SPRING MANOR.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. PRINTED: 05/06/2025 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 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3610 PALM STREET SAINT LOUIS, MO 63107 (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) SPRING MANOR 19 CSR 30-86.022(4)(C) Range Hood Certification Range Hood Extinguishing Systems. (C) The range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. II/III This regulation is not met as evidenced by: Class II The higher classification from a class III to a class Il was upgraded due to the violations effect on residents and the impact when combined with other deficiencies. Based on record review and interview on April 24, 2025, the facility failed to ensure the kitchen range hood and its extinguishing system be certified at least twice annually in accordance with National Fire Protection Association (NFPA) 96, 1998 edition. The facility census on April 24, 2025 was 58. This deficiency potentially affects 58 of 58 residents. Record review on April 24, 2025, at 1:25 P.M. showed no semi-annual kitchen range extinguishing system inspection had been completed as required by (NFPA) 96, 1998 edition. During an interview on April 24, 2025, at 2:20 P.M. the facility Office Manager said he/she would schedule a kitchen hood inspection. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OKNW11 If continuation sheet 1 of 4 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 SPRING MANOR (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63107 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 This regulation is not met as evidenced by: Class II Based on record review and interview on April 24, 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 edition. The facility census on April 24, 2025 was 58. This deficiency potentially affects 58 of 58 residents. Record review on April 24, 2025, at 1:25 P.M. showed no semi-annual inspection had been conducted of the fire alarm system as required by (NFPA) 72, 1999 edition. Table 7-3.1. During an interview on April 24, 2025, at 2:20 P.M. the facility Office Manager said he/she would schedule a semi-annual fire alarm inspection. 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 on April 24, Missouri Department of Health and Senior Services STATE FORM 6899 OKNW11 PRINTED: 05/06/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/24/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3610 PALM STREET PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE 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 IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER SPRING MANOR (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63107 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 2025, the facility failed to have inspections and written certifications of the approved sprinkler system completed by an approved qualified service representative in accordance with National Fire Protection Association (NFPA) 25, 1998 edition, at least annually. The facility census on April 24, 2025 was 58. This deficiency potentially affects 58 of 58 residents. Record review on April 24, 2025, at 1:25 P.M. showed no annual sprinkler system inspection had been conducted. Records show the last inspection was completed on November 16, 2023. During an interview on April 24, 2025, at 2:20 P.M. the facility Office Manager said he/she would schedule a sprinkler system inspection. 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 Missouri Department of Health and Senior Services STATE FORM 6899 OKNW11 PRINTED: 05/06/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/24/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3610 PALM STREET PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 4 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 SPRING MANOR (X2) MULTIPLE CONSTRUCTION A. BUILDING: SAINT LOUIS, MO 63107 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 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/IIl This regulation is not met as evidenced by: Class III Based on record review and interview on April 24, 2025, the facility failed to have the electrical wiring inspected every two (2) years by a qualified electrician. Electrical wiring shall be installed and maintained in accordance with the requirements of the National Electric Code, 1999 edition. The facility census on April 24, 2025 was 58. This deficiency potentially affects 58 of 58 residents. Record review on April 24, 2025, at 1:25 P.M. showed the last bi-annual electrical wiring certification was completed on April 17, 2023. During an interview on April 24, 2025, at 2:20 P.M. the facility Office Manager said he/she had scheduled a bi-annual electrical wiring certification for April 24, 2025. Missouri Department of Health and Senior Services STATE FORM 6899 OKNW11 PRINTED: 05/06/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/24/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3610 PALM STREET PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 4 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 05/09/2024 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 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3610 PALM STREET SAINT LOUIS, MO 63107 (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) SPRING MANOR 19 CSR 30-86.022(9)(C) Fire Alarm | System-Test/Maintain | Complete Fire Alarm Systems. (C) All facilities shall test and maintain the This regulation is not met as evidenced by: b month S fol Jem Lannual Class II Based on record review and interview on April 30, a Eg f (Uh ; li 4 Ih is (om p | itd 2024, the facility failed to ensure the complete fire ‘ alarm system was tested and maintained in fh | | accordance with National Fire Protection Ue [| (An Uk ] NOpley (0 AL Association (NFPA) 72, 1999 edition. The facility census on April 30, 2024 was 55. This deficiency ON (Vl Hy v0) 10 Z ¢ | potentially affects 55 of 55 residents. Record review on April 30, 2024, at 2:17 P.M. ” £ oe a showed no semi-annual inspection had been Busuers @ L ( ce conducted of the fire alarm system as required by (NFPA) 72, 1999 edition. Table 7-3.1. WU Ge We id Eu | During an interview on April 30, 2024, at 2:45 AQ A pr ron Oot P.M. the facility Office Manager said he/she would forward the information about the Le 44) semi-annual fire alarm inspection to the facility | al SALTO /U ol b> / Administrator. 19 CSR 30-86.022(9)(D) Fire Alarm System | I GUN. Yat Septem be Inspections/Certifications (\ | W) £ k Mh id Lehn ol C7 on 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: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER 7. eres aa 4 STATE F@ 6899 RUUG11 If continuation sh€et 1 of 2 PRINTED: 05/09/2024 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 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3610 PALM STREET SAINT LOUIS, MO 63107 (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) | SPRING MANOR Continued From page 1 Class II Based on record review and interview on April 30, 2024, the facility failed to have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, at least annually. The facility census on April 30, 2024 was 55. This deficiency potentially affects 55 of 55 residents. Record review on April 30, 2024, at 2:17 P.M. showed no annual fire alarm system inspection had been completed of the fire alarm system as required by (NFPA) 72, 1999 edition. During an interview on April 30, 2024, at 2:45 P.M. the facility Office Manager said he/she would forward the information about the annual fire alarm inspection to the facility Administrator. Missouri Department of Health and Senior Services STATE FORM — RUUG11 If continuation sheet 2 of 2