BARATHAVEN MEMORY CARE.

PRINTED: 04/10/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1030 BARATHAVEN DRIVE DARDENNE PRAIRIE, MO 63368 BARATHAVEN ALZHEIMER'S SPECIAL CARE CENTE! (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A3214| 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans | approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, | Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, | Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities | built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not | present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/lll | This regulation is not met as evidenced by: Class Ill | Based on record review and interview the facility failed to properly maintain the buildings electrical wiring. The facility census was 46, This deficiency affects 46 of 46 residents. Arecords review showed no documentation provided for the two year electrical wire | certification. | During an interview on 3-28-2024 at 1:30 P.M. the | maintenance director said he would contact the | electrical company to see when the last one was ment of Health and Senior Services IRECTOR'S OR PROVIDER/SUPPLIER REl RESENTATIVE'S SIGNATURE TITLE (X6) DATE 7PL811 If continuation sheat 1 of 2 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 B.WING 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1030 BARATHAVEN DRIVE DARDENNE PRAIRIE, MO 63368 (X4) ID | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (X6) 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) BARATHAVEN ALZHEIMER'S SPECIAL CARE CENTEI A3214, Continued From page 1 completed. Missouri Department of Health and Senior Services STATE FORM sae9 7PL811 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: So EST Wale Ss [7 oe \ Street Address, ‘DecAerma. wale ce City, Zip: \O=>o Bacc a 2. = Date of Survey: ob Lie-taect 2 ass (ey PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER GAO2Q. ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE Asai¢ |Hader’ Bre cemmrsaern bf. | ol (3) 58h 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.