SUNRISE OF CHESTERFIELD.

PRINTED: 05/01/2026 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 Cc 23767B B. WING 04/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD CHESTERFIELD, MO 63017 SUMMARY STATEMENT OF DEFICIENCIES 'D PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUNRISE OF CHESTERFIELD A2016 19 CSR 30-85.022(8)(D) Fire Extinguisher | UL/FM, Monthly Check Fire Extinguishers. _ (D) All fire extinguishers shall bear the label of _ the UL or the FM Laboratories and shall be _ installed and maintained in accordance with NFPA 10, 1998 edition. This includes the ! documentation and dating of a monthly pressure | check. Ill | This regulation is not met as evidenced by: | Class il* Based on observation and interview, the facility _ failed to ensure fire extinguishers received a ' monthly visual inspection. This failure had the _ potential fo affect all staff and residents. The | facility census was 67. | 4, Observation on 4/16/26 at 10:44 A.M., showed _ a portable fire extinguisher service tag on the | main floor, in the area near the Fire Contro! Panel i which was marked for visual inspection on _ 10/4/25 and 11/1/25, There were no other visual _ inspection dates documented. | 2. Observation on 4/16/26 at 11:39 A.M., showed _a fire extinguisher on the 2nd floor in a room at | the top of the stairs, that had a portable golf | putting green. The fire extinguisher service tag | showed the extinguisher was visually inspected | 1140/25, 12/2/25, and 2/12/26. There were no _ other visual inspection dates documented. _ 3. Observation on 4/16/26 at 11:42 A.M., showed _ a fire extinguisher on the 2nd floor in the vicinity _ of the elevator and faundry. The service tag was | marked as visually inspected on 10/11/25, | 11/1/25,12/2/25, 1/1/26, and 4/2/26. No February | or March 2026 visual inspections were Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE THLE Shy ar we . 6899 FOS814 {€ continuation sheet 1 of 22 PRINTED: 05/01/2026 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 Cc 23767B — 04/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON 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) SUNRISE OF CHESTERFIELD Continued From page 1 documented. 4. Observation on 4/16/26 at 11:57 A.M., showed a fire extinguisher located on the 3rd floor nearest to the elevator and electrical room. The service tag was marked as visually inspected 10/11/25, 11/1/25, 12/2/25, 1/1/25, 2/16/26, and 4/2/26. No March 2026 visual inspection was documented. 5. Observation on 4/16/26 at 11:59 A.M. of a fire extinguisher located near room 321 and the exit stairs, showed the extinguisher service tag was marked for 11/10/25, 12/2/25, 1/1/26, 2/16/26, and 4/2/26. No March 2026 visual inspection was documented. 6. During an interview on 4/17/26 at 10:31 A.M., the facility Maintenance Coordinator said fire extinguishers were checked monthly. He expected all fire extinguishers to be checked monthly and the service tag to be initialed and dated for that inspection. 7. During an interview on 4/17/26 at 10:51 A.M., the Administrator said she expected all of the fire extinguishers to be inspected monthly. *The higher classification merited due to the extent of the violation. 19 CSR 30-85.042(40) Nursing Staff-Non-nursing Duties if 20- Res Nursing personnel in facilities with twenty (20) residents or less shall perform non-nursing duties only if acceptable infection control measures are maintained. II/III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 FO5S11 If continuation sheet 2 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Class II* Based on interview and record review, the facility failed to ensure a valid exception was in place regarding certified nursing assistants routinely performing non-nursing duties. The census was 67. Review of the approval exception letter, dated 11/3/20, showed the facility was approved for an exception to regulation 19 CSR 30-85.042 (40). The exception will be valid for four years. If the exception required renewal, the facility should request renewal 45 days prior to the expiration date of 11/30/24. Review of the exceptions on 4/15/26, prior to the start of the onsite licensure, showed no current exception had been granted. During an interview on 4/17/26 at 1:48 P.M., the Executive Director said the facility aides completed tasks such as laundry, housekeeping tasks and meal services. The facility did not re-apply for the exception and should have. She would contact corporate to assist to re-apply for the exception. *The higher classification merited due to the extent of the violation. 19 CSR 30-85.042(45) Written Orders; Restraints No medication, treatment, or diet shall be given without a written order from a person lawfully authorized to prescribe such and the order shall be followed. No restraint shall be applied except as provided in 13 CSR 15-18.010, Resident Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 23767B NAME OF PROVIDER OR SUPPLIER 1880 CLARKSON ROAD SUNRISE OF CHESTERFIELD 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 3 Rights. I/II This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to ensure a resident who had a left forearm wound received wound assessment, and wound care orders (Resident #2). The facility also failed to ensure wound care orders were in the facility's physician order sheets for a resident who received wound care by an outside provider (Resident #3). In addition, the facility failed to provide required providers on the resident's face sheet and assess and obtain orders for the resident to self-administer medication (Resident #11). The sample size was 11. The census was 67. 