WASHINGTON PLACE ASSISTED LIVING.

PRINTED: 07/14/2025 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 i? 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 (X4) ID | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X8) 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} VICTORIAN PLACE OF WASHINGTON, ASTLVNG BY / 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 Il 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 26. This deficiency affects 26 of 26 residents. Observation showed the fire alarm control panel with @ trouble signal on the panel, indicating a dirty photo detector outside room 27. During the exit interview on July 1, 2025 at 2:30 PM, the facility representative advised she would contact the alarm company for repairs. 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs } Emergency Lighting. | (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-haif (1 1/2) hours. 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 ensure all emergency lighting was operational. The facility census was 26. This deficiency affects 26 of 26 residents. Missouri Department of Health and Senior Services “LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 8899 L32911 If continuation sheet 1 of 2 ; _ Ve. AD ~ Prien estado 14 [2s PRINTED: 07/14/2025 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: COMPLETED A, BUILDING: B.WING 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2800 RABBIT TRAIL 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) VICTORIAN PLACE OF WASHINGTON, ASTLVNG BY / Continued From page 1 Observation revealed the emergency light/exit sign at exit 6, failed to illuminate while depressing the test button. Observation revealed emergency light #4 failed to illuminate while depressing the test button. During the exit interview on July 1, 2025 at 2:25 PM, the facility representative advised she would have the lights repaired. Missouri Department of Health and Senior Services STATE FORM seee 1329114 If continuation sheet 2 of 2 UNABLE TO LOCATE PLAN OF CORRECTION

A copy of the administrator signature to the 2567, was not found for the file. PRINTED: 10/31/2023 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 27659 $$$ i$ 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2800 RABBIT TRAIL DRIVE 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 VICTORIAN PLACE OF WASHINGTON, RES CARE AM 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility 's entire plan shall be provided to the local jurisdiction 's emergency management director. II/III This regulation is not met as evidenced by: Class III Based on record review and interview during the fire safety inspection process on October 25, 2023 the facility failed to request consultation and assistance annually or provide documentation the consultation had been scheduled from the local fire unit for review of fire and evacuation plans. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Record review on October 25, 2023 at 1240 revealed the last Fire Department consultation on file for review was dated in 2021. During an interview on October 25, 2023 at 1240 the maintenance manager stated she did have access to the all of the director's files and that they would request a consult if they don't already have a recent one. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 273J311 If continuation sheet 1 of 12 PRINTED: 10/31/2023 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 27659 $$$ i$ 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2800 RABBIT TRAIL DRIVE 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 VICTORIAN PLACE OF WASHINGTON, RES CARE AM Continued From page 1 19 CSR 30-86.022(8)(B) Exit-Directional Indicators Exit Signs. (B) Directional indicators showing the direction of travel shall be placed in corridors, passageways, or other locations where the direction of travel to reach the nearest exit is not apparent. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process on October 25, 2023, the facility had confusing exit signs which had illuminated directional arrows in inappropriate locations. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Observation on October 25, 2023 at 1100 revealed an exit sign with both directional arrow at at the automatic fire door on the southwest wing, indicating turns that were not there. Observation on October 25, 2023 at 1105 revealed exit sign two (2) with a directional arrow indicating a turn that was not there Observation on October 25, 2023 at 1125 revealed an exit sign with both directional arrow at at the automatic fire door on the southeast wing, indicating turns that were not there. Observation on October 25, 2023 at 1130 revealed an exit sign with a directional arrow, across from the med room, indicating a turn that was not there. During an interview on October 25, 2023 at 1430 Missouri Department of Health and Senior Services STATE FORM oem 273J11 If continuation sheet 2 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE VICTORIAN PLACE OF WASHINGTON, RES CARE AM WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (X4) ID PREFIX TAG Continued From page 2 the maintenance manager stated she would cover the misleading arrows. 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on October 25, 2023, the facility failed to ensure all emergency lighting/exit signs were operational. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Observation on October 25, 2023 at 1057 revealed an emergency light/exit sign failed to illuminate while depressing the test button at the main entrance. Observation on October 25, 2023 at 1124 revealed an emergency light/exit sign failed to illuminate while depressing the test button at emergency exit three (3). Observation on October 25, 2023 at 1201 revealed an exit sign failed to illuminate while depressing the test button. Exit sign number ten (10). During an interview on October 25, 2023 at 1253 the maintenance manager stated they will be Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID PREFIX TAG Continued From page 3 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 record review and interview during a fire safety inspection on October 25, 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 October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Record review on October 25, 2023 at 1232 reveled no semi-annual inspection had been performed on the fire alarm system. The last dated inspection was April 29, 2022. | observed a pattern of semi-annual inspections in close proximity of annual inspections. Semi-annual inspections are to be completed six (6) months after an annual inspection. During an interview on October 25, 2023 at 1233 the maintenance manager stated she believes the inspection has been conducted, but doesn't have access to the reports. Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 4 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID PREFIX TAG Continued From page 4 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II This regulation is not met as evidenced by: Class II Based on review and interview during the fire safety inspection process on October 25, 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 October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Record review on October 25, 2023 at 1230 showed the last annual fire alarm inspection and certification was completed May 21, 2021. During an interview on October 25, 2023 at 1230 the maintenance manager stated she believed the testing was performed, but that the administrator has the records. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 5 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID PREFIX TAG Continued From page 5 (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on October 25, 2023 the facility failed to maintain self closing smoke partition doors that separate the kitchen area from the dining area. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Observation on October 25, 2023 at 1053 revealed one of the kitchen smoke partition doors mechanically blocked open with a door hold magnet, that is not attached to the fire alarm system. Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 6 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID PREFIX TAG Continued From page 6 Observation on October 25, 2023 at 1054 revealed one of the kitchen smoke partition doors mechanically blocked open with an attached door chock. During an interview on October 25, 2023 at 1243 with the maintenance manager said she would remove the door stops and see that the kitchen staff either keeps the door closed or they will install a magnetic hold on it that is tied into the fire alarm system. 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/II This regulation is not met as evidenced by: Class II Based on observation, record review, and interview during the fire safety inspection process on October 25, 2023 the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 7 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE VICTORIAN PLACE OF WASHINGTON, RES CARE AM WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (X4) ID PREFIX TAG Continued From page 7 Observation on October 25, 2023 at 1052 revealed six (6) missing escutcheon rings from sprinkler heads in the driveway canopy. Observation on October 25, 2023 at 1052 revealed an escutcheon ring and sprinkler head hanging down in room three (3). Record review on October 25, 2023 at 1234 revealed no current annual sprinkler inspection. Last inspection dated April 13, 2022. Record review on October 25, 2023 at 1234 revealed the 5 year sprinkler inspection expired October 24, 2023. During an interview on October 23, 2023 at 1235 the maintenance manager stated she believed the inspection were done, but cannot access the records, and that she would have others problems corrected. 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on October 25, 2023, the facility failed to ensure all emergency Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 8 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID PREFIX TAG Continued From page 8 lighting/exit signs were operational. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Observation on October 25, 2023 at 1057 revealed an emergency light/exit sign failed to illuminate while depressing the test button at the main entrance. Observation on October 25, 2023 at 1124 revealed an emergency light/exit sign failed to illuminate while depressing the test button at emergency exit three (3). During an interview on October 25, 2023 at 1253 the maintenance manager stated they will be fixed. 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 during the fire safety inspection process on October 25, 2023 the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 9 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID PREFIX TAG Continued From page 9 nineteen (19) residents. Observation on October 25, 2023 at 1128 revealed an oxygen cylinder, standing upright and not stored in an approved rack, or secured by chain or band in the oxygen storage closet. During an interview on October 25, 2023 at 1250 the maintenance manager said she would make sure to have the oxygen cylinders properly stored. 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 Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 10 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 27659 NAME OF PROVIDER OR SUPPLIER 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID PREFIX TAG Continued From page 10 This regulation is not met as evidenced by: Class III Based on observation and interview during the fire inspection process on October 25, 2023 the facility failed to ensure the facility's electric wiring was properly maintained. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Observation on October 25, 2023 at 1103 revealed a multiplug being used as permanent wiring in room three (3). Observation on October 25, 2023 at 1205 revealed exposed wiring hanging from the ceiling where a light fixture had been removed in room forty (40) Record review on October 25, 2023 at 1239 revealed the last electrical inspection on record was dated March 18, 2021. During an interview on October 25, 2023 at 1240 the maintenance manager stated she would remove multiplug, ensure all exposed wiring is properly enclosed, and check with the administrator regarding a current electrical inspection. 