interview during the fire safety inspection process, the sprinklered facility, licensed for more than twelve (12) beds on or after November 13, 1980, failed to provide separation from a hazardous area with self-closing, smoke-resistant partitions or doors. The facility census was twenty-eight. This deficiency affects twenty-eight of twenty-eight residents. Observation revealed that the door to the center hallway water heater room of South Pointe was a sliding wood door, 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 gaps around the doors, so they do not provide the required separation between the mechanical room and a resident corridor. Observation revealed that the two doors to the mechanical room,off the center seating and TV room of South Pointe, are both hollow core doors and do not have self closure devices. Observation revealed that the resident laundry room door of South Pointe, does not have a self closure device. Observation revealed that the service window of the kitchen of the Arbors does not have a roll door attached to the fire alarm. This window is always open and will not prevent the passing of smoke to the resident areas of the facility. Observation revealed that the doors to mechanical rooms 3 and 4 of the Arbors do not have self closure devices. Missouri Department of Health arid Senior Services STATE FORM B99 6I7V11 if continuation sheet 4 of 6 PRINTED: 04/17/2025 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 13735C B.WING 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 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} SOUTH POINTE-ASSISTED LIVING BY AMERIC A2256 Continued From page 4 During the exit interview on September 3, 2024 at 1555 the Administrator stated they had always been that way, but they would make the appropriate changes. 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 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/ll This regulation is not met as evidenced by: Class Il Based on observation, record review, and interview during the fire safety inspection process, the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census was twenty-eight. This deficiency affects twenty-eight of twenty-eight residents. Record review revealed no current annual sprinkler inspection on file for review. The last annual report was from January of 2023. During the exit interview on September 3, 2024 at 1600 the Administrator stated she had been on out for an extended period, due to a family health crisis, and that the person replacing her should have had this done, but she could not find the reports. Missouri Department of Health arid Senior Services STATE FORM B99 6I7V11 if continuation sheet 5 of 6 PRINTED: 04/17/2025 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 13735C B.WING 09/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 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} SOUTH POINTE-ASSISTED LIVING BY AMERIC A2298 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. H/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 oxygen storage shall be in accordance with NFPA 99, 1999 Edition. The facility census was twenty-eight. This deficiency affects twenty-eight of twenty-eight residents. Observation on revealed no "Oxygen Storage” signage on the door of South Pointe room 7. Observation revealed an unsecured, standing oxygen cylinder in South Pointe room 7. Observation revealed an unsecured, standing oxygen cylinder in Arbors room 2. During the exit interview on September 3, 2024 at 1605, the Administrator stated she would place the appropriate signage on the door and have the loose oxygen cylinders stored properly in a rack. Missouri Department of Health arid Senior Services STATE FORM B99 6I7V11 if continuation sheet 6 of 6 THE PLAN OF CORRECTION WAS REJECTED AND NEVER APPROVED, THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 12/14/2023 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 13735C | ae 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY SOUTH POINTE-ASSISTED LIVING BY AMERICARE A2282 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant | Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. !I | This regulation is not met as evidenced by: | Class II Based on observation and record review during the fire safety inspection process on December 4, 2023 the facility failed to ensure all curtains and drapes in a licensed facility are certified or treated with flame-resistant material as defined in NFPA 101, 2000 edition. The facility census on December 4, 2023 was twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine (29) residents. Observation on December 4, 2023 revealed curtains and window coverings throughout the facility, the curtains showed no tags attached of _ being manufactured with, or being treated with a flame resistant material. | Record review on December 4, 2023 at 1132 revealed that although the facility had created a Flame Retardant Spray Tracking form, it has never been used. During the exit interview on December 4 2023 at 1135 the maintenance man stated he would treat the curtains and maintain the log. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE ‘acy Yasser {PLWHA het 23 STATE FORM 63 = SE9E11 If continuation sheet 1 of 6 NAME OF PROVIDER OR SUPPLIER SOUTH POINTE-ASSISTED LIVING BY AMERICARE (X4) ID PREFIX TAG Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 13735C (X2) MULTIPLE CONSTRUCTION A, BUILDING: B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A2286 | Continued From page 1 Missouri Department of Health and Senior Services STATE FORM Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire safety inspection process on December 4, 2023 the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being | used for trash. The facility census on December 4, 2023 was twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine (29) residents. Observation on December 4, 2023 at 1050 revealed an unapproved wastebasket in use in the resident use kitchen. During an interview on December 4, 2023 at 1105 the maintenance man stated he would remove the wastebasket. 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 This regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire safety inspection process on December 4, 2023, the facility failed to maintain the structure in good ID PREFIX TAG SE9E11 (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE PRINTED: 12/14/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/04/2023 PROVIDER'S PLAN OF CORRECTION (x5) COMPLETE DATE DEFICIENCY If continuation sheet 2 of 6 PRINTED: 12/14/2023 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 13735C B. WING 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE mae SOUTH POINTE-ASSISTED LIVING BY AMERICARE A3201 Continued From page 2 repair by allowing penetrations of horizontal and vertical smoke partitions. The facility census on December 4, 2023 was twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine (29) residents. Observation on December 4, 2023 at 1027 revealed gaps around vents and pipes in the walls and ceilings of the central mechanical room of the _ South Pointe building Observation on December 4, 2023 at 1057 revealed two (2) holes in the closet wall of room F3 in the South Pointe Building. Observation on December 4, 2023 at 1206 revealed a hole in the wall, behind the door entering the laundry room, in the Arbors building. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the | building During the exit interview on December 4, 2023 at 1215 the maintenance man stated he would make the needed repairs. 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 Missouri Department of Health and Senior Services STATE FORM S809 SE9E11 If continuation sheet 3 of 6 PRINTED: 12/14/2023 ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X38) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED 13735C Bo WING 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 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 to TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY SOUTH POINTE-ASSISTED LIVING BY AMERICARE A3214 Continued From page 3 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 Ill Based on record review and interview during the fire safety inspection process on December 4, 2023 the facility failed to ensure the facility's electric wiring was properly maintained. The facility census on December 4, 2023 was twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine (29) residents. Observation on December 4, 2023 at 1027 revealed a smoke/heat detector hanging by wiring in the central mechanical room of South Pointe | building. Record review on December 4, 2023 at 1130 revealed no electrical wiring inspection report for review on either building. During the exit interview on December 4, 2023 at 1130 the maintenance man stated he would get Missouri Department of Health and Senior Services STATE FORM 6899 SE9E11 If continuation sheet 4 of 6 PRINTED: 12/14/2023 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 13735C —— 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE | | DEFICIENCY SOUTH POINTE-ASSISTED LIVING BY AMERICARE A3214 | Continued From page 4 the detector mounted back in place and have an electrical wiring inspection scheduled. 19 CSR 30-87.020(25) Plumbing per Code Plumbing shall be sized, installed and maintained according to the National Plumbing Code. II/III This regulation is not met as evidenced by: | Class III Based on observation and interview during the fire safety inspection process on December 4, 2023 the facility failed to maintain plumbing in accordance to the National Plumbing Code. The facility census on December 4, 2023 was | twenty-nine (29). This deficiency affects twenty-nine (29) of twenty-nine (29) residents. Observation on December 4, 2023 at 1018 revealed a water heater with a drip leg that terminated greater than 6 inches above the floor. Located in the sprinkler control valve mechanical room of the South Pointe building Observation on December 4, 2023 at 1032 revealed a water heater with a drip leg that terminated greater than 6 inches above the floor. Located in the mechanical room near room nineteen (19) of the South Pointe building. Observation on December 4, 2023 at 1151 revealed both water heaters with PVC drip legs of a decreased diameter to the pressure relief valve.. Located in mechanical room four (4) of the Arbors building Missouri Department of Health and Senior Services STATE FORM 6399 SE9E11 If continuation sheet 5 of 6 PRINTED: 12/14/2023 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 13735C Ce ee 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5125 OLD HWY 100 WASHINGTON, MO 63090 (X4) 1D | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY SOUTH POINTE-ASSISTED LIVING BY AMERICARE A6025 Continued From page 5 Drip legs should terminate less than six (6) inches above the floor. Drip legs must be of the same diameter of the pressure relief valve and made of copper, iron, steel, or rated PEX. During the exit interview on December 4, 2023 at | 1210 the maintenance man stated he would _ extend or replace the short drip legs and replace the PVC drip legs. Missouri Department of Health and Senior Services STATE FORM a SE9E11 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Name: South Pointe Assisted Living by Americare Street Address, City, Zip: 5125 Old Hwy 100 Washington, MO 63090 12/4/23 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ia ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE All campus window treatments received treatment of flame A2282 12/18/23 retardant spray and recorded on tracking form. All future changes in window treatments will have flame retardant tag A2286 12/20/23 12/20/23 remain intact or be treated immediately with flame retardant 12/18/23 spray and recorded on tracking log. After laundering window 12/26/23 Date of Survey: treatments all will be treated and recorded. This will be maintained by maintenance department and verified by administrator. All noncompliant wastebaskets that are not metal/UL/FM were removed from the campus and replaced with metal/UL/FM wastebaskets. Staff educated re: monitoring all resident areas for compliance. This is added to the monthly monitoring list for maintenance and will be monitored for compliance by administrator. All new resident's families will be educated to not bring in unapproved waste cans.Approved wastecans are ordered for kitchen and resident kitchen in the assisted living All gaps and holes repaired in noted areas of the central mechanical room and closet room F3 in the assisted living building and behind the laundry room door of the memory care. During rounds it will be monitored for any damage that would allow for penetration of horizontal and vertical smoke. If any damage is noted to walls and/or ceilings, this will immediately be repaired by the maintenance department or outside licensed contractor. Williams Electric performed the 2-year electrical inspection on 3/1/23 and full compliance noted. This record is maintained in the survey ready binder located in the administration office, with the tracking form located on the front inside sleeve. The leted inspection is located under subsection tab 12. The drip legs of the water heater located in the assisted living building and in the memory care were repaired by the maintenance department to meet the specific guidelines of terminating less than 6-inches from the floor and maintain same diameter as the pressure relief valve. The PVC piping was replaced by approved copper, iron, steel, rated PEX. These specifications will be kept on site to monitor for any future repairs and/or replacement. A3201 A6025 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.