WASHINGTON PLACE MEMORY CARE.

PRINTED: 01/23/2025 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 BWING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 2701 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) ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al 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. [/Il This regulation is not met as evidenced by: Class II Based on record review and interview during a fire safety inspection, 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 fifteen, this deficiency affects fifteen of fifteen residents. Record review revealed no semi-annual inspection had been performed on the fire alarm system. Semi-annual inspections are to be completed six (6) months after an annual inspection. During the exit interview on January 16, 2024 at 1340 the maintenance manager stated he believes the inspection has been conducted and would email me a copy. Followed-up at the facility on January 21, 2025 at 1145 to retrieve a copy of semi-annual fire alarm testing and inspection report. Opening the file revealed that it was an inspection report for a different facility. Contacted the alarm company and they advised they were not hired to do a semi-annual fire alarm inspection. 19 CSR 30-86.022(10)(A} Hazardous Area Requirements Missouri Department of Health and Senior Services A LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE tme AdMunsrrvatok— — woypate 1/23 25 STATE FORM 6298 3J1511 lf continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 2701 RABBIT TRAIL DRIVE ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 1 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. 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 maintain self closing smoke partition doors that separate the kitchen area from the dining area. The facility census was fifteen, this deficiency affects fifteen of fifteen residents. Observation revealed the kitchen smoke partition door leading to the serving line was mechanically blocked open with a chock. This violation was corrected while on site. However, it is a reoccurring violation and requires a new plan of correction to prevent future occurrences. Missouri Department of Health and Senior Services STATE FORM 6899 3J1511 (X2) MULTIPLE CONSTRUCTION PRINTED: 01/23/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/16/2025 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 6 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2701 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 During the exit interview on January 16, 2024 at 1310, maintenance stated he would see that the kitchen staff keeps the door closed. 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, the facility failed to ensure all emergency lighting was operational. The facility census was fifteen, this deficiency affects fifteen of fifteen residents. Observation revealed an emergency light that failed to illuminate while depressing the test button next to furnace room 10&11. During the exit interview on January 16, 2024 at 1315, maintenance stated it would 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 Missouri Department of Health and Senior Services STATE FORM 6899 3J1511 PRINTED: 01/23/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/16/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 6 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2701 RABBIT TRAIL DRIVE WASHINGTON, MO 63090 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 Based on observation and interview during the fire safety inspection process, the facility failed to store portable compressed gas cylinders in accordance with NFPA 99, 1999 Edition. The facility census was fifteen, this deficiency affects fifteen of fifteen residents.. Observation revealed 3 freestanding portable oxygen tanks not stored in an approved rack, or secured by chain or band in room 31. Further, there was no signage indicating the storage of oxygen in the room. During the exit interview on January 16, 2024 at 1320, maintenance stated he would make sure to have the compressed gas cylinders properly stored and the room appropriately labeled. 19 CSR 30-86.032(2) Substantially Constructed & A3201 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 fifteen, this deficiency affects fifteen of fifteen residents. Observation revealed a wall penetrations behind the faucets of the floor sink in the laundry room near room 29. Missouri Department of Health and Senior Services STATE FORM 6899 3J1511 PRINTED: 01/23/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/16/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 6 PRINTED: 01/23/2025 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2701 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) ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al Continued From page 4 These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. During the exit interview on January 16, 2024 at 1325, maintenance stated he would would repair the holes in the drywall. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the Missouri Department of Health and Senior Services STATE FORM 6899 3J1511 If continuation sheet 5 of 6 PRINTED: 01/23/2025 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2701 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) ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al Continued From page 5 fire inspection process, the facility failed to ensure the facility's electric wiring was properly maintained. The facility census was fifteen, this deficiency affects fifteen of fifteen residents . Observation revealed an open junction box in the ceiling of the spa. Observation revealed an open junction box on the wall of furnace room 2. Observation revealed an open junction box behind the smoke partition door next to the salon. Observation revealed an open junction box behind the smoke partition door next to the storage room. Observation revealed a missing cover plate on the dryer outlet in the laundry. During the exit interview on January 16, 2024 at 1330, maintenance stated he would replace missing covers. Missouri Department of Health and Senior Services STATE FORM 6899 3J1511 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Name: Arbors at VP Washington Citi 2701 Rabbit Trail Drive Washington MO 63090 Date of Survey: 1/16/2025 ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1. Set up semi-annual fire alarm inspection to be conducted. 