CRAB APPLE VILLAGE SENIOR ESTATES.

THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) PRINTED: 02/09/2026 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 10/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 (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) CRAB APPLE VILLAGE SENIOR ESTATES 19 CSR 30-86.022(7)(G) Stairways/Corridors Free of Obstructions Exits, Stairways, and Fire Escapes. (G) All stairways and corridors shall be easily negotiable and shall be maintained free of obstructions. II This regulation is not met as evidenced by: Class II Based on an observation and interview during the fire safety inspection process on October 7, 2025, the facility failed to maintain their exit corridors free of obstructions. The facility census was sixty (60). This deficiency affected sixty (60) of sixty (60) residents. Observation on October 7, 2025 at 2:45 PM revealed the basement rear exit corridor partially obstructed with beds, furniture, and assistive devices. During the exit interview on October 7, 2025 at 3:25 PM, the DON advised she would have staff clear the hallway. 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II This regulation is not met as evidenced by: Class II Based on record review and interview during a Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 x0S611 If continuation sheet 1 of 5 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 (X2) MULTIPLE CONSTRUCTION PRINTED: 02/09/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/07/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 1 fire safety inspection process on October 7, 2025, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed.. The facility census was sixty (60). This deficiency affected sixty (60) of sixty (60) residents. Record review on October 7, 2025 at 3:10 PM, revealed no annual or semi annual fire inspection reports for the fire alarm system for 2025. During the exit interview on October 7, 2025 at 3:30 PM , the DON called the administrator. | spoke with her and she stated she was out of town, but would return on October 8, 2025 and email the reports to me. Follow up on October 8, 2025 at 8:00 PM, no reports were received by the close of business today. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which Missouri Department of Health and Senior Services STATE FORM 6899 X0S611 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 2 of 5 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 (X2) MULTIPLE CONSTRUCTION PRINTED: 02/09/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/07/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on October 7, 2025, the facility failed to properly maintain a self-closing smoke partition door to hazardous areas that separate them from the residential spaces. The facility census was sixty (60). This deficiency affected sixty (60) of sixty (60) residents. Observation on October 7, 2025 at 1:35 PM, revealed that the kitchen serving window was 2 shutter style doors that are not self-closing, nor attached to the fire alarm, and are not suitable smoke partitions. Observation on October 7, 2025 at 3:20 PM, revealed staff had blocked open the first floor laundry door. The door had been closed earlier in the inspection. During the exit interview on October 7, 2025 at 3:40 PM , the DON advised she would pass along to the owners. 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Missouri Department of Health and Senior Services STATE FORM 6899 X0S611 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 3 of 5 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 CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 3 Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on October 7, 2025, the facility, licensed after December 31, 1987 for more than twenty (20) beds, failed to ensure doors in a smoke partition closed completely. The facility census was sixty (60). This deficiency affected sixty (60) of sixty (60) residents. Observation on October 7, 2025 at 2:20 PM, revealed that the smoke partition doors next to room 210 failed to close completely on any of three (3) attempts. Smoke doors failing to close completely could allow smoke and toxic gases to spread to unaffected areas of the building. During the exit interview on October 7, 2025 at 3:45 PM , the DON advised she would notify the owners. Missouri Department of Health and Senior Services STATE FORM 6899 X0S611 (X2) MULTIPLE CONSTRUCTION PRINTED: 02/09/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/07/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 4 of 5 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 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 CRAB APPLE VILLAGE SENIOR ESTATES SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 4 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 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 II Based on record review and interview during the fire safety inspection process on October 7, 2025, the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, 1998 edition. The facility census was sixty (60). This deficiency affected sixty (60) of sixty (60) residents. Record review on October 7, 2025 at 3:15 PM, revealed no current annual fire sprinkler inspection report. During the exit interview on October 7, 2025 at 3:30 PM , the DON called the administrator. | spoke with her and she stated she was out of town, but would return on October 8, 2025 and email the reports to me. Follow up on October 8, 2025 at 8:00 PM, no reports were received by the close of business today. Missouri Department of Health and Senior Services STATE FORM 6899 X0S611 (X2) MULTIPLE CONSTRUCTION CROSS-REFERENCED TO THE APPROPRIATE PRINTED: 02/09/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/07/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 5 of 5