1. Review of the Skin Care management program, dated 1/2019, showed: -Introduction: describes the interdisciplinary approach to skin care; -The treatment that uses a standard approach to promoting and healing and prevent infection when breakdown occurs; -Goal: help residents attain or maintain the highest level of well-being and manage injuries; -Objectives: -Create individualized service plan for residents with wounds; -ldentify new wounds; -Document a change of condition; -Provide standardized treatment and interventions that promote healing and infection prevention; -Evaluate the effectiveness of interventions through care planning process and make Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 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 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 23767B NAME OF PROVIDER OR SUPPLIER 1880 CLARKSON ROAD SUNRISE OF CHESTERFIELD 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 4 changes, as necessary to prevent further injury; -Provide team member education, training and resources; -ldentification: Care managers often identify skin issues in the course of care; -Injuries identified during care, the care manager should inform the nurse; -The nurse determines that the identified area is a new injury, the nurse should: -Complete an assessment and document the results into the progress notes in the record; -Complete a pain evaluation and document the results; -Discusses the injury with the resident and discuss next step and complete an incident report; -Notification and coordination of care: -Notify the physician and collaborate on a treatment order; -Notify the resident, family, additional care providers and legal representative; -Notify the interdisciplinary team about the wound and the role in observation and reporting; -Review and root cause analysis: -determine potential causes of the injury; -reviews and updates the individualized service plan of care (ISP); -educate and train care manager and department coordinators on any new treatment and interventions; -Communicate with the IDT (interdisciplinary team); -Planning: An individualized plan: -The nurse communicates with the medical provider, reports the wound evaluation results and obtains an order for wound management. The medical provider may also recommend additional support from a home health agency; -Based upon the assessment, the IDT develops an ISP to decrease the risk of skin Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 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 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 breakdown or treat any current skin breakdown. The plan will include interventions specific to the risk factor identified through the assessment process this will meet the resident needs and educate the care managers with the information; -Skin integrity/Wound care guidelines: -The guidelines are used as an additional resource to help the health care provider determine which topical treatments should be considered. The order must contain the following components: -Location: the location of the site for which the treatment order is being requested; -Cleaning agent: the cleaning agent that should be used to clean the site; -Primary dressing: the primary dressing to be used; -Secondary dressing: the secondary dressing to be used, if necessary; -Frequency: the frequency of the dressing change. 2. Review of Resident #2's medical record, showed: -Re-admitted: 10/24/25: -Diagnoses included: kidney disease, depression, fall history and diabetes; -Able to make needs and wants known. Observation and interview on 4/16/26 at 1:28 P.M., showed a bandage to the resident's left forearm. The bandage was undated and an area of yellow drainage was noted to the surface of the bandage. The resident said he/she experienced a skin tear (surface of the skin is damaged) while outdoors in the patio area a few days ago. The staff applied a dry dressing to the wound. No further care had been provided by the facility staff to the wound. Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 Review of the weekly wound evaluation report, showed it did not list the resident. Review of the current electronic physician order sheet (ePOS), showed no current wound care orders or treatments to the left forearm. Review of the ISP, dated 10/10/25, showed: -Focus: skin; -Goal: educate and encourage good nutrition and hydration, open skin surgical area due to skin cancer removed and radiation treatment was completed, keep skin clean and dry, observe and report changes in skin condition. During an interview on 4/16/26 at 1:20 P.M., Care Manager A said he/she assisted the resident with dressing when needed. He/She noted the dressing to the resident's left arm, he/she assumed the nurse was aware of the area. The dressing had been in place several days. Review of the progress notes, showed no documented entries regarding the wound to the left forearm. 