CHATEAU GIRARDEAU.

PRINTED: 11/20/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: (XQ MULTIPLE CONSTRUCTION A BUILDING: (X3} DATE SURVEY COMPLETED B. WiNG 01386C 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3120 INDEPENDENCE STREET CAPE GIRARDEAU, MO 63703 CHATEAU GIRARDEAU SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IOENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 19 CSR 30-87.020(15) Walils/Ceilings/Doors/Windows Clean Walls and ceilings, including doors, windows and skylights, shall be clean and maintained in good repair. Ill This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure ceilings were kept clean and in good repair. The facility's census was 58. Observation on 11/18/25 at 11:55 A.M. of the ceiling located in the Laundry Closet area at the end of the hail on The Chateau Terraces Assisted Living First Floor showed: - An approximate 6 inch by 18 inch ceiling tile at the back wall of the closet area was missing and left an open area fo the fipor above; - An approximate 18 inch by 18 inch ceiling tile in front of the missing tile was not in place and slid over to the side which left another open space to the fioor above; - The open space above the washer and dryer exposed pipes and the floor above; ~ The other cailing tiles in the closet area were covered with jarge brown stains. During an interview on 11/18/25 at 1:15 P.M., the Administrator said he/she was not aware of the issues with the ceiling and did call the maintenance to check and repair the issue as soon as possible. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATU ™Rawivshatar "ha Jelas STATE FORM eeu P28K11 Hf continuation shaet 1 of 1 PLAN OF CORRECTION Provider/Supplier Name: Street Address, City, Zip: Date of Survey: Chateau Girardeau 3120 independence Street Cape Girardeau, MO 63703 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Corrective Action: The 6x18 ceiling tile was replaced immediately while surveyors were still in the building; as well as surrounding areas inspected and cleaned to ensure resident safety. Identifying others affected: A facility-wide inspection of all similar ceiling areas was conducted to identify any additional damaged or missing tiles that could pose similar risks. No other affected areas found. Measures to avoid recurrence: Ceiling inspections added \\ lisla Ss to routine preventive maintenance rounds. Staff also trained to immediately report damaged or missing tiles. Monitoring: Maintenance Director to complete weekly audits for 4 weeks, then monthly audits for 3 months. Audit findings will be reviewed during QA meetings and any concerns will be addressed promptly. \2|a\as 3| 31a 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.

PRINTED: 04/10/2024 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 01386C — 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3120 INDEPENDENCE STREET CAPE GIRARDEAU, MO 63703 (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) CHATEAU GIRARDEAU 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 record review and interview on March 28, 2024 the facility failed to ensure the complete fire alarm system was tested annually and semi-annually in accordance with NFPA 72, 1999 edition. The facility census was thirty two (32). This deficiency affects thirty two (32) of thirty two (32) residents. Record review showed no current annual fire alarm inspection on file for review. During an interview on March 28, 2024 at 3:50 P.M. the Maintenance Supervisor stated the alarm company failed to come to the facility on the scheduled date. He has the inspection rescheduled in April. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 O5CZ11 If continuation sheet 1 of 1 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)