Inspection Reports for
Fountains of West County Al, LLC the

19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on record review and interview, the facility failed to conduct at least one fire drill every three months on each shift and had no documentation of a fire drill on the first shift from April through October 2025. This deficiency affected 60 out of 60 residents.

19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: The facility failed to ensure the complete fire alarm system was inspected and that written certification of the annual inspection was available, and record review showed no documentation of an annual inspection.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to ensure the facility's electric wiring was inspected every two years as required and documentation showed the required inspection interval was not met.

19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements: Based on interview and record review, the facility failed to ensure resident individualized evacuation plans (IEP) included specific staff positions and their responsibilities for five of six sampled residents.

19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements: Based on observation and interview, the facility failed to ensure a diagram showing the location of the Area of Refuge connected to the stairwell was located at the bottom of each exit stairwell for two of two exits.

19 CSR 30-86.047(46) Safe & Effective Medication System: Based on observation, interview and record review, the facility failed to ensure a safe and effective medication pass when staff did not hold the inner canthus or instruct residents regarding self-administration of eye drops, as observed during medication administration.

19 CSR 30-86.047(47)(A) Physicians Orders Followed: Based on observation, interview and record review, the facility failed to obtain a physician's order to allow residents to self-administer their own medications during an observed medication pass for three of five observed residents.

19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Based on observation and interview, the facility failed to ensure proper use of hair restraints and beard restraints by food service employees during one day of observation.

11 CSR 40-2.022 Section (4) State Statute: The facility did not have a current boiler inspection certification as evidenced by no state inspection certificate posted for the water heater room, no documentation of a current inspection for the heaters, and information showing the three water heaters were 250,000 BTU, affecting sixty-seven (67) out of sixty-seven (67) residents.

19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements: Based on observation and interview the facility failed to provide a functioning two-way communication system between the areas of refuge and a remote monitored area on multiple floors; the communication system did not operate properly in repeated attempts. This deficiency affected 64 out of 64 residents.

19 CSR 30-86.022(7)(E) Locked Exit Doors: Based on observation and interview the facility failed to ensure exit locks did not require the use of a key, tool or special knowledge to unlock from inside; a delayed egress door required a door code and failed to open in multiple attempts. This deficiency could delay egress and affected 64 out of 64 residents.

19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant change: The facility failed to update a resident's community-based assessment when the resident had a change in condition and services for one of five sampled residents.

19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to provide proper care per the resident's individualized service plan when staff did not address the resident's increased confusion, anxiety, weakness and depression for one of five sampled residents.

19 CSR 30-87.020(5) Toxic Material Storage: The facility failed to ensure poisonous or toxic materials were kept locked or stored in a place not accessible to residents, as numerous chemical containers were observed in unlocked supply and kitchen areas where residents could get to them.