3. Review of Resident #3's medical record, showed: -Admitted: 1/9/26; -Diagnoses included diabetes, high blood pressure, vascular disease, lung disease and fall history; -Able to make needs and wants known. Review of the progress notes, showed: -On 3/20/26 at 8:14 A.M., a health status note: steri-strips to the left forearm intact. Staff encourage the resident to allow the area to be open to air (OTA, leave wound uncovered). Moderate drainage and slight odor noted. The Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 resident agreed to leave OTA during the day, and requested a dressing at night to prevent catching on bed sheets; -On 3/21/26 at 1:42 P.M., a health status note: steri-strips remained OTA. Area cleaned with wound cleanser and applied triple antibiotic ointment (TAO, topical antibiotic cream) and the resident agreed to leave the area OTA. Assured the resident a boarded gauze dressing would be applied before he/she went to bed for protection against the bed sheets. Review of the ISP, updated 4/3/26, showed: -Focus: skin; -Goal: the resident will not develop any breakdown through the review date and minimize the risk of breakdown; -Interventions: educate and encourage good nutrition, encourage times of rest out of the wheelchair and time to rest in bed. Staff should observe and report any changes in skin to the nurse. Observation and interview on 4/16/26 at 1:28 P.M., showed a dressing to the left forearm dated 4/13/26. The resident said he/she burned his/her arm and developed a skin tear. The home health agency nurse visited a few times a week to apply a treatment. Review of the current ePOS, showed no wound care orders. During an interview on 4/17/26 at 12:05 P.M., the Resident Care Director (RCD) said she expected all wound care orders to be listed on the facility POS. If a resident received wound care from home health, the facility should reflect the orders, so if the dressing needed to be changed, the facility nurse would have wound care orders to Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 administer. The wound measurements and documentation should reflect in the facility documentation. The care members should report all changes in skin condition to the facility nurse for assessment. The nurse should assess and document the wounds and obtain orders and home health care orders. During an interview on 4/17/26 at 1:48 P.M., the Executive Director (ED) said she expected all ordered to be accurately documented in the facility orders. ISP's should be current and reflect the current needs of the residents. 4. Review of Resident #11's medical record, showed the following: -Admission date: 5/27/25; -Diagnoses of hyperlipidemia (high cholesterol), dementia, anxiety, diabetes mellitus, hypertension (high blood pressure). Review of the resident's face sheet, showed no documented information for the following: -Pharmacist; -Physician; -Funeral home; -Dentist; -Next of kin (NOK). During an interview on 4/17/26 at 9:10 A.M., the resident said he/she self-administered some of his/her medications. He/she self-administered his/her naproxen (treats pain) 500 milligrams (MG) and his/her Levothyroxine (hormone). He/She had other medications the facility administered for him/her. For the Naproxen and the Levothyroxine, he/she marked off the date and initialed the package beside each hole, so staff knew he/she had taken it. He/She just started doing this a few days ago. Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 23767B NAME OF PROVIDER OR SUPPLIER 1880 CLARKSON ROAD CHESTERFIELD, MO 63017 SUNRISE OF CHESTERFIELD SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 9 Review of resident's service plan, showed no indication of the resident's ability to self-administer his/her own medication. Review of resident's physician order sheet (POS), showed no order for a self-administration assessment for the resident. Review of the progress notes, showed no self-administration assessment had been completed for the resident. During an interview on 4/17/26 at 1:30 P.M., the ED said she would expect for a self-administration assessment to be in the resident's medical file in addition to a physician order for the resident to self-administer medication. The Wellness nurse was responsible for ensuring self-administration assessments were completed. All residents face sheets should include providers for dental, medical, pharmacy, funeral home and the resident's next of kin. This information should be gathered at the time of admission. 19 CSR 30-87.020(12) Floor Surfaces All floors in the facility shall be clean and shall be maintained in good repair. Floors and floor coverings of all food-preparation, food-storage and utensil-washing areas, and the floors of all walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealed concrete, terrazzo, ceramic tile, durable grades of linoleum or plastic, or tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip floor covering in Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 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 10 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 areas where necessary for safety reasons. Ill This regulation is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the kitchen floor was clean and free of debris and stains. This deficient practice had the potential to affect all residents who consumed food from the facility kitchen. The census was 67. Review of the facility's Food Storage, Preparation and Service Policy dated 8/7/25, showed: -Responsible Parties: -Dining Services Coordinator/Director; -Policy Statement: -Safe food handling practices are followed during the storage, preparation, and service of food; -Scope: -This policy applies to US and Canadian communities. Communities must comply with applicable state/provincial laws and regulations; -Highlights: -General Food Handling: -Definitions: -A food storage area includes walk-in and reach in refrigerators and freezers, under counter refrigeration and freezer units, bistro and common area refrigeration and freezer units, and any dry storage units; -Action Steps: -General Food Handling: -Food storage areas are clean and orderly, and free from moisture, insects, rodents, and physical and chemical hazards; -All food items are labeled, dated and rotated to maintain a system of First In First Out (FIFO); -Expired food is discarded; -Food Preparation: Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 -Food is prepared on clean, sanitized surfaces with clean, sanitized equipment and tools. Appropriate precautions are taken to prevent