KINWELL AT CHESTERFIELD.

PRINTED: 08/20/2024 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 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16300 JUSTUS POST ROAD CHESTERFIELD, MO 63017 (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) GRANDE AT CHESTERFIELD THE A2217| 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 assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/IIl This regulation is not met as evidenced by: Class III Based on record review and interview on August 15, 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 was 53. This deficiency affects 53 out of 53 residents. Record review at 11:00 A.M. showed no documentation of fire drills being done on second shift from Feburary 2024 thru August 2024 and on third shift from October 2023 thru Feburary 2024 and from April 2024 thru August 2024. During an interview on August 15, 2024, at the time of discovery, the Maintenance Director he/she had only been at the facility for a couple of months and could not find records from the previous Director. 19 CSR 30-86.022(5)(E) Fire Drill Records Fire Drills and Emergency Preparedness. (E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE ) 09/03/2024 STATE FORM If continuation sheet 1 of 6 1E6H11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 16300 JUSTUS POST ROAD GRANDE AT CHESTERFIELD THE CHESTERFIELD, MO 63017 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 1 problems. Ill This regulation is not met as evidenced by: Class III Based on record review and interview on August 15, 2024, the facility failed to keep records of all fire drills to include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. The facility census was 53.This deficiency affects 53 out of 53 residents. Record review, at 11:05 A.M. showed no records of any fire drills on second shift from Feburary 2024 thru August 2024 and on third shift from October 2023 thru Feburary 2024 and from April 2024 thru August 2024. During an interview on August 15, 2024, at the time of discovery, the Maintenance Director said he/she would ensure that fire drills would be recorded monthly with the proper information. 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 on August 15, 2024, the facility failed to insure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition.. The Missouri Department of Health and Senior Services STATE FORM e8s9 1E6H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 16300 JUSTUS POST ROAD GRANDE AT CHESTERFIELD THE CHESTERFIELD, MO 63017 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 facility census was 53. This affected 53 out of 53 residents. Record review at 11:15 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. Further review showed the last semi-annual inspection was done in June of 2023. During an interview on August 15, 2024 at the time of discovery, the Maintenance Director stated he/she had only been at the facility a couple of months and thought the inspection had been done. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on August 15, 2024, the facility failed to insure the complete fire alarm system was tested monthly. The facility census was 53. This deficiency affects 53 out of 53 residents. Record review at 11:20 A.M. showed no documentation the fire alarm system had been tested in the previous twelve (12) months. During an interview on August 15, 2024 at the time of discovery, the Maintenance Director Missouri Department of Health and Senior Services STATE FORM e8s9 1E6H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 16300 JUSTUS POST ROAD CHESTERFIELD, MO 63017 GRANDE AT CHESTERFIELD THE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 3 stated he/she would make sure the alarm was sounded monthly. 19 CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults Complete Fire Alarm Systems. (G) Upon discovery of a fault with the complete fire alarm system, the facility shall correct the fault. I/II This regulation is not met as evidenced by: Class Il Based on observation and interview on August 15, 2024, the facility failed to correct faults of the fire alarm system. The facility census was 53. This deficiency affects 53 out of 53 residents. Observation at 10:45 A.M., showed the fire alarm system with trouble signals on the panel. The director of maintenance stated they were upgrading to 5G and Siemens was waiting for a part. During an interview on August 15, 2024 at the time of discovery, the Maintenance Director said that Siemens was upgrading the communication from 3G to 5G and the part needed was ordered. A firre drill was performed and signals were received by the monitoring agency. 19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. Sprinkler Systems. (F) All facilities shall have inspections and written certifications of the approved sprinkler system Missouri Department of Health and Senior Services STATE FORM e8s9 1E6H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 16300 JUSTUS POST ROAD CHESTERFIELD, MO 63017 GRANDE AT CHESTERFIELD THE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 4 completed by an approved qualified service representative in accordance with NFPA 25, 1998 edition. The inspections shall be in accordance with the provisions of NFPA 25, 1998 edition, with certification at least annually by a qualified service representative. 1/Il This regulation is not met as evidenced by: Class Il Based on observation, record review and interview on August 15, 2024, the facility failed to supply a current annual sprinkler system inspection report. The facility census was 53.This deficiency affects 53 out of 53 residents. Observation 12:00 P.M. showed an inspection tag dated 10/4/22 located on the sprinkler riser Record review at 11:30 A.M. showed no current inspection documentation. During an interview on August 15, 2024 at the time of discovery, the Maintenance Director stated he/she had only been at the facility a couple of months and thought the inspection was current. 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 Missouri Department of Health and Senior Services STATE FORM e8s9 1E6H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE If continuation sheet 5 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 16300 JUSTUS POST ROAD GRANDE AT CHESTERFIELD THE CHESTERFIELD, MO 63017 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 5 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 Ill Based on document review and interview on August 15, 2024, the facility failed to insure the facility's electric wiring was inspected every two (2) years by a qualified electrician. The facility census was 53. This deficiency affects 53 out of 53 residents. Document review at 11:35 A.M. showed the facility failed to have the electric wiring inspected every 2 years. Further review showed the last electrical inspection was done on October 28, 2021. During an interview on August 15, 2024 at the time of discovery, the Maintenance Director stated he/she would have the inspection done. Missouri Department of Health and Senior Services STATE FORM e8s9 1E6H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE If continuation sheet 6 of 6 UNABLE TO LOCATE PLAN OF CORRECTION 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 16300 JUSTUS POST ROAD CHESTERFIELD, MO 63017 GRANDE AT CHESTERFIELD THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 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. II/III This regulation is not met as evidenced by: Class III Based on observation, record review and interview on November 18, 2024, the facility failed to have the semi-annual service performed on the hood extinguishing system. The facility census was 55. This deficiency affects 55 out of 55 residents. Observation on November 18, 2024 at 11:20 A.M. showed the last inspection of the hood system was performed in March of 2024. Record review on November 18, 2024 at 11:15 A.M., showed no documentation of the hood system being service semi-annually. During interview on November 18, 2024 at the time of discovery, the Maintenance Director stated he/she had only been at the facility for a month and was not aware the hood system had not been serviced. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 1E6H12 PRINTED: 11/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED R 11/18/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (X6) DATE 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)