PRINTED: 10/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X93) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B.WING 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 (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) CRAB APPLE VILLAGE SENIOR ESTATES : 19CSR 30-86.022(7)(A) Exits-2 per Floor-Remote/Unobstructed Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. Ill This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the facility failed to maintain unobstructed exits remote from each other. The facility census was sixty-two. This deficiency affected sixty-two of sixty-two residents. Observation revealed the exit door beyond the basement laundry is sticking, excessive force was required to open the door. During the exit interview on October 3, 2024 at 0930, the manager stated that they preferred the door be hard to open, due to it being in Memory Care, but would repair it if needed. 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/Iil This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process, the facility failed to ensure all exit signs were operational, The facility census was sixty-two. This deficiency affected ment of Health and Senior Services Missouri Dapg EG9SR11 If coniInuatibn s bel 10f6 STATE FORM Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIGER/SUPPLIER/CLIA AND PLAN OF CORRECTION (DENTIFICATION NUMBER: A. BUILDING: B. WING NAME OF PROVIDER OR SUPPLIER CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 1 | sixty-two of sixty-two residents. Observation revealed an exit sign/emergency light that would illuminate while depressing the test button, but only for a couple of seconds before it failed, in the dining room. During the exit interview on October 3, 2024 at 0935, the manager stated she would have the exit sign repaired, 19 CSR 30-86.022(10}(A) Hazardous Area Requirements Protection from Hazards. {A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shail be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: : Class Il Missouri Department of Health and Senior Services STATE FORM 6e29 EG9R11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/03/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 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 PRINTED; 10/45/2024 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 BWINGO 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 (x4) 1D 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 LSG IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CRAB APPLE VILLAGE SENIOR ESTATES Continued From page 2 Based on observation and interview during the fire safety inspection process on November 15, 2023 the facility failed to properly maintain a self-closing smoke partition door to hazardous areas that separate them from the residential spaces. The facility census was sixty-two. This deficiency affected sixty-two of sixty-two residents. Observation revealed the self-closure devices on the laundry room smoke partition doors were not adjusted properly to close the doors. Observation revealed the self-closure device on the kitchen scullery smoke partition door was not properly adjusted to close the door Observation revealed no self-closure device on the main kitchen smoke partition.door. Observation reveled the kitchen window was 2 shutter style doors that were not self-closing, nor attached to the fire alarm, and are not smoke partitions. During the exit interview on October 3, 2024 at 0940, the manager stated that the window was approved in plan review and has always been this way. She stated she would have maintenance adjust the doors on all the faundry rooms and kitchen, plus install a self-closure device on the other kitchen door. 19 CSR 30-86.022(10)(I} Smoke Section Partitions > than 20 beds Protection from Hazards. (!) In facilities whose plans were approved ar Missouri Department of Health and Senior Services STATE FORM e699 EGOR11 If continuation sheet 3 of 6 PRINTED: 10/15/2024 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 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 (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) 1 CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} CRAB APPLE VILLAGE SENIOR ESTATES Continued From page 3 which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shail be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. I! This regulation is not met as evidenced by: Class || Based on observation and interview during the fire safety inspection process, the facility, licensed after December 31, 1987 for more than twenty (20) beds, failed to ensure doors in a smoke partition closed completely. The facility census was sixty-two. This deficiency affected sixty-two of sixty-two residents. Observation of a smoke door next to room 308 revealed that the smoke doors missing the trim, leaving a noticeable gap between the doors. Smoke doors failing to close completely will allow smoke and toxic gases to spread to other areas of the building. During the exit interview on October 3, 2024 at 0945, the manager stated that they would have the door repaired. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Missouri Department of Health and Senior Services STATE FORM 5ae8 EGSR11 IF continuation sheet 4 of 6 PRINTED; 10/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (%1} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED BWING 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED @Y FULL : (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) : CRAB APPLE VILLAGE SENIOR ESTATES Continued From page 4 Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class JI Based on observation and interview during the fire safety inspection process, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was sixty-two. This deficiency affected sixty-two of sixty-two residents. Observation revealed a missing escutcheon ring in roam 115. Observation revealed a missing escutcheon ring in roam 304. These penetrations would allow smoke, fire and toxic gases to travel to unaffected areas on the building During the exit interview on October 3, 2024 at 0950, the manager stated she replace the missing escutcheon rings. 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, Missouri Department of Heallh and Senior Services STATE FORM p90 EGOR11 If continuation sheet 5 of 6 PRINTED: 10/15/2024 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 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 (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) CRAB APPLE VILLAGE SENIOR ESTATES Continued From page 5 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 4, 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/Ill This regulation is not met as evidenced by: Class II] Based on observation and interview during the fire safety inspection process, the facility failed to ensure the facility's electric wiring was properly maintained. The facility census was sixty-two. This deficiency affected sixty-two of sixty-two residents. Observation revealed a ceiling light fixture hanging loose from the junction box in room 311 Observation revealed a ceiling light fixture hanging by it's wires in room 310. During the exit interview on October 3, 2024 at 0955, the manager stated stated she would have lights repaired. Missouri Department of Heaith and Senior Services STATE FORM 5098 EGSR11 If continuation sheet 6 of 6 Street Address, City, Zip: Date of Survey: PLAN OF CORRECTION CrabApple Village Senior Estates Name: 214 Hartman Place St. Clair, MO 63077 10/3/2024 A2238 A2256 A2264 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER This plan of correction submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conclusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. This exit now opens freely when code is entered. There are two other exits that were not obstructed remote to this exit door. This exit door only affected 24 residents and not 62. The total census for whole building is 62 but the floor where this door is located there is only 24 residents. This plan of correction submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conclusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. Exit light batteries were replaced and exit light is working properly. This exit light only affected the number of residents on that floor which was 38 residents. This plan of correction submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conclusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. Self-closure hinges were applied to the laundry room door and kitchen door in memory care. This only affected 24 residents, not 62. Self-closure hinges were applied to the main kitchen door. This only affected 38 residents, not 62 residents. This plan of correction submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conclusions drawn there from. The facility submission of ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2222 10/16/2024 10/15/2024 41/14/2024 11/7/2024 part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. Trim was replaced to the fire doors in the memory care. This only affected 24 residents and not 62 residents. This plan of correction submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings : nor the conclusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. Escutcheon ring was replaced to sprinkler heads in rooms 115 and 304 by Johnson Control. This plan of correction submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conclusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. Light fixture was resecured by Williams Electric in rooms 311 and 310. This citation only affected 24 residents and not 62. 10/29/2024 11/7/2024 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 11/27/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2} MULTIPLE CONSTRUCTION A. BUILDING: 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 iD PROVIDER'S PLAN OF CORRECTION 5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE CRAB APPLE VILLAGE SENIOR ESTATES SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A2249 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. WH This regulation is not met as evidenced by: Class ll Based on record review and interview during the fire safety inspection process on November 20, 2023 the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 7999 ed. The facility census November 20, 2023 was fifty-two (52). This deficiency affects fifty-two (52) of fifty-two (52) residents. Record review on November 20, 2023 at 1215 teveled no semi-annual inspection had been performed on the fire alarm system in 2023. During an interview on November 20, 2023 at 1400 the administrator had contacted the fire alarm company, but despite having a valid contract, the alarm company had mistakenly failed to perform the semi-annual inspection.. 