cross-contamination during production; -Label and date the container(s); -Left-over food must be properly cooled, covered, labeled, dated, refrigerated, reheated no more than one (1) time, and discarded if not used within three (3) days. Review of the facility's Kitchen Safety and Sanitation Policy, reviewed 8/7/25, showed: -Responsible Parties: -Dining Services Coordinator/Director; -Executive Chef; Policy Statement: -Proper precautions are followed in the kitchen to ensure a safe and sanitary production environment; Scope: -This policy applies to US and Canadian communities. Communities must comply with applicable state/provincial laws and regulations; -Equipment Safety: -Equipment Safety: -The Dining Services Coordinator/Director (DSC/DSD) trains team members on the safe and proper use, maintenance and cleaning of all kitchen equipment; -The DSC/DSD retains operating instructions for all kitchen equipment Instructions are available to all team members; -Kitchen Sanitation: -Kitchen Sanitation: -The DSC/DSD ensures the completion of Form 751 - Daily Cleaning Schedule, Form 752 - Weekly Cleaning Schedule, and the Satellite Kitchen Daily and Weekly Cleaning Schedule. The DSC/DSD Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 23767B NAME OF PROVIDER OR SUPPLIER 1880 CLARKSON ROAD SUNRISE OF CHESTERFIELD 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 12 retains completed cleaning schedules for a minimum of one (1) year, or in accordance with state/provincial regulations if a longer retention period is required. -The DSC/DSD ensures the completion of regularly scheduled quarterly and annual cleaning and maintenance of equipment in collaboration with the Maintenance Coordinator (MC). Observation of the Kitchen 2/16/26 at 9:47 A.M., showed food crumbs, dirt, debris and stains on the floor. Review of the Kitchen's Monthly Cleaning Schedule, showed no tasks marked for the month of April 2026. During an interview on 4/17/26 at approximately 2:30 P.M., the DM said it was his expectation that the kitchen floor should be swept, clean, mopped, and free of debris and stains. General cleaning was done daily. With some items, deep cleaning, done weekly. 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure the Dietary Manager (DM) wore a beard net while working in Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 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 13 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 the kitchen. This deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 67. Review of the facility's Uniforms and Personal Hygiene for Food Service policy, reviewed 8/7/25, showed: -Responsible Parties: -Dining Services Coordinator/Director; -Neighborhood Coordinator; -Policy Statement: -Team members follow uniform and personal hygiene guidelines to present a professional appearance and promote a safe and sanitary Dining Services operation; -Scope: -This policy applies to US and Canadian communities. Communities must comply with applicable state/provincial laws and regulations; -Definitions: -Approved Hair Restraints are hair nets, Sunrise logo baseball caps, solid black or white skull caps, or white toques (DSC/DSD only); -Highlights: -Uniform requirements for Dining Services Coordinator/Director and cooks -Action Steps: -Uniform Requirements: -Dining Services Coordinator/Director and Cooks: -Approved hair restraint; -Uniform Requirements for Dishwashers: -Dish Washer: -Approved hair restraint; -Hygiene: -Hair is neat and clean, and worn pulled away from the face. An approved hair restraint is worn at all times while preparing or plating food; -Facial hair is trimmed, neat and clean. A beard net is worn over facial hair at all times while Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 14 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 preparing or plating food. Observation of the DM in the kitchen on 2/16/26 at 9:47 A.M., showed him to have a full facial beard measuring approximately one to two inches in length without a beard net on. During an interview on 4/17/26 at approximately 2:30 P.M., the DM said he should have had a beard net over his beard. It was his expectation that all staff would wear hair restraints and/or a beard net if they had facial hair. 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 15 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 This regulation is not met as evidenced by: Class |I* Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to label, date, and cover food and discard outdated Mildly Thick Nectar (thickener). These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 67. Review of the facility's Food Storage, Preparation and Service Policy dated 8/7/25, showed: -Responsible Parties: -Dining Services Coordinator/Director; -Policy Statement: -Safe food handling practices are followed during the storage, preparation, and service of food; -Scope: -This policy applies to US and Canadian communities. Communities must comply with applicable state/provincial laws and regulations; -Highlights: -General Food Handling: -Definitions: -A food storage area includes walk-in and reach in refrigerators and freezers, under counter refrigeration and freezer units, bistro and common area refrigeration and freezer units, and any dry storage units; -Action Steps: -General Food Handling: -Food storage areas are clean and orderly, and free from moisture, insects, rodents, and physical and chemical hazards; -All food items are labeled, dated and rotated to maintain a system of First In First Out (FIFO); Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 16 -Expired food is discarded; -Food Preparation: -Food is prepared on clean, sanitized surfaces with clean, sanitized equipment