ST ELIZABETH HALL.

PRINTED: 06/10/2025 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 (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING; 8. WING 06/04/2025 07516C STREET ADDRESS, CITY, STATE, ZIP CODE 325 NORTH NEWSTEAD AVENUE ST ELIZABETH HALL SAINT LOUIS, MO 63108 NAME OF PROVIDER OR SUPPLIER (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 1x5) 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) 49 CSR 30-86.022(9}{C) Fire Alarm System-Test/Maintain : Complete Fire Alarm Systems. (C) All facitities shail test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. Jl This regulation is not met as evidenced by: Class Il Based on record review and interview on June , 04, 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 June 04, 2025 was 39. This deficiency potentially affects 39 of 39 residents. Record review on June 04, 2025, at 2:14 P.M. of the annual fire alarm system inspection report dated May 29, 2025 showed defects or malfunctions in the fire alarm system that haven't been corrected that consist of the following: | *Left and right tampers in the maintenance shop on zone L.1-142 failed to send a signal to the FACP and/or the ERC. | *Tamper on zone L-145 south hall L1-145 failed to send a signal to the FACP and/or the ERC. ' *Tamper 1st floor west on zone L1-156 failed to send a signal to the FACP and/or the ERC. | *Tamper third floor west on zone L2-146 failed to _ send a signal to the FACP and/or the ERC. “Tamper 4th floor south stairwell on zone L2-146 failed to send a signal to the FACP and/or the _ ERC. Missouri Department of Heaith and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TE LB DAES AAO (K6) DATE lf continuation sheet 1 of 2 STATE FORM 3838 UG3I11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 07516C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 325 NORTH NEWSTEAD AVENUE ST ELIZABETH HALL SAINT LOUIS, MO 63108 PRINTED: 06/10/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 06/04/2025 (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 A2249_ Continued From page 1 During an interview on June 04, 2025, at 3:02 P.M. the facilities Maintenance Supervisor said he/she would contact the fire alarm company and schedule a date for the defects to be corrected. Missouri Department of Health and Senior Services STATE FORM 6899 UG3I11 DEFICIENCY) If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier | c+ ejizabeth Hall Name: Street Address, City, Zip: 325 N. Newstead Ave. Date of Survey: 6/4/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 07516C COMPLETION DATE ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Complete fire alarm system test to be conducted semi-annually. Results reported to the building Maintenance Supervisor and A2249 facility Administrator. Any deficiencies will be repaired in a timely manner. ltems listed in tag A2249 have been addressed by fire suppression vendor with a report provided. Alarm system to be 7/21/25 tested for compliance with a report provided. the plan of correction being submitted on this form.

PRINTED: 06/21/2024 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 07516C B. WING 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 325 NORTH NEWSTEAD AVENUE SAINT LOUIS, MO 63108 (X4y10 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 ELIZABETH HALL 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 on June 17, 2024, 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 June 17, 2024 was 40. This deficiency potentially affects 40 of 40 residents. | Record review on June 17, 2024, at 2:36 P.M. | showed no semi-annual inspection system inspection had been conducted of the fire alarm system as required by (NFPA) 72, 1999 edition. . Table 7-3.1. Records show the iast annual fire | alarm system inspection was completed on July 44, 2023. During an interview on June 17, 2024, at 3:45 P.M. the facility Maintenace Supervisor said he/she has schedule an annual fire alarm system inspection for July 03, 2024 to be completed by July 08, 2024. 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily | Rooms shall be neat, orderly and cleaned daily. Wi/tlt This regulation is not met as evidenced by: Class Ill Missouri Department of Health and Senior Services / “ef ff > LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE 1” fru VegS Te tp ce nsrrt tre 2 xe)pare efiaty rer reer TSR ERAT errr erenrrreintthnntnriie AAR STi STATE FORM 6899 3ZDJ41 If continuation sheet 1 of 2 PRINTED: 06/21/2024 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 07516C — 06/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 325 NORTH NEWSTEAD AVENUE SAINT LOUIS, MO 63108 (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 ELIZABETH HALL Continued From page 1 Based on observation and interview on June 17, 2024, the facility failed to ensure rooms shall be neat, orderly and cleaned daily. The facility census on June 17, 2024 was 40. This deficiency potentially affects 40 of 40 residents. Observation of room #206 on June 17, 2024, at 3:02 P.M. showed the room was heavily loaded with trash and other ordinary combustible items. During an interview on June 17, 2024, at 3:45 P.M. the facility Maintenance Supervisor said he/she would have the room cleaned. Missouri Department of Health and Senior Services STATE FORM 6899 3ZDJ11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier St. Elizabeth Hall Name: Street Address, | 355. Newstead Ave. St. Louis, MO 63108 City, Zip: Date of Survey: 6/17/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Contract has been initiated with buildings fire alarm system provider to conduct semi-annual inspections. The first of these was completed 7/5/24. The second (semi-annual) inspection will occur prior to 1/5/25. Administrator will confirm with Building 7/2/24 Maintenance Supervisor the inspection is scheduled with fire alarm system provider. Administrator will obtain copy of completed inspection for review from the Building Maintenance Supervisor. Room #206 has been cleared of excess debris, allowing the room to entered and cleaned by facility staff. Inspected by Administrator. Staff is working with room occupant to organize and store belongings properly, allowing for continued access by 6/28/24 facility staff. All resident rooms are entered daily to remove trash and provide cleaning services as needed. Documentation of room coverage is kept by facility housekeeping staff and reviewed by facility administration. A2249 A3224 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.