ST CLAIR PLACE ASSISTED LIVING.

PRINTED: 10/10/2025 ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 26005 BWMING oo ee 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE SAINT CLAIR, MO 63077 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} ST CLAIR PLACE ASSISTED LIVING A2249 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shalt 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 Il Based on record review and interview during the fire safety inspection process on September 25, 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 34. This deficiency affects 34 of 34 residents. Record review on September 25, 2025 at 9:15 AM, revealed that no semi-annual fire alarm testing and inspection report was available for 2024 or 2025. During the exit interview on September 25, 2025 at 9:25 AM, the administrator stated she would would have a semi-annual fire alarm test conducted. 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 shail 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE NAN, ~ = Se ., ‘ - Wer S = Wve iu O-QAD-H STATE FORM see 4JQ211 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: NAME OF PROVIDER OR SUPPLIER ST CLAIR PLACE ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT CLAIR, MO 63077 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 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 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 September 25, 2025, the sprinklered facility, licensed for more than twelve (12) beds on or after November 13, 1980, failed to provide separation from a hazardous area with self-closing, smoke-resistant partitions or doors. The facility census was 34. This deficiency affects 34 of 34 residents. Observation on September 25, 2025 at 7:28 AM, revealed the kitchen door to the dining room was blocked open with a door chock. Observation on September 25, 2025 at 7:30 AM, revealed the laundry door was blocked open with milk crates. During the exit interview on September 25, 2025 at 9:30 AM, the administrator stated she would address the situation, Missouri Department of Health and Senior Services STATE FORM 6899 1JQ211 PRINTED: 10/10/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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: NAME OF PROVIDER OR SUPPLIER ST CLAIR PLACE ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT CLAIR, MO 63077 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds 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 September 25, 2025, the facility, licensed after December 31, 1987 for more than twenty (20) beds, failed to ensure doors in a smoke partition shall be self-closing. The facility census was 34. This deficiency affects 34 of 34 residents. Observation on September 25, 2025 at 7:47 AM, revealed that the smoke partition door to the Toyland wing failed to self-close completely after three (3) attempts. During the exit interview on September 25, 2025 at 9:35 AM, the administrator stated she would have maintenance adjust the door to close. Missouri Department of Health and Senior Services STATE FORM 6899 1JQ211 PRINTED: 10/10/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 5 PRINTED: 10/10/2025 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 09/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE 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) ST CLAIR PLACE ASSISTED LIVING Continued From page 3 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/II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on September 25, 2025, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was 34. This deficiency affects 34 of 34 residents. Observation on September 25, 2025 at 7:09 AM, revealed a sprinkler head with a gap between an escutcheon ring and the ceiling, located under the front canopy of the building. Observation on September 25, 2025 at 7:15 AM, revealed a missing escutcheon ring in the maintenance closet. During the exit interview on September 25, 2025 at 9:40 AM, the administrator stated she would have the maintenance fix them. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance Missouri Department of Health and Senior Services STATE FORM 6899 1JQ211 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: NAME OF PROVIDER OR SUPPLIER ST CLAIR PLACE ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT CLAIR, MO 63077 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 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/Ill This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process on September 25, 2025, the facility failed to ensure only one appliance shall be connected to one extension cord and only two electrical appliances may be served by one duplex receptacle. The facility census was 34. This deficiency affects 34 of 34 residents. Observation on September 25, 2025 at 7:29 AM, revealed a pig tail extension cord being used as permanent wiring in the kitchen, being used to power three (3) small kitchen appliances. Observation on September 25, 2025 at 7:46 AM revealed a multiplug electrical adapter in use in room 45. Observation on September 25, 2025 at 7:22 AM, revealed a multiplug electrical adapter in use in room 12. During the exit interview on September 25, 2025 at 9:45 AM, the administrator stated she would have the extension cord and multiplugs removed. Missouri Department of Health and Senior Services STATE FORM 6899 1JQ211 PRINTED: 10/10/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 5 Name: Street