and tools. Appropriate precautions are taken to prevent cross-contamination during production; -Label and date the container(s); -Left-over food must be properly cooled, covered, labeled, dated, refrigerated, reheated no more than one (1) time, and discarded if not used within three (3) days. 1. Observation of the Kitchen on 2/16/26 at 9:47 A.M., showed: -Walk in cooler; -Two packages of mini carrots wrapped in plastic and without a date; -Old brown food item, appeared to be old wilted lettuce and without a date; -A plastic bag of green leafy food item tied in a knot at the end of bag and without a date; -A package of tortillas completely opened and exposed to air and without a date; -A quart of half and half without a date; -Walk in freezer; -An opened box of catfish fillets exposed to air; -An opened box of veggie burgers exposed to air; -An opened box of pita bread, box turned on the side with the pita bread halfway out the box, exposed to air; -An opened box of shredded mozzarella; -An opened box of egg rolls exposed to air; -A plastic bag that contained French fries, opened and exposed to air; -Dry storage room: -A Ziploc bag that contained crispy fried onions, without a date; Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 17 of 22 PRINTED: 05/01/2026 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 Cc 23767B — 04/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON 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) SUNRISE OF CHESTERFIELD Continued From page 17 -A package of Confectioners Care Sugar, wrapped in plastic and without a date; -An opened bag of pecans sat inside of a box without a date; -A packaged of spaghetti rolled up, not wrapped in plastic and without a date; -An opened package of graham crumbs sat in a box, not wrapped in plastic and without a date; -The sugar bin, no lid on bin; sugar exposed to air; -The flour bin, no lid on bin; flour exposed to air; -The salt bin, no lid on bin; salt exposed to air; 2. Observation of the Kitchen's dry storage room on 2/16/26 at 9:47 A.M., showed: -Four boxes of Mildly Thick Nectar, with best if used by date of 2/5/25; -Four boxes of Mildly Thick Nectar, with best if used by date of 6/11/24; -One box of Mildly Thick Nectar, without a best if used by and/or expiration date 3. During an interview on 4/17/26 at approximately 2:30 P.M., the Dietary Manager (DM) said it was his expectation that all food items were to be properly labeled, dated, and stored. It was also expected that the dairy thickened product should have been discarded. They didn't use them, and he kept them in there in the storage room for a while. He just hadn't had a chance to discard it. It was currently just him and another staff member. He had to let a brand new cook go only after three weeks because he was refusing to do things the right way so he was still "picking up the pieces" from the cook. *The higher classification merited due to the Missouri Department of Health and Senior Services STATE FORM 6899 FO5S11 If continuation sheet 18 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 extent of the violation. 19 CSR 30-87.030(54) Nonfood Contact Surfaces, Cleaning Surfaces of equipment not intended for contact with food, but which are exposed to splash or food debris or which otherwise require frequent cleaning, shall be designed and fabricated to be smooth, washable, free of unnecessary ledges, projections or crevices, and readily accessible for cleaning, and shall be of such material and in a repair as to be easily maintained in a clean and sanitary condition. Ill This regulation is not met as evidenced by: Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure that the kitchen equipment was clean. This deficient practice had the potential to affect all residents who consumed food from the facility kitchen. The sample size was 11. The census was 67. Review of the facility's Food Storage, Preparation and Service Policy, dated 8/7/25, showed: -Responsible Parties: -Dining Services Coordinator/Director; -Policy Statement: -Safe food handling practices are followed during the storage, preparation, and service of food; -Scope: -This policy applies to US and Canadian communities. Communities must comply with applicable state/provincial laws and regulations; -Highlights: Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 19 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 23767B NAME OF PROVIDER OR SUPPLIER 1880 CLARKSON ROAD SUNRISE OF CHESTERFIELD 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 19 -General Food Handling: -Definitions: -A food storage area includes walk-in and reach in refrigerators and freezers, under counter refrigeration and freezer units, bistro and common area refrigeration and freezer units, and any dry storage units; -Action Steps: -General Food Handling: -Food storage areas are clean and orderly, and free from moisture, insects, rodents, and physical and chemical hazards; -All food items are labeled, dated and rotated to maintain a system of First In First Out (FIFO); -Expired food is discarded; -Food Preparation: -Food is prepared on clean, sanitized surfaces with clean, sanitized equipment and tools. Appropriate precautions are taken to prevent cross-contamination during production; -Label and date the container(s); -Left-over food must be properly cooled, covered, labeled, dated, refrigerated, reheated no more than one (1) time, and discarded if not used within three (3) days. Review of the facility's Kitchen Safety and Sanitation Policy, reviewed 8/7/25, showed: -Responsible Parties: -Dining Services Coordinator/Director; -Executive Chef; Policy Statement: -Proper precautions are followed in the kitchen to ensure a safe and sanitary production