FOXBERRY TERRACE ASSISTED LIVING.

PRINTED: 03/27/2025 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 6 MM 03/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4316 NORTH ST LOUIS AVENUE WEBB CITY, MO 64870 (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) FOXBERRY TERRACE-ASSISTED LIVING BY AMERIC 19 CSR 30-86.022(7)(A) Exits-2 per Floor-Remote/Unobstructed Exits, Stairnways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. Wl 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 unobstructed exits. The facility census was forty-three. This deficiency affected forty-three of forty-three residents. Observation revealed the exit door on C Hall is sticking, excessive force was required to open the door. Observation revealed the exit door on E Hall can be opened, but does not close properly. During the exit interview on March 25, 2025 at 1725, the maintenance man stated they have a new door on order for E Hall, it just hasn't arrived yet, and that he will make adjustments to the C Hall door to eliminate the sticking problem. 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 Missouri Department of Health and Senior Services ALT) PROVIDER/SUPPLIER REPRESENT/ on | TITLE _ (X6) DATE LM 4200s RM 6899 PRYN11 If 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: NAME OF PROVIDER OR SUPPLIER FOXBERRY TERRACE-ASSISTED LIVING BY AMERIC (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Based on observation and interview during the fire inspection process, the facility had an exit sign with illuminated directional arrows in an inappropriate location. The facility census was forty-three. This deficiency affected forty-three of forty-three residents. Observation revealed the exit sign next to the laundry had both directional arrows illuminated, indicating turns that were not there. During the exit interview on March 25, 2025 at 1730, the maintenance man stated he 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 Ill Based on observation and interview during the fire safety inspection process, the facility failed to ensure all emergency lighting/exit signs were operational. The facility census was forty-three. This deficiency affected forty-three of forty-three residents. Observation revealed an exit sign/emergency light combination unit failed to illuminate while depressing the test button in B Hall. During the exit interview on March 25, 2025 at 1735, the maintenance man stated he would Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 PRYN11 PRINTED: 03/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4316 NORTH ST LOUIS AVENUE WEBB CITY, MO 64870 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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 FOXBERRY TERRACE-ASSISTED LIVING BY AMERIC (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 repair the unit. 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 process, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was forty-three. This deficiency affected forty-three of forty-three residents. Observation revealed the fire alarm for the Arbors in trouble mode. During the exit interview on March 25, 2025 at 1740, the administrator stated they have a confirmed contract to make the repair, but the alarm company has yet to set an appointment. 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 PRYN11 PRINTED: 03/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4316 NORTH ST LOUIS AVENUE WEBB CITY, MO 64870 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 FOXBERRY TERRACE-ASSISTED LIVING BY AMERIC (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 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 Il Based on observation and interview during the fire safety inspection process, the facility failed to install and maintain self-closing smoke partition doors. The facility census was forty-three. This deficiency affected forty-three of forty-three residents. Observation revealed the smoke partition door of the laundry was not self-closing. During the exit interview on March 25, 2025 at 1745, the maintenance man stated he would install a self-closure device on the door. 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 PRYN11 PRINTED: 03/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4316 NORTH ST LOUIS AVENUE WEBB CITY, MO 64870 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 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 FOXBERRY TERRACE-ASSISTED LIVING BY AMERIC (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 as defined in NFPA 101, 2000 edition. || This regulation is not met as evidenced by: Class II Based on observation and interview on during the fire safety inspection process, the facility failed to ensure that curtains shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. The facility census was forty-three. This deficiency affected forty-three of forty-three residents. Observation revealed a curtain in the Foxberry administrative assistant's office, with no documentation of treatment or being certified of flame-resistant. During the exit interview on March 25, 2025 at 1750, the administrator stated the curtains were new and had not been treated yet. NFPA 101, 2000 edition, Chapter 10.3.1, reads: "Where required by the applicable provisions of this code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Film." 