2. Add semi annuai fire alarm inspection to current contract with provider. 2249- No 3. Keep inspection record log up to date to reflect semi- ; ‘ . nae . when semi annual fire alarm inspection is due. annual fire ,; ; . 4. Call provider for fire alarm inspection semi- alarm ; ; . annually by the end of the month prior to get inspection on schedule. Class Il 5. Completion date:1/28/2025 6. Completed by Maintenance Director and/or authorized representative. 2256 1. Hang sign notifying employees that the door Kitchen must always remain shut. door 2. Monitor door during work hours. blocked 3. Completion date: 1/28/2025 open Class 4. Completed by Director of Dining Services I and/or authorized representative. 1. Replace light in affected emergency light. 2. Check all emergency lights and replace any lights. 3. Complete monthly emergency light checks. 2278 Non ; functional 4. Complete annual emergency light checks. emeraenc 5. Replace any needed lights in emergency lights i hting y noticed during checks. Clase i 6. Completion date: 1/28/2025 7. Completed by Maintenance director and/or authorized representative. COMPLETION DATE 1/28/2025 1/28/2025 1/28/2025 ee . Move affected oxygen tanks to proper location and store properly until able to dispose of. 2. Check ail rooms in community to take 2298 ; inventory of oxygen tanks and proper storage. oon 3. Check oxygen tanks in community monthly for storage proper storage. Class III 4. Completion date:1/28/2025 5. Completed by Maintenance Director and/or authorized representative. . Patch holes in wall around affected faucets. 3201 Holes 2. Check all rooms for holes in walls around faucets and repair holes. in wall 3. Check all rooms monthly for holes in walls faucets around faucets and repair holes. Class Ill 4. Completion date: 1/28/2025 5. Completed by Maintenance Director and/or authorized representative. 1. Put cover plates on affected areas. 3214 2. Check all rooms for missing cover plates Missing and replace. electrical 3. Check all rooms monthly for cover plates cover and replace. plates 4. Completion date: 1/28/2025 Class III 5. Completed by Maintenance Director and/or authorized representative. 1/28/2025 1/28/2025 1/28/2025

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 28065 $$$ i$ 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2701 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 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/Ill This regulation is not met as evidenced by: Class II Based on record review and interview during the fire inspection process on October 25, 2023, the facility failed to ensure a minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. The facility census October 25, 2023 was sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Review of the fire drill records on October 25, 2023 at 1438 revealed no fire drills had been conducted in May, June, July, October and November of 2022 and March, May, June, September, and October of 2023. Of the drills with paperwork February, April, and August 2023 and August of 2022 were either missing the shift, time, or both of when the drill was conducted. During an interview on October 25, 2023 at 1440 the maintenance manager stated she had conducted some of the missing drills, but wasn't responsible for the paperwork, but she will set up a proper schedule for fire drills every month and one Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 8K6B11 If continuation sheet 1 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 28065 NAME OF PROVIDER OR SUPPLIER 2701 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 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al (X4) ID PREFIX TAG Continued From page 1 per shift each quarter and documentation. 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 sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Record review on October 25, 2023 at 1433 reveled no semi-annual inspection had been performed on the fire alarm system. The last dated inspection was March 18, 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 1435 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 8K6B11 (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 2 of 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 28065 NAME OF PROVIDER OR SUPPLIER 2701 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 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al (X4) ID PREFIX TAG Continued From page 2 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 sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Record review on October 25, 2023 at 1440 showed the last annual fire alarm inspection and certification was completed May 20, 2021. During an interview on October 25, 2023 at 1445 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 8K6B11 (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 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 28065 NAME OF PROVIDER OR SUPPLIER 2701 RABBIT TRAIL DRIVE ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al WASHINGTON, MO 63090 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG ID PREFIX TAG Continued From page 3 (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 sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Observation on October 25, 2023 at 1344 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 8K6B11 (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 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 28065 NAME OF PROVIDER OR SUPPLIER 2701 RABBIT TRAIL DRIVE ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al 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 4 During an interview on October 25, 2023 at 1505 with the maintenance manager said she would remove the door stop 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(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 lighting/exit signs were operational. The facility census October 25, 2023 was sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Observation on October 25, 2023 at 1338 revealed an emergency light/exit sign failed to illuminate while depressing the test button at emergency exit five (5). During an interview on October 25, 2023 at 1510 the maintenance manager stated it would be fixed. 