CEDARHURST OF ARNOLD.

THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) PRINTED: 01/23/2026 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 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2069 MISSOURI STATE ROAD ARNOLD, MO 63010 (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) CEDARHURST OF ARNOLD A3214) 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 document review and interview, the facility failed to insure the facility's electric wiring was inspected every two (2) years by a qualified electrician. The facility census on was 67. This deficiency affects 67 out of 67 residents. Document review on October 29, 2025 at 1:04 P.M. showed the facility failed to have the electric wiring inspected every 2 years. Further review showed the last electrical inspection was done on June 22, 2023 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ZNO111 If continuation sheet 1 of 2 PRINTED: 01/23/2026 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 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2069 MISSOURI STATE ROAD ARNOLD, MO 63010 (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) CEDARHURST OF ARNOLD Continued From page 1 During an interview on October 29, 2025 at 1:30 P.M., the Maintenance Director said he/she would have the inspection done. Missouri Department of Health and Senior Services STATE FORM 6899 ZNO111 If continuation sheet 2 of 2

PRINTED: 07/18/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DCFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED B. WING 32428 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2069 MISSOURI STATE ROAD ARNOLD, MO 63010 CEDARHURST OF ARNOLD SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (X4) 1D 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) A2213, 19 CSR 30-86.022(4)(C) Range Hood Certification Range Hood Extinguishing Systems. (C) The range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. IIAll This regulation is not met as evidenced by: Class lil Based on observation, record review and interview on July 11, 2024, the facility failed to have the semi-annual service performed on the hood extinguishing system. The facility census on July 11, 2024 was 83. This deficiency affects 83 out of 83 residents. Observation on July 11, 2024 at 1:30 P.M. showed the last inspection of the hood system was performed in May of 2023. Record review on July 11, 2024 at 1:35 P.M., showed no documentation of the hood system being service semi-annually. During interview on July 11, 2024 at the time of discovery, the Maintenance Director stated he/she thought the system had been serviced, He/she further stated he/swhe would contact a service company. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE If continuation sheat 1 af 3 STATE FORM ; OJNE11 PRINTED: 07/18/2024 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 32428 By WING 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2069 MISSOURI STATE ROAD ARNOLD, MO 63010 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PREGEDEO BY FULL (EACH GORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CEDARHURST OF ARNOLD A2217| Continued From page 1 assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. fI/II This regulation is not met as evidenced by: Class Ill Based on record review and interview on July 11, 2024, the facility failed to conduct fire drills with at least one (1) fire drill every three (3) months on each shift. The facility census on August 4, 2014, was 10. This deficiency affects 10 out of 10 residents. Record review on July 11, 2024, at 1:35 P..M. showed fire drills were done in January 2024 on the 1st shift and Feburary of 2024 on the 3rd shift, no other drills had been recorded for the previous 12 months. During an interview on July 11, 2024 at the time of discovery, the Maintenance Director stated he/she would make sure the drills were done quarterly on each shift. 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/1l This regulation is not met as evidenced by: Class II Based on record review and interview on July 11, 2024, the facility failed to insure the complete fire alarm system was maintained according to Missouri Department of Health and Senior Services STATE FORM — OJNE11 Hf continuation sheat 2 of 3 PRINTED; 07/18/2024 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 32428 B. WING 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2069 MISSOURI STATE ROAD ARNOLD, MO 63010 (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) CEDARHURST OF ARNOLD Continued From page 2 National Fire Protection Association (NFPA) 72, 1999 ed. The facility census on July 11, 2024 was 83. This deficiency affects 83 of 83 residents. Record review on July 11, 2024 at 1:15 P.M., showed two pull station were not functioning. The fire alarm report stated the pull stations by the memory care and the front door failed the system test. During an interview on July 11, 2024 at the time of discovery., the Maintenance Director stated he would contact the fire alarm company to replace the pull stations. Missouri Department of Health and Senior Services STATE FORM ones OJNE11 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Cedarhurst of Arnold Name: Street Address, a fa 2069 Missouri State Rd Arnold, MO 63010 City, Zip: Date of Survey: 07/11/2024 ——=T PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 32428 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The Maintenance Director in the community will ensure all hoods (3) are inspected twice annually. These inspections will occur in Junauary and July of every calendar year. These inspections will be scheduled in our work order system, TELS, and the Maintenance Director will ensure the scheduled 07/15/2024 A2213 inspections are completed. A red folder will be utilized to house and twice these inspection results to ensure proper documentation is annually presented at the date of community inspections and when thereafter requested. On 7/15/2024 Pyrotech came out to inspect all three hoods in the community. All three hoods passed at the time of inspection and our next inspection is scheduled for January of 2025. The Maintenance Director in the community will ensure fire drills are conducted 12 times in a calendar year once per shift atleast | 07/30/2024 A2217 every three months. 4 of our 12 will be unannounced. These and once drills will be documented on an in-service form and will be monthly housed in a red folder to ensure proper documentation of drill is thereafter retained onsite. The Maintenance Director in the community will ensure all fire alarm inspections are done in the community twice annually. These inspections will occur in June and December of every 07/19/2024 A2249 calendar year. These inspections will be scheduled in our work and twice order system, TELS, and the Maintenance Director will ensure annually these scheduled inspections are completed. On 7/19 Midwest thereafter Fire came out to correct pull stations and reported system is up in operating order. 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.