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, Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 PRYN11 PRINTED: 03/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4316 NORTH ST LOUIS AVENUE WEBB CITY, MO 64870 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 6 PRINTED: 03/27/2025 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 03/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4316 NORTH ST LOUIS AVENUE WEBB CITY, MO 64870 (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) FOXBERRY TERRACE-ASSISTED LIVING BY AMERIC Continued From page 5 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, record review, and interview during the fire safety inspection process, the facility failed to ensure flexible power cords shall not be placed under rugs, through doorways, or located where they are subject to physical damage, thereby ensuring the facility's electric wiring was properly maintained. The facility census was forty-three. This deficiency affected forty-three of forty-three residents. Observation revealed a flexible power cord duct taped to a rug, across a walkway, in room C-9. During the exit interview on March 25, 2025 at 1755, the maintenance man stated they would get a cord protector for room C-9. Missouri Department of Health and Senior Services STATE FORM 6899 PRYN11 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier ae FOXBERRY TERRACE ASSISTED LIVING BY AMERICARE Street Address, City, Zip: 4316 N ST. LOUIS AVENUE, WEBB CITY MO 64870 Date of Survey: 3/25/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Observation during the fire safety inspection revealed that Exit door on C hall of ALF building was sticking and required excessive force to open. Observation also revealed Exit door on E hall of ALF was not opening properly. Door had been ordered 3/26/2025 but has not arrived yet. Maintenance made adjustments to Exit door on C hall that eliminated the sticking problem. Hinges were removed and hinge pins were lubricated with white lithium grease. A2222 Exit door on E has been ordered. Verified with supplier on 3/26/2025 that door had been ordered and shipped. Door to be 5/15/2025 . installed by CB Construction upon arrival. All employees to be educated on alternate evacuation routes to ; . . 4/4/2025 ensure timely evacuations of residents. Maintenance to monitor proper mechanics of all exit doors monthly with documentation provided to Admin 4/10/2025 A2237 Observation during the fire safety inspection revealed that exit sign next to the laundry at ALF, had both directional arrows illuminated indicating turns that were not there. Maintenance covered the misleading arrows per conversation with inspector during site visit. Maintenance will continue to ensure all exits signs appropriately indicate exit routes as part of routine preventative maintenance. Observation during the fire safety inspection revealed that the A2238 exit sign/emergency light combination on B hall of ALF failed to illuminate while being depressed. a a Maintenance replaced battery to exit sign/emergency light combination correcting the unit. ecacaaaliad 3/26/2025 Maintenance will review functionality weekly per preventative maintenance checks. Admin will verify completion weekly after completion by maintenance. It was observed during fire safety inspection that fire alarm panel at the Arbors building was in trouble mode. Marmic Fire & Safety to repair issue with Dual Path, Dual Sim, Verizon & AT&T Cell Communicator but service had not been completed yet. Marmic did arrive on 3/26/2025 to replace cell communicator. A2249 Marmic Fire and Safety completed replacement of Dual Path, Dual Sim, Verizon & AT&T Cell Communicator on 3/26/2025. Staff to be educated on fire panel readings and communication expectations related to any abnormal trouble codes to ensure timely correction of any issues. During fire safety inspection it was observed that door to laundry A2256 room at ALF did not have a self-closing smoke partition door. Self closures ordered and installed on laundry room door. Staff educated on smoke partitions and keeping self-closing doors unobstructed and shut. Admin and Maintenance to monitor for pliance during normal rounding During fire safety inspection it was observed that curtains in A2282 Assistant Admin/Bkkp at ALF office had not been treated with a flame resistant retardant. Admin purchased Fire Guard manufactured by ForceField Maintenance to record all applications of flame retardant on log kept in admin office. PO Maintenance to check rooms/office spaces/ common areas quarterly to ensure all drapes/curtains and all other loosely hanging furnishings and decorations are flame resistant in accordance with NFPA 101. Admin to review quarterly & sign for compliance During fire safety inspection, room C3 on ALF, revealed a flexible power cord attached to the floor using duct tape, across Family was educated to the risk of physical damage to power cord due to it being placed in a walkway of the resident. Maintenance to apply plastic cord protector over any unprotected power cords per conversation with inspector during site visit. Staff to be educated on proper maintenance of electrical cords in resident rooms. Admin to monitor resident rooms for compliance monthly. 3/26/2025 4/17/2025 4/4/2025 4/4/2025 3/26/2025 4/17/2025 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.