19 CSR 30-86.022(10}(C) Clothes Dryers Venied, Lint Traps Protection from Hazards. (C) Electric or gas clothes dryers shall be vented to the outside. Lint traps shall be cleaned regularly to protect against fire hazard. H/II ave RQSQ1t If contindation sheet 1 of 5 ANY Missouri Departmefit of Heakh and Senior Service: LABORATORPANRECTOR'S ORPROVIDER/SUPPLJER a) SENTATIVE'S SIGNATURE . TITLE (X6) DAT! AHI {7 t) ASSISTAN Ate 023 6899 STATE FORM SSIES ae PRINTED: 11/27/2023 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 24395 $$$ i$ 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 (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 DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY CRAB APPLE VILLAGE SENIOR ESTATES 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 during the fire safety inspection process on November 20, 2023 the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census November 20, 2023 was fifty-two (52). This deficiency affects fifty-two (52) of fifty-two (52) residents. Record review on November 20, 2023 at 1215 reveled no semi-annual inspection had been performed on the fire alarm system in 2023. During an interview on November 20, 2023 at 1400 the administrator had contacted the fire alarm company, but despite having a valid contract, the alarm company had mistakenly failed to perform the semi-annual inspection. 19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps Protection from Hazards. (C) Electric or gas clothes dryers shall be vented to the outside. Lint traps shall be cleaned regularly to protect against fire hazard. II/IIl Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 RQ9Q11 If continuation sheet 1 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 24395 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION PRINTED: 11/27/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/20/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 1 This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection on November 20, 2023, the facility failed to properly vent the clothes dryers to the outside. The facility census on November 20, 2023 was fifty-two (52). This deficiency affects fifty-two (52) of fifty-two (52) residents. Observation of the basement laundry room on November 20, 2023 at 1306 revealed a dryer vent held together with duct tape. Heat tape is designed for these applications, duct tape is combustible and should not be used. During an interview on November 20, 2023 at 1425 the owner stated he would buy heat tape and replace the duct tape. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/Il This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on November 20, 2023, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. Missouri Department of Health and Senior Services STATE FORM 6899 RQ9Q11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 24395 NAME OF PROVIDER OR SUPPLIER CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG ID PREFIX TAG Continued From page 2 The facility census on November 20, 2023 was fifty-two (52). This deficiency affects fifty-two (52) of fifty-two (52) residents. Observation on November 20, 2023 at 1253 revealed a painted sprinkler head in water heater room next to room 304. During the exit interview on November 20, 2023 at 1430 the owner stated he would call the sprinkler company. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process on November 20, 2023 the facility failed to maintain the building in good repair. The facility census November 20, 2023 was fifty-two (52). This deficiency affects fifty-two (52) of fifty-two (52) residents. Observation on November 20, 2023 between 1230 and 1315 revealed wall penetrations behind all of the showers of the basement rooms. Observation on November 20, 2023 at 1253 revealed a ceiling penetration around a water pipe in the water heater room next to room 304. Missouri Department of Health and Senior Services STATE FORM 6899 RQ9Q11 (X2) MULTIPLE CONSTRUCTION PRINTED: 11/27/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/20/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 24395 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION PRINTED: 11/27/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/20/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 3 Observation on November 20, 2023 at 1304 revealed a ceiling penetration around a water pipe in the basement electrical room. Observation on November 20, 2023 at 1305 revealed ceiling penetrations around two (2) dryer vent pipes in the basement laundry room. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building. During an interview on November 30, 2023 at 1420 the owner stated he would drywall over the wall penetrations and fire caulk the ceiling penetrations.. 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. II/IIl This regulation is not met as evidenced by: Class Ill Based on observation, record review, and interview during the fire safety inspection process on November 20, 2023 the facility failed to provide a current approved Division of Fire Safety elevator inspection certificate under state statute 11CSR40-5.065. The facility census November 20, 2023 was fifty-two (52). This deficiency affects fifty-two (52) of fifty-two (52) residents. Observation on November 20, 2023 at 1239 Missouri Department of Health and Senior Services STATE FORM 6899 RQ9Q11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 24395 NAME OF PROVIDER OR SUPPLIER CRAB APPLE VILLAGE SENIOR ESTATES (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 11/27/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/20/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A3220 Continued From page 4 revealed elevator certifications located in the elevator hydraulics room with the last valid certificate expiring June 1, 2016. Record review on November 20, 2023 at 1410 revealed no current state elevator inspection certificate records. During an interview on November 20, 2023 at 1410 the administrator contacted DFS Elevator Safety Unit and learned they had failed to make payments to the state and that there was a deficiency on the their last elevator inspection in need of correction. Missouri Department of Health and Senior Services STATE FORM 6899 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY RQ9Q11 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: CrabApple Village Senior Estates Street Address, . . 