environment; Scope: -This policy applies to US and Canadian communities. Communities must comply with Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 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 20 of 22 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23767B NAME OF PROVIDER OR SUPPLIER SUNRISE OF CHESTERFIELD (X2) MULTIPLE CONSTRUCTION A. BUILDING: CHESTERFIELD, MO 63017 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 applicable state/provincial laws and regulations; -Equipment Safety: -Equipment Safety: -The Dining Services Coordinator/Director (DSC/DSD) trains team members on the safe and proper use, maintenance and cleaning of all kitchen equipment; -The DSC/DSD retains operating instructions for all kitchen equipment Instructions are available to all team members; -Kitchen Sanitation: -Kitchen Sanitation: -The DSC/DSD ensures the completion of Form 751 - Daily Cleaning Schedule, Form 752 - Weekly Cleaning Schedule, and the Satellite Kitchen Daily and Weekly Cleaning Schedule. The DSC/DSD retains completed cleaning schedules for a minimum of one (1) year, or in accordance with state/provincial regulations if a longer retention period is required. -The DSC/DSD ensures the completion of regularly scheduled quarterly and annual cleaning and maintenance of equipment in collaboration with the Maintenance Coordinator (MC). 1. Observation of the Kitchen on 2/16/26 at 9:47 A.M., showed: -Oven: -Right side oven: -Food particles lay at the bottom of oven; -Caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, and sides of oven; -Left side oven: -Caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, Missouri Department of Health and Senior Services STATE FORM 6899 FOSS11 PRINTED: 05/01/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 21 of 22 PRINTED: 05/01/2026 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 Cc 23767B — 04/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1880 CLARKSON 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) SUNRISE OF CHESTERFIELD Continued From page 21 and sides of oven; -Stand-along oven: -Caked-on stains along the front inside doors; -Heavy charcoaled stains along the bottom of oven; -Caked stains along the sides of oven; 2. Review of the Kitchen's Monthly Cleaning Schedule, showed no tasks marked for the month of April 2026. 3. During an interview on 4/17/26 at approximately 2:30 P.M., the Dietary Manager said it was his expectation that the kitchen should be cleaned. General cleaning was done daily. With some items, deep cleaning, done weekly. It was currently just him and another staff member. He had to let a brand new cook go only after three weeks because the cook refused to do things the right way so he was still "picking up the pieces" from the cook. Missouri Department of Health and Senior Services STATE FORM 6899 FO5S11 If continuation sheet 22 of 22 PLAN OF CORRECTION Sunrise of Chesterfield ame: Street Address, City, Zip: jensen 4/16/26 & 4/17/26 ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE On 4/17/26, the Maintenance Coordinator completed an . immediate visual inspection of 100% of fire extinguishers throughout the facility. All fire extinguishers were checked for: e UL/FM labeling e Pressure within operable range e Pin and seal integrity e Proper placement and accessibility All missing monthly visual inspection dates were documented on the service tags, and any tags lacking sufficient space were replaced. The inspections were dated and initialed in accordance with NFPA 10 (1998 edition) requirements. 1880 Clarkson Road Chesterfield, MO 63017 A facility-wide review was conducted on 4/17/26 to identify whether any additional fire extinguishers lacked consistent monthly inspection documentation. The review confirmed that all extinguishers had been inspected and brought into compliance, correcting the identified gaps A2016 across all floors and locations. 4/20/26 Fire Extinguisher Monthly Inspection Log was implemented to supplement service tags and ensure consistent tracking. The Maintenance Coordinator was re-educated on 4/17/26 regarding regulatory requirements for: e Monthly visual inspections e Initialing and dating service tags e £nsuring no months are missed The Executive Director or designee will conduct monthly audits of fire extinguisher inspection documentation for three (3) months. After three months of sustained compliance, monitoring will continue on a quarterly basis. Audit results will be documented and reviewed through the Quality Assurance and Performance Irhprovement (QAPI) process. Any missed or incomplete inspections will be immediately corrected, and additional staff education will be provided as necessary. On 5/5/26, the Executive Director submitted an application to the Department of Health and Senior Services requesting renewal/approval of the required exception allowing certified nursing assistants (CNAs) to perform limited non-nursing duties. The Executive Director reviewed facility regulatory documentation on 5/5/26 to ensure no other required exceptions or approvals were expired or missing. No additional missing or expired exceptions were _ identified. The facility implemented a Regulatory Exception 5/5/26 Tracking Log that includes: Approval date Expiration date Required renewal timeframe The Executive Director will review the exception: status annually. The exception status will also be reviewed 90 days prior to expiration to ensure timely renewal submission. For Resident #2, on 5/5/26, the wellness nurse assessed the left forearm wound upon identification, documented the assessment, and notified the physician. A complete wound care order was obtained, including wound location, cleansing agent, dressing type, and