PRINTED: 09/13/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X11) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) BATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc BeWiNG, 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16300 JUSTUS POST ROAD CHESTERFIELD, MO 63017 (x4} ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (GACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) GRANDE AT CHESTERFIELD THE | 19 CSR 30-86.047(34)(A) Disease/Infection Conirol, Report Category | The facility shall follow appropriate infection control procedures. The administrator or his or her designee shall make a report to the local health authority or the department of the presence or suspected presence of any diseases or findings listed in 19 CSR 20-20.020, sections (1)-(3) according to the specified time frames as follaws: (A) Category | diseases or findings shall be reported to the local health authority or to the department within twenty-four (24) hours of first knowledge or suspicion by telephone, facsimile, or other rapid communication; |/Il This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to follaw appropriate infection control procedures and standards of practice for the Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic when the facility failed to report all positive COVID-19 cases, for residents and staff, to the appropriate health authority for three residents (Residents #4, #5 and #6) and three staff members. The census was 56. During an interview and observation on 8/29/23 at 8:10 A.M., of the front desk, showed a digital thermometer, masks, hand sanitizer and the Concierge wore a mask. The regulatory auditor asked the Concierge if there was COVID-19 in the building. The Concierge said three residents tested positive for COVID-19 recently, but he/she Missouri Department of Health and Senior Services wl DIRECTOR'S OR PROVIDER/SUPPLIER REPREQENTATIVE'S SIGNATURE TITLE (X86) DATE lf continuation sheet 1 of 3 STATE FORM ey VxXU811 PRINTED: 09/13/2023 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 Cc 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 16300 JUSTUS POST ROAD CHESTERFIELD, MO 63017 (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) GRANDE AT CHESTERFIELD THE Continued From page 1 could not remember how long it has been since the residents tested positive. The Concierge said two of the three residents were in the hospital and he/she knew the other resident, in room 211, was on isolation. The Concierge said there were some employees out with COVID-19 as well, but he/she did not know who or for how long they have been out. Observation on 8/29/23 between 8:56 A.M. and 2:00 P.M., of resident room 211, right outside the door, showed a black plastic, three compartment storage container with personal protective equipment inside each drawer. Review of documentation provided by the facility on 8/29/23, showed the following: -Three residents tested positive for COVID-19, Residents #4, #5 and #6; -Two employees (Care Associates) tested positive for COVID-19 and were out of the facility. Review of the Department of Health and Senior Services/Section for Long-Term Care Regulation (DHSS/SLCR) COVID-19 positive report on 8/29/23, showed no reported residents and no reported staff tested positive for COVID-19. During an interview on 8/29/23 at 10:00 A.M., the Business Office Manager said there were three employees out with COVID-19. There were two Care Associates out with COVID-19 and another employee, who was a Nurse, out with COVID-19. During interviews on 8/29/23 at 10:30 A.M. and on 8/30/23 at 11:18 A.M., the Administrator said she had one resident positive with COVID-19 in the building, Resident #6. Two other residents, Residents #4 and #5, were at the hospital. Both Residents #4 and #5 tested positive when they Missouri Department of Health and Senior Services STATE FORM 6899 VXU811 If continuation sheet 2 of 3 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 16300 JUSTUS POST ROAD CHESTERFIELD, MO 63017 GRANDE AT CHESTERFIELD THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 arrived at the hospital. The Administrator did not know for certain if the two residents were positive while at the facility or when they got to the hospital because she did not know when the hospital tested the residents. The Administrator said she had three employees out with COVID-19. The Administrator said she was not aware she had to report positive COVID-19 tests to the Department for residents and staff members. The Administrator said she and the prior Administrator had a short time period of overlap and he told her the facility did not have to report the positive cases to the Department. The Administrator said her corporate team also told her she did not have to report the positive cases to the Department. M000223801 Missouri Department of Health and Senior Services STATE FORM 6899 VXU811 PRINTED: 09/13/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/30/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: Street Address, City, Zip: Date of Survey: The Grande at Chesterfield 16300 Justus Post Rd, Chesterfield MO, 63017 L August 30, 2023 (D PREFIX TAG A4773 26D2127431 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 44321 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The facility will follow appropriate infection control procedures and standards of practice for the Coronavirus Disease 2019, and report to local health authority or to the department within 09/20/2023 twenty-four (24) hour of first knowledge or suspicion by telephone, facsimile, or other rapid communication Residents who test positive at the facility for Coronavirus Disease 2019 have the potential to be affected. Resident #6's positive Coronavirus results was electronically reported on 09/05/2023 on MODROP : | Vice President of Operations in serviced Executive Director of reporting positive Coronavirus results The Executive Director or designee will monitor Coronavirus testing and reporting of positive cases on a weekly basis for 4 weeks, and will review monthly during QA for 3 months. ——— The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their app roval of the plan of correction being submitted on this form.