Address, City, Zip: Date of Survey: ID PREFIX TAG A2249 A2256 A2264 A2269 A3219 PLAN OF CORRECTION Provider/Supplier St. Clair Place 160 Charles Drive St. Clair MO, 63077 October 10% 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 4. Education provided to Maintenance Person 2. Semi Annual inspection completed and documented 3. Semi Annual inspection added to Gateway’s contract moving forward Door chock removed from kitchen door & crate removed from blocking Laundry room door 2. Education provided to team 3. Signs instructing doors must remain araeed to be placed near both doors, in a conspicuous location 4. Education provided to Maintenance person & team . | 2. Smoke patrician door on Toyland adjusted to close completely 3. Addendum to monthly fire drill form checking that all fire are doors closed completely to be completed monthly during fire drill by Admin or designee 1. Education provided to maintenance person 2. Repair to sprinkler head with gap between escutcheon ring and the ceiling located under the front canopy completed by Gateway 3. Missing escutcheon ring in maintenance closet replaced 1. Pig tail extension cord being used as permanent wiring in the kitchen removed & replaced with approved electrical connection 2. Multiplug in rooms 12 removed 3. Multiplug in room 45 removed 4. Education regarding the monthly resident room audit section located on monthly maintenance check list provided to maintenance person 5. Admin or designee to review monthly maintenance checklist, when submitted for completion, to be documented on the monthly maintenance checklists upon verification of completion COMPLETION DATE 11-4-2025 11/4/2025 10/15/2025 10/15/2025 11/4/2025 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. “SS On Roe Enurtve Virewto”, 108-45

PRINTED: 07/25/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF CEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: {X3) DATE SURVEY COMPLETED Cc 07/17/2024 26005 3. WING NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY. STATE, ZIP CODE 160 CHARLES DRIVE VICTORIAN PLACE OF ST CLAIR ASSIST LVA SAINT CLAIR, MO 63077 (X4} ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 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) ' 18 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable In newly licensed facilities or if a new heating system is installed in an existing licensed facility, : the heating of the building shall be restricted to steam, hot water, permanently installed electric | heating devices or a warm air system employing : central heating plants with installation such as to | | : safeguard the inherent fire hazard, or approved - installation of outside wall heaters which bear the ‘ approved label of the American Gas Association | or National Board of Fire Underwriters. The ' foregoing requirements are applicable to residential care facilities. In assisted living ' facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with | installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of | Fire Underwriters. For all facilities. oil or gas i heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are | ' used, adequate guards shall be provided to safeguard residents. 1/1 This regulation is not met as evidenced by: Class fl Based on observations and interviews, facility staff failed to ensure only approved heating ; sources were used within the facility. The facility census was 21. 1. Areview of facility policies did not contain a : policy for heat sources in the facility. Missouri Department of Health and Seniors Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRE! TITLE (X6) DATE Sn 7 - OD: id continuation sheet 1 of 2 = STATE FORM 8 2800 11 PRINTED: 07/25/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED G 26005 — 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE SAINT CLAIR, MO 63077 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING {NFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) VICTORIAN PLACE OF ST CLAIR ASSIST LVA A3211 | Continued From page 1 1. Observation on 07/17/2024 at 1:14 P.M., showed the shared bathroom room between resident room #37 and #38 with a portable space heater hung on the wail and plugged into the outlet above the bathroom sink. Observation on 07/17/2024 at 1:26 P.M., showed resident room #43 with a portable space heater : hung on the wall adjacent to the foot of the bed and plugged into the outlet. During an interview on 07/17/2024 at 3:45 P.M., the administrator said he/she thought the heaters were acceptable since they could be hung on the wall. Missouri Department of Health and Senior Services STATE FORM saga ZSooti Hf continuation sheet 2 of 2 ————__—____—_— PLAN OF CORRECTION en | Supplier _Nighorian piace of St. Clair Assisted living by Americare | Street im | City, Zip: _ 160 Charles Drive St. Clair MO, 63077 | , Date of Survey: 07/17/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER : 26005 PROVIDER'S PLAN OF CORRECTION: (EACH ID PREFIX TAG CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED oe a ___YOTHE APPROPRIATE DEFICIENCY) | _ A3211, | Education on regulation, 19 CSR 30-86.032(10) 19 CSR 30-86.032(10) regarding heat sources requiring to be hard wired Heaters-Approved Label | provided to Administrator r : , Venting, No Portable Unapproved heat source removed from shared =| 7/17/2024, bathroom between resident rooms #37 and #38 In Observation 1. On addition all other unapproved heat sources {17/2024 -14 P.M, removed from #29 #30, #7 and #8 O7/1 7/2024 at 1:14 P.M, 7/17/2024 showed the shared , bathroom room between | aggendum reflecting visual checks for “non-hard- resident room #37 and wired” heat sources made to the Resident room #38 with a portable space | audits section of the, PREVENTATIVE 8/16/2024 heater hung on the wall | MAINTENANCE MONTHLY CHECKLIST, to be monitored and plugged into the by Administrator or designee outlet above the | bathroom sink eee Education on regulation, 19 CSR 30-86.032(10) regarding heat sources requiring to be hard wired | | pravided to Administrator Observation 2. On 7/17/2024, 07/17/2024 at 1:26 P.M., | Unapproved heat source removed from resident showed resident room room #43 #43 with a portable space heater hung onthe wall Er eaaes . ia | Addendum reflecting visual checks for “non-hard- adjacent to the foot of the | ~~~. . | bed and plugged into the wired” heat sources made to the Resident room ; | audits made to the section of the, | outlet. PREVENTATIVE MAINTENANCE MONTHLY CHECKLIST gns/n024 to be monitored by Administrator or designee to begin in the month of August addendum to be | completed August 15". fees ree | 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: 07/22/2025 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 26005 B. WING 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE 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) VICTORIAN PLACE OF ST CLAIR ASSIST LVA 19 CSR 30-86.022(8)(B) Exit-Directional Indicators Exit Signs. (B) Directional indicators showing the direction of travel shall be placed in corridors, passageways, or other locations where the direction of travel to reach the nearest exit is not apparent. 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 had confusing exit signs which had illuminated directional arrows in inappropriate locations. The facility census on November 20, 2023 was seventeen (17). This deficiency affects seventeen (17) of seventeen (17) residents. Observation on November 20, 2023 at 0900 revealed an exit sign with both directional arrows illuminated on exit sign four (4), indicating turns that were not there. Observation on November 20, 2023 at 0910 revealed an exit sign with a right directional arrow illuminated on exit sign five (5), indicating a turn that was not there. Observation on November 20, 2023 at 0952 revealed an exit sign with a right directional arrow illuminated on exit sign two (2), indicating a turn that was not there. Observation on November 20, 2023 at 1004 revealed an exit sign with a right directional arrow illuminated on exit sign eight (8), indicating a turn that was not there. Observation on November 20, 2023 at 1015 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 VSN711 If continuation sheet 1 of 4 PRINTED: 07/22/2025 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 26005 B. WING 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE 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) VICTORIAN PLACE OF ST CLAIR ASSIST LVA Continued From page 1 revealed an exit sign with both directional arrows illuminated on exit sign nine (9), indicating turns that were not there. Observation on November 20, 2023 at 1025 revealed an exit sign with a left directional arrow illuminated on exit sign eleven (11), indicating a turn that was not there. Observation on November 20, 2023 at 1034 revealed an exit sign with a right directional arrow illuminated on exit sign ten (10), indicating a turn that was not there. During an interview on November 20, 2023 at 1100 the maintenance man stated he would repair the exit signs, covering the confusing directional arrows. 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/III 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 seventeen (17). This deficiency affects seventeen (17) of seventeen (17) residents. Observation of the laundry room on November 20, 2023 at 1023 revealed three (3) dryer pipes Missouri Department of Health and Senior Services STATE FORM 6899 VSN711 If continuation sheet 2 of 4 PRINTED: 07/22/2025 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 26005 B. WING 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE 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) VICTORIAN PLACE OF ST CLAIR ASSIST LVA Continued From page 2 with joints held 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 1110 the maintenance man stated he would buy heat tape and replace the duct tape. 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/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, Missouri Department of Health and Senior Services STATE FORM 6899 VSN711 If continuation sheet 3 of 4 PRINTED: 07/22/2025 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 26005 B. WING 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 160 CHARLES DRIVE 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) VICTORIAN PLACE OF ST CLAIR ASSIST LVA Continued From page 3 2023 the facility failed to ensure the facility's electric wiring was properly maintained. The facility census on November 20, 2023 was seventeen (17). This deficiency affects seventeen (17) of seventeen (17) residents. Observation on November 20, 2023 at 1002 revealed an open circuit breaker slot inside of circuit breaker panel five (5). During an interview on November 20, 2023 at 1115 the maintenance man stated he would place a blank in the panel. Missouri Department of Health and Senior Services STATE FORM 6899 VSN711 If continuation sheet 4 of 4