frequency. The wound was added to the weekly wound evaluation report, and ongoing monitoring was initiated. For Resident #3, on 5/5/25, the Wellness Nurse reviewed the resident's record and confirmed the resident was receiving wound care services from a home health agency. The facility obtained and entered the current wound care orders from the outside provider into the facility's physician order sheet (POS) to ensure continuity of care when facility staff assist with wound management. Facility documentation was updated to reflect wound assessments and collaboration with home health. For Resident #11, on 5/6/26, the Wellness Nurse compieted a self-medication assessment after learning the resident had begun self-administering certain medications. A physician order for 5/7/26 self-administration was obtained and documented. The resident's service plan and progress notes were updated to reflect the resident's assessed ability to safely self-administer medications. Missing face sheet information (physician, pharmacist, dentist, funeral home, and next of kin) was obtained and documented. On 4/20/26, the Wellness Nurse conducted a review of all residents currently receiving wound care and all residents with any degree of self-medication privileges. The review verified that wound assessments had corresponding physician orders documented in the facility POS and that residents self-administering medications had both a documented assessment and physician authorization. Any missing documentation identified during this review was corrected at the time of discovery. The facility reinforced its Skin Care Management Program to require immediate nurse assessment and physician notification for all newly identified wounds, regardless of severity. Nursing and care staff were re-educated on the standardized wound identification and reporting process. The facility also reinforced the requirement that all wound care provided by outside agencies must have corresponding orders documented in the facility's physician order sheet (POS). Nursing leadership will ensure that orders are obtained, transcribed, and available for staff to follow upon initiation of outside services. Regarding medication management, on 4/20/26 the facility re-educated nursing staff and leadership that any resident self-administering medications must first have a completed assessment and physician authorization, with updates reflected in the service plan and medical record. Additionally, admission and record review processes were reinforced to ensure all required face sheet information is obtained and maintained in accordance with regulatory requirements. Compliance will be monitored through monthly review during Interdisciplinary Team (IDT) meetings, including: Residents with wounds to ensure assessments and physician orders are in place and followed Residents receiving services from outside providers to ensure orders are documented in the POS Residents self-administering medications to ensure assessments, physician orders, and care plans are complete , Any deficiencies identified will be corrected immediately, with additional staff re-education provided as needed. Monitoring outcomes will be documented and maintained through the facility’s QAPI process to ensure ongoing compliance. On 4/17/26, upon identification of debris, dirt, and stains on the kitchen floor, dietary staff immediately cleaned and sanitized the kitchen floor to remove all visible debris and stains. The Dining Manager verified that the floor was swept, mopped, and returned to a clean and sanitary condition in accordance with the facility’s Kitchen Safety and Sanitation Policy. Additionally, the Kitchen Monthly Cleaning Schedule - was reviewed and updated to ensure all required daily, weekly, and monthly cleaning tasks were documented for April 2026. 4/20/26 On 4/20/26, the Dining Manager conducted a review of all kitchen and food-service areas, including food storage, preparation, and service spaces, to ensure floors were clean and free of debris. No additional areas were identified as not meeting cleanliness standards at that time. Cleaning schedules were A7003 reviewed to ensure documentation was current and complete. On 4/20/26 the Dining Services Coordinator re-educated kitchen staff on proper cleaning frequencies, documentation requirements, and accountability for maintaining sanitary conditions. The Dining Services Coordinator will now review completed cleaning schedules routinely to ensure all required tasks are completed and documented. Missing or incomplete documentation will be addressed promptly through staff coaching and corrective action as needed. The Dining Services Coordinator or designee will conduct weekly visual inspections of kitchen floors for four (4) weeks to ensure cleanliness is maintained. In addition, monthly reviews of kitchen cleaning schedules will be completed for three (3) months to verify documentation accuracy and completion. Results of inspections and schedule reviews will be documented and reviewed through the Quality Assurance and Performance Improvement (QAP) process. After sustained compliance is demonstrated, monitoring will continue on a quarterly basis. On 4/17/26, the Dietary Manager was immediately educated regarding the requirement to wear an approved beard net while working in food preparation areas. A beard net was applied, and compliance was observed. The kitchen was reviewed to ensure all dietary staff present were wearing appropriate hair restraints in accordance with the facility's Uniforms 4/20/26 and Personal Hygiene for Food Service Policy. On 4/20/26, the Dining Services Coordinator conducted a review of all dietary staff to ensure compliance with hair