19 CSR 30-86.032(2) Substantially Constructed & Maintained Missouri Department of Health and Senior Services STATE FORM 6899 8K6B11 (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 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 28065 NAME OF PROVIDER OR SUPPLIER 2701 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 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al (X4) ID PREFIX TAG Continued From page 5 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 on October 25, 2023 the facility failed to maintain the building in good repair. The facility census October 25, 2023 was sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Observation on October 25, 2023 at 1312 revealed a wall penetration above the fire alarm pull station at the main entrance. Observation on October 25, 2023 at 1335 revealed a wall penetration behind the washing machine in the laundry room near room twenty-nine (29). Observation on October 25, 2023 at 1335 revealed a wall penetrations behind the faucet of the floor sink in the laundry room near room twenty-nine (29). These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. During an interview on October 25, 2023 at 1510 the maintenance manager stated she would repair all the holes in the drywall. Missouri Department of Health and Senior Services STATE FORM 6899 8K6B11 (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 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 28065 NAME OF PROVIDER OR SUPPLIER 2701 RABBIT TRAIL DRIVE ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al 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 6 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class Ill 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 sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Observation on October 25, 2023 at 1312 revealed an exit sign hanging by it's wires at the main Missouri Department of Health and Senior Services STATE FORM 6899 8K6B11 (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 9 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 28065 NAME OF PROVIDER OR SUPPLIER 2701 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 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al (X4) ID PREFIX TAG Continued From page 7 entrance. Observation on October 25, 2023 at 1320 revealed a relocateable power tap plugged into another relocateable power tap in the IT room. Observation on October 25, 2023 at 1357 revealed a multiplug being used as permanent wiring in room nine (9). During an interview on October 25, 2023 at 1515 the maintenance manager stated she would remove multiplug, fix the exit sign, and remove the relocateable power tap daisy chain. 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 October 25, 2023, the facility failed to maintain plumbing in accordance to the National Plumbing Code. The facility census October 25, 2023 was sixteen (16). This deficiency affects sixteen (16) of sixteen (16) residents. Observation on October 25, 2023 at 1314 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 one/two (1/2). Missouri Department of Health and Senior Services STATE FORM 6899 8K6B11 (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 9 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 28065 $$$ i$ 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2701 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 ARBORS VICT PL WASH, MEM CAR ASSTD LIVING Al A6025_ Continued From page 8 Observation on October 25, 2023 at 1358 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 six/seven (6/7). During an interview on October 25, 2023 at 1520 the maintenance manager stated she would extend or replace the drip legs. Missouri Department of Health and Senior Services STATE FORM oeee 8K6B11 If continuation sheet 9 of 9 PLAN OF CORRECTION The Aros & Victorian Place of Washington Provider/Supplier Name: 2701 Rabbit Trail Drive Washington, MO 63090 Street Address, City, Zip: Date of Survey: 10/25/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Administrator to conduct one drill per shift per quarter with 10/31/2023 Po ID PREFIX TAG maintenance director to ensure completion and documentation. Documentation to be placed in binder in administrator's office after completion. A2217 All wall penetrations in drywall repaired by maintenance. Administrator to conduct quarterly walk through of building to A3201 ensure compliance is maintained. Regional director will conduct TNOG/2023 walk through annually to ensure compliance. | po A2249 Avid electrical conducted annual fire inspection on 11/06/2023. 41/06/2023 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. 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. A2250 Le 11/06/2023 P| 11/06/2023 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 compliance Gateway Fire Protection completed annual sprinkler inspection on 4/24/2023. Documentation to be attached. Administrator will be responsibie for maintaining inspections accordingly in a binder in administrator office. Regional Director will review documentation on an annual basis. A2256 A2274 04/24/2023 A2274 Gateway Fire Protection completed 5 year Sprinkler inspection 05/24/2023 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. All exit and emergency lights in question have been replaced with new fixtures. Administrator will conduct quarterly walk A2278 through to ensure compliance is maintained. Regional Director 11/06/2023 will conduct annual walk through to ensure compliance is maintained Bi-yearly electrical inspection completed by William’s Electric. 01/20/23 Documentation to be kept in inspection binder in administrator's office. Relocatable power tap plugged into another power tap and was 11/01/2023 replaced with surge protector outlet strips in |IT room. Maintenance will check rooms monthly for any multi plugs/extension cords. Administrator will conduct walk through quarterly to check for compliance. A3214 Multi plug removed from room 9. Administrator will conduct walk 11/06/2023 through quarterly to check for compliance Exit sign at main entrance tighten so it’s no longer hanging by 11/06/2023 wires. Administrator will conduct walk through quarterly to check 11/06/2023 for compliance All drip legs in question have been extended to proper length. 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. Administrator/Maintenance will review quarterly to maintain compliance. Regional Director will conduct review annuall