CLARENDALE OF ST PETERS.

PRINTED: 04/02/2025 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 32095 B. WING 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10 DUBRAY DRIVE SAINT PETERS, MO 63376 (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) CLARENDALE OF ST PETERS A3214) 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 Electricat 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/IIl This regulation is not met as evidenced by: Class Ill Based on record review and interview the facility failed to properly maintain the buildings electrical wiring. The facility census was 96. This deficiency affects 96 of 96 residents. Arecords review showed no current two year electrical wiring inspection documentation could be provided During an interview on 3-27-2925 at 11:30 A.M. the maintenance director said it was not completed and would have to schedule it. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE (X6) DATE 50M0O11 If continuation sheet 1 of 2 PRINTED: 04/02/2025 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 32095 B.WING 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10 DUBRAY DRIVE SAINT PETERS, MO 63376 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XB) 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) CLARENDALE OF ST PETERS Missouri Department of Health and Senior Services STATE FORM 699 50