214 Hartman Place St. Clair, MO 63077 City, Zip: Date of Survey: November 20, 2023 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 submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conciusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the A2249 scope and severity regarding any of deficiencies cited is 11/20/2023 correctly applied. The Administrator and the Assistant Administrator wiil not solely SHRESART ESS SSS OT rely on alarm company to schedule the annual and semi-annual fire inspections, each person will have on their calendar to make sure alarm company does not overlook these inspections again. The dryer vent located in Memory Lane was corrected with heat 42/15/2023 tape by the owner and the duct tape was removed. The painted sprinkler head has been removed and a new sprinkler head has been instalied by Johnson Control. This will 1/15/2024 be monitored by the Administrator. The penetrations for the dryers were corrected with fire caulk. | fares " And, the penetrations for the water pipe, were corrected with. 12/15/2023 drywall. This will be monitored by the Administrator. All elevator payments have been paid and the certification has | been obtained. All elevator inspections are up to date. This will 1/15/2024 1 be monitored by the Administrator. a eer TAOS TT RASTER ST TTES The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 10/04/2023 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 24395 B. WING 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 214 HARTMAN PLACE, SUITE 100 CRAB APPLE VILLAGE SENIOR ESTATES SAINT CLAIR, MO 63077 ID PROVIDER'S PLAN OF CORRECTION (5) PREFIX EACH CORRECTIVE ACTION SHOULD BE ee. TAG (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ( CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A4724 A4724| 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility staff failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered as required for five of six sampled staff members Housekeeping A, Housekeeping B, Level One Medication Aide (LIMA) D, Kitchen staff E, and Care Aide F. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) two (2)-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two years. 1, Review of Housekeeping A's personnel record showed a hire date of May 25, 2023. The record Gurl Department of Healttyand Senior Services ORY DIRECTOR'S Of PROPIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE = TITLE (48) DATE A LV. Tl hd HIN ASS (STAN Hd MIN SIPAAC lo lo 202 STATE ‘| 6899 40YO11 If corRinuation sheet 1 of 4 PRINTED: 10/04/2023 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 24395 B.WING 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} CRAB APPLE VILLAGE SENIOR ESTATES A4724 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. 1] This regulation is not met as evidenced by: Class II Based on interview and record review, the facility staff failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered as required for five of six sampled staff members Housekeeping A, Housekeeping B, Level One Medication Aide (LIMA) D, Kitchen staff E, and Care Aide F. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test fo determine if you have tuberculosis) two (2)-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two years. 1. Review of Housekeeping A's personnel record showed a hire date of May 25, 2023. The record Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) DATE STATE FORM sao 40YO11 If continuation sheet 1 of 4 NAME OF PROVIDER OR SUPPLIER CRAB APPLE VILLAGE SENIOR ESTATES AAT24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 24395 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 did not contain documentation of a two-step TB screen test. 2. Review of Housekeeping B's personnel record showed a hire date of May 29, 2023. The record did not contain documentation of a two-step TB screen test. 3. Review of LIMA D'S personnel file showed a hire date of September 15, 2023. The record did not contain documentation of a two-step TB screen test. 4. Review of Kitchen staff E's personnel file showed a hire date of June 6, 2022. The record did not contain documentation of a two-step TB screen test. 5. Review of Care Aide F's personnel file showed a hire date of December 6, 2022. The record did not contain documentation of a two-step TB screen test. During an interview on September 20, 2023 at 3:15 P.M_, the Director of Nursing (DON) said he/she is responsible to complete the required two step TB test for new employees and residents. The DON said he/she has not sent new employees to an outside service to receive the two step TB test. During an interview on September 20, 2023 at 3:05 P.M., the Assistant Administrator said the Director of Nursing (DON) is responsible to complete the required two step TB test for all new employees, and to keep documentation of TB results. Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE 40YO11 PRINTED: 10/04/2023 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 09/20/2023 STREET ADDRESS, CITY, STATE, ZiP CODE 214 HARTMAN PLACE, SUITE 100 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} if continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CRAB APPLE VILLAGE SENIOR ESTATES AAT33 A4733 IDENTIFICATION NUMBER: 24395 {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING STREET ADDRESS, CITY, STATE, ZiP CODE 214 HARTMAN PLACE, SUITE 100 SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (1) Written statement signed by a licensed physician or physician 's designee indicating the person can work in a long-term care facility and indicating any limitations; Hil This regulation is not met as evidenced by: Class Ill Based on interview and record review, facility staff failed to ensure five (Housekeeper A, Housekeeper B, Housekeeper C, Level One Medication Aide D (LIMA), Kitchen staff E) of six sampled staff, had a written statement by a licensed physician or physician designee to ensure staff is capable to work in a long-term care facility. The facility census was 50. 1. Review of Housekeeping A's personnel record showed a hire date of May 25, 2023. Review showed the personnel record did not contain documentation from a physician statement or designee to ensure he/she did not have limitations to work in a long term care facility. 2. Review of Housekeeping B's personnel record showed a hire date of May 29, 2023. Review showed the personnel record did not contain documentation from a physician statement or designee to ensure he/she did not have limitations to work in a long term care facility. 3. Review of Housekeeping C's personnel record Missouri Department of Health and Senior Services STATE FORM 6899 PRINTED: 10/04/2023 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 09/20/2023 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE 40YO11 if continuation sheet 3 of 4 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER CRAB AP AAT33 Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 24395 PLE VILLAGE SENIOR ESTATES {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING SAINT CLAIR, MO 63077 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 showed a hire date of September 7, 2023. Review showed the personnel record did not contain documentation from a physician statement or designee to ensure he/she did not have limitations to work in a long term care facility. 4. Review of Level One Medication Aide D's personnel record showed a hire date of September 16, 2022. Review showed the personnel record did not contain documentation from a physician statement or designee to ensure he/she did not have limitations to work in a long term care facility. 5. Review of Level One Kitchen staff E's personnel record showed a hire date of June 6, 2022. Review showed the personnel record did not contain documentation from a physician statement or designee to ensure he/she did not have limitations to work in a long term care facility. During an interview on September 20, 2023 at 3:05 P.M_, the facility Assistant Administrator said he/she was not aware this document was required for their staff. The Assistant Administrator said he/she is primarily responsible to ensure all documentation for employee personnel files. He/She said the facility does not have a policy for requring physician statements for employees. Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE 40YO11 PRINTED: 10/04/2023 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 09/20/2023 STREET ADDRESS, CITY, STATE, ZiP CODE 214 HARTMAN PLACE, SUITE 100 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} if continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier ; : ae CrabApple Village Senior Estates Street Address, 214 Hartman Place St. Clair, MO 63077 City, Zip: Date of Survey: 09/20/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER pC 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 submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conclusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. All residents new to CrabApple Village who do not have A4724 documentation of a previous skin test reaction >10mm or a 9/22/2023 history of adequate treatment of TB infection or disease, should have the initial test of a Mantoux PPD two-step test to rule out TB within one month prior to or one week after admission. If the initial result is 0-9mm, the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test. All TB records will be kept in same location, separating resident from employee, to help keep track of each step. This plan of correction submitted as required under State law. The submission of this POC does not constitute an admission on the part of CrabApple Village Senior Estates to the findings nor the conclusions drawn there from. The facility submission of part of the facility that the findings constitute a deficiency or the scope and severity regarding any of deficiencies cited is correctly applied. All employee's are required by DHSS to have a written statement signed by a licensed physician or physician's designee indicating the person can work in a long-term care facility and indicating any limitations. All employee's will be required to have this physical completed two month's after hire date. This will give management time to audit records and it will also give the employee time to decide if they like the job and want to continue. Employee’s who do not have this physical —————————— The Administrator signing and dating the first page of the CIMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form. 10/10/2023 A4733