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 Missouri Department of Health and Senior Services STATE FORM 6899 273J11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 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 11 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 27659 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 10/31/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/25/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 2800 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 VICTORIAN PLACE OF WASHINGTON, RES CARE AM (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 Based on observation and interview during the fire safety inspection process on October 25, 2023, the facility failed to maintain plumbing in accordance to the National Plumbing Code. The facility census October 25, 2023 was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Observation on October 25, 2023 at 1153 revealed a water heater with a drip leg that ended several feet above the floor. Drip legs should terminate no more than four (4) inches above the floor. Located in mechanical room off dining room During an interview on October 25, 2023 at 1245 the maintenance manager stated she would extend or replace the drip leg. Missouri Department of Health and Senior Services STATE FORM 6899 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY 273J11 If continuation sheet 12 of 12 PLAN OF CORRECTION Provider/Supplier Victorian Place of Washington Name: Street Address, 2800 Rabbit Trail Drive City, Zip: Washington, MO 63090 Date of Survey: 10/25/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER Asad; ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Community will contact Washington Fire Protection to schedule a consultation and review fire and evacuation plans. Task to be scheduled for completion and documentation by Nov. 30" 2023. Administrator will be responsible for scheduling annual consult each year. Regional director will oversee documentation at annual scorecard. Documentation will be available upon revisit A2214 Exit signs have been altered to have only pertinent directional guidance for safe exiting of the building. Administrator will for quarterly inspection of signs. Maintenance and Regional 11/1/2023 Director to assist with inspections on an annual basis. All exit signs in question were replaced by Maintenance director. A2238 Maintenance director will insure exit signs are operational each 41/06/2023 month during routine building checks. Administrator will review monthly building checks to ensure compliance. Avid electrical conducted annual fire inspection on 11/06/2023. Buildings maintenance person will be responsible for bi-annual Inspection. Bi-annual fire inspection to be completed on or before 05/06/2023. Administrator to insure compliance and recording keeping on a monthly basis. Regional Director will monitor inspection completion during administrator annual scorecard. 11/06/2023 Avid electrical conducted annual fire inspection on 11/06/2023. Buildings maintenance person will be responsible for bi-annual Inspection. Bi-annual fire inspection to be completed on or A2250 before 05/06/2023. Administrator to insure compliance and 11/06/2023 recording keeping on a monthly basis. Regional Director will monitor inspection completion during administrator annual scorecard. All devices uses to proper doors open have been removed by Maintenance Director. All kitchen doors to remain closed unless kitchen is being entered or exited. Staff educated on keeping doors closed vs. propped open. Administrator to monitor for A2256 11/06/2023 Gateway Fire Protection completed annual sprinkler inspection on 4/24/2023. Documentation to be attached. Administrator will A2274 be responsible for maintaining inspections accordingly in a 04/24/2023 binder in administrator office. Regional Director will review documentation on an annual basis. po Outdoor canopy was under construction during Fire Marshall's A2274 inspection. Upon review on 11/07/2023 all escutcheon rings 11/07/2023 from sprinkler heads have been placed. Room #3 escutcheon ring and sprinkler head have been A2274 repaired. Administrator will be responsible for quarterly walk 11/06/2023 through to ensure compliance is maintained. Gateway Fire Protection completed 5 year Sprinkler inspection on 5/24/2023. Administrator will be responsible for maintaining inspections accordingly in a binder in administrator office. Regional Director will review documentation on an annual basis. A2274 05/24/2023 All exit and emergency lights in question have been replaced with new fixtures. Administrator will conduct quarterly walk through to ensure compliance is maintained. Regional Director will conduct annual walk through to ensure compliance is maintained A2278 11/06/2023 Oxygen cart ordered and oxygen cylinder placed securely in A2298 cart. Oxygen placement to be checked for proper placement 11/06/2023 monthly by Administrator J A3214 Bi-yearly electrical inspection completed by Wiiliam’s Electric. 01/20/23 Documentation to be kept in inspection binder in administrator's office | A3124 Muiti plug removed from room 3 and was replaced with surge 41/01/2023 protector ouilet strip. Maintenance will check rooms monthly for any multi plugs/extension cords. Administrator will conduct walk through quarterly to check for compliance. | A3214 Light fixture replaced in room 40 and no longer has exposed 11/06/2023 wires. . Administrator will conduct walk through quarterly to check for compliance Cid” __ A6025 All drip legs in question have been extended to proper length. 11/06/2023 Administrator/Maintenance will review quarterly to maintain compliance. Regional Director will conduct review annuall 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.