BOULEVARD SENIOR LIVING OF ST CHARLES,THE.

PRINTED: 11/18/2024 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: COMPLETED A. BUILDING: B WING) 11/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3340 EHLMANN ROAD SAINT CHARLES, MO 63301 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) BOULEVARD SENIOR LIVING OF ST CHARLES, THE 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview the facility failed to use only metal or UL- or FM-fire-resistant rated wastebaskets. The facility census was 87 and this affected 87 of the 87. Observation showed waste basket made of unapproved material being used in the following rooms: rm# 202 one plastic trash can, rm# 205 one plastic trash can, rm# 14 one plastic trash can, rm# 215 two plastic trash cans, rm# 26 one plastic trash can, rm# 119 one plastic trash can, rm 18 one plastic trash can, rm# 211 one plastic trash can, rm 127 one wicker trash can, rm# 226 one plastic trash can, rm# 209 one plastic trash can, rm # 19 one plastic trash can, rm 221 one plastic trash can, rm# 114 one plastic trash can, rm 113 three plastic trash cans, rm# 110 one plastic trash can, rm#103 three plastic trash cans rm# 102 two plastic trash cans, rm#124 one plastic trash can, rm# 216 two plastic trash cans, tm# 217 two plastic trash cans, and rm# 218 one plastic trash can. Only metal, listed FM, or UL fire resistance wastebaskets shall be used. During an interview on 2-21-2024 at 1:08 P.M., the maintenance director said the residents bring them in on their own, but he will remove them. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles . Missouri Department of Health and Senior Services LABORATORY,DIRECTOR'S OR. PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE NHK [i 37-ad STATE — If continuation sheet 1 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 BOULEVARD SENIOR LIVING OF ST CHARLES, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT CHARLES, MO 63301 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/IIl This regulation is not met as evidenced by: **Class Il Based on observation and an interview showed the facility failed to prevent extension cords, powerstrips, and six-way adapter from being used that allow more than two electrical items to be plugged into a duplex receptacle in resident's rooms. The facility census was 87. This potentially affected 87 of 87 residents. Observations during walk through showed the following resident rooms that either had extension cords with more than one item plugged into them, power strips connected to another multi-plug device, or that had multi-plug adapters plugged in; rm# 215 had two power strips in the same outlet, rm# 102 has an extension cord with two devices plugged into it, Memory Care Break Room had three powerstrips plugged into the same outlet, rm# 111 had multi-plug with a power strip plugged into it, rm# 202 had two extension cords plugged to same outlet, rm# 227 had an extension cord with three items plugged in, rm# 103 had a double extension cord with multiple items plugged into it, rm# 201 had a four way adapter with multiple items plugged into it, rm# 232 had power strip plugged into a six way Missouri Department of Health and Senior Services STATE FORM 6899 BMMZ11 PRINTED: 11/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/13/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3340 EHLMANN ROAD PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3340 EHLMANN ROAD BOULEVARD SENIOR LIVING OF ST CHARLES, THE SAINT CHARLES, MO 63301 PRINTED: 11/18/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/13/2024 (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 Continued From page 2 adapter, and rm# 130 had power strip plugged into a six way adapter, During an interview on 8/24/23 at 3:42 P.M. the director said she would educate the residents, families, and staff. They will be removing the items. ** The higher Class is merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 BMMZ11 DEFICIENCY) If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Name: . Boulevard Senior Living of Saint Charles Street Address, City, Zip: 3340 Ehlmann, St. Charles, MO, 63301 Date of Survey: 11.13.2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM- | Requirements Ps | a | ———___si{ Identify Other Areas with Potential to Be Affected: fF ia Since all apartments, office and common spaces could be affected, we will conduct a thorough audit of all areas where 12.18.2024 | The community failed to ensure only metal or UL- or-FM-fire- resistant rated wastebaskets were used for trash. Corrective Actions Taken: Immediate Removal and Replacement - All wastebaskets found to be non-compliant were removed at the time of the survey. Family and Resident notification: All families and residents with deficient wastebaskets were notified and some families opted to replace with metal trash cans. They were given the option to purchase fire resistant through the community. wastebaskets are used. Measures to Be Put in Place: | 12.18.2024 New wastebaskets purchased by the community will only be done by designated staff in Plant Operations ensuring compliance with fire codes. Develop and maintain a list of approved wastebasket models for all areas of the facility and incorporate this list to new hire orientation for housekeeping and plant operations staff. This will be a topic of education at resident town halls. Monitoring for compliance: The Plant Operations Director or designee will complete monthly audits for 3 months to ensure non-compliant waste baskets have not been brought into the community. Following this, ongoing 12.18.2024 quarterly audits will be completed. For ongoing monitoring, wastebasket compliance will be added 12.18.2024 an item on housekeeping check off lists. ot es es 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles PY Pd 12.11.2024 surrounding both extension cords and duplex receptacles, so they can replace with compliant devices. Identification of Potentially Affected Areas | audits of electrical outlets and devices for 3 months to ensure only compliant wiring is being used. Following this, ongoing quarterly audits will be completed. —_ The community failed to ensure extension cords would only be | | Since all apartments, office and common spaces could be affected, we will conduct a thorough audit of all areas where 12.11.2024 extension cords or duplex receptacles could be used. [| | | | used as temporary wiring and only one appliance connected to one extension cord and only two appliances may be served by one duplex receptacle. Corrective Actions: Identify and remove any non-compliant or unsafe extension cords and duplex receptacles. Notify and educate family and residents on compliant duplex receptacles and the rules Measures to Be Put in Place: | An in-service for all staff, educating staff about the risks of using extension cords improperly, including fire hazards, and the need to use power strips with surge protection for non-essential use. This will be a topic of education at resident town hall meetings. Monitoring for Compliance | The Plant Operations Director or designee will complete monthly 12.18.2024 12.18.2024 rr ee ee 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.

THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) PRINTED: 10/26/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 31029 $$ 10/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3340 EHLMANN ROAD SAINT CHARLES, MO 63301 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE BOULEVARD SENIOR LIVING OF ST CHARLES A3220| 19 CSR 30-86.032(19) Elevator Requirements lf elevators are used, installation and maintenance shall comply with local and state codes and the National Electric Code. [/Hl This regulation is not met as evidenced by: Class Ill Based on record review and interview the facility failed fo have a current approved elevator inspection certification from either the city or the state available. The facility census was eighty-eight (88). This affected eighty-eight (88) of eighiy-eight (88) residents. Record review showed the current posted state elevator inspection certificates for all the elevators expiring on 8-12-2023. During an interview on 10/23/2023 at 1:00 P.M. the director of plant operations stated he/she it is scheduled to be completed. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {X6} DATE STATE FORM 8838 63V811 Hf continuation sheet 1 of 4