PINE VALLEY AT THE WOODLANDS.

PRINTED: 12/17/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 9, BUNEIRIG (X3) DATE SURVEY COMPLETED 31974 B. WING 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE VALLEY AT THE WOODLANDS OGRE AD BEADONS ARNOLD, MO 63010 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) {EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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. I/II This regulation is not met as evidenced by: Class II Missouri Department of H hd Senior Services PROV. [SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE wing Ahy: 2- 2 <— OXGM11 If continuation sheet 1 of 2 PRINTED: 12/17/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (0X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDING: COMPLETED 31974 B.WING 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 620 WOODLAND MEADOWS 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) PINE VALLEY AT THE WOODLANDS Continued From page 1 Based on record review and interview on December 16, 2024, the factlity failed to insure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition.. The facility census was 37. This deficiency affects 37 out of 37 residents. Record review at 11:30 A.M. showed no semi-annual inspection had been done on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1 and 7.3.2. Based on dates of the last annual inspection, the semi-annual was due in June of 2024. During an interview on December 16, 2024 at the time of discovery, the Maintenance Director stated he/she would make sure the inspection was scheduled. Missouri Department of Health and Senior Services STATE FORM eas9 OXGM11 if continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: Street Address, City, Zip: Pine Valley 620 Woodland Meadows, Arnold, MO, 63010 Date of Survey: 12/16/24 ID PREFIX TAG A2249 COMPLETION DATE PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) It is Pine Valleys intention to have a semi-annual inspection of the facility fire alarm system completed. Corrective Action Ont2/t8/24 Pine Valley a inspection of the facility fire alarm system was completed. See attached inspection. Action to Prevent Recurrence 12/18/24 Onrt27+8/24-asemi-annuat inspection of the facility fire alarm system was added to the preventive maintenance program. Maintenance Director will report inspection results at least semi-annually to the Quarterly QA meeting.