restraint requirements, including beard nets for staff with facial hair. No additional non-compliance was observed at that time. The facility in-serviced all staff working in food preparation and service areas regarding expectations for maintaining proper hygiene and wearing required hair restraints to prevent contamination. Dietary staff, including the Dietary Manager, were re-educated on 4/20/26 regarding the facility’s Uniforms and Personal Hygiene for Food Service Policy, specifically emphasizing the requirement for approved hair restraints and beard nets while preparing or serving food. The Dining Services Coordinator reinforced expectations that compliance with hygiene standards is mandatory at all times and is a critical component of safe food handling practices. Leadership will enforce adherence through routine supervision and immediate correction of any observed non-compliance. Compliance will be monitored monthly through the facility's Quality Assurance and Performance Improvement (QAPI) program, with oversight by the Dining Services Coordinator to ensure dietary staff consistently adhere to hair restraint and hygiene requirements. Routine observations of staff practices will be conducted, and any identified deficiencies will be corrected immediately with additional re-education as needed. Monitoring results will be documented and maintained through QAPI to ensure sustained compliance. On 4/17/26, all identified food items in the walk-in cooler, freezer, and dry storage areas that were not labeled, dated, covered, or were expired were immediately addressed. Unlabeled and exposed food items were either properly labeled, dated, and 4/20/26 covered or discarded as appropriate. All expired Mildly Thick Nectar products were removed and discarded. The Dietary Manager verified that all food storage areas were organized, covered, labeled, and A7056 ‘Dining Services Coordinator to ensure all food items dated in accordance with facility policy and safe food handling standards. On 4/20/26, the Dining Services Coordinator conducted a comprehensive review of all food storage areas, including walk-in cooler, freezer, and dry storage, to ensure compliance with labeling, dating, covering, and food rotation requirements. No additional expired food items were identified after corrective actions were completed. All areas were confirmed to be in compliance at the time of review. Dietary staff, including the Dietary Manager, were re-educated on 4/20/26 on the facility's Food Storage, Preparation and Service Policy with emphasis on proper labeling, dating, covering, and storage of all food items, as well as adherence to FIFO guidelines and timely disposal of expired products. Expectations were reinforced that all food must be protected from contamination at all times and that compliance with food safety standards is mandatory. Leadership will enforce adherence through routine oversight, ensuring staff consistently follow established policies and complete required food handling practices correctly. Compliance will be monitored monthly through the facility’s Quality Assurance and Performance Improvement (QAPI) program, with oversight by the are properly labeled, dated, covered, and stored, and that expired items are discarded timely. Routine observations and review of food storage practices will be conducted, and any identified deficiencies will be corrected immediately with additional staff re-education as needed. Monitoring results will be documented and maintained through QAPI to ensure sustained compliance. On 4/20/26, all identified kitchen equipment, including ovens noted during survey, were thoroughly cleaned to remove food particles, grease, and caked-on 4/20/26 residue. The Dietary Manager verified that all equipment was returned to a clean and sanitary condition in accordance with facility policy. The Kitchen Monthly Cleaning Schedule was reviewed and updated to ensure cleaning tasks were documented and brought current for April 2026. On 4/20/26, the Dining Services Coordinator conducted a comprehensive inspection of all kitchen equipment, including ovens, preparation surfaces, and additional non-food contact surfaces exposed to debris or splash. No additional equipment was found to be out of compliance after corrective cleaning was completed. Cleaning schedules were reviewed across all areas to ensure all required tasks were identified and documented appropriately. Dietary staff, including the Dietary Manager, were re-educated on 4/20/26 on the facility's Kitchen Safety and Sanitation Policy and Food Storage, Preparation and Service Policy, with emphasis on maintaining all equipment in a clean and sanitary condition. Staff were instructed on proper cleaning frequencies, including daily and scheduled deep cleaning requirements, and on the importance of completing and documenting cleaning tasks on required schedules. Leadership reinforced that maintaining clean equipment is a mandatory expectation and will enforce adherence through routine supervision and accountability for completion of assigned cleaning duties. Compliance will be monitored monthly through the facility's Quality Assurance and Performance Improvement (QAPI) program, with oversight by the Dining Services Coordinator to ensure all kitchen equipment is properly cleaned and maintained. Cleaning schedules will be reviewed for completion and accuracy, and routine observations will be conducted to verify equipment cleanliness. Any identified deficiencies will be corrected immediately with additional staff re-education as needed, and monitoring results will be documented and maintained through QAPI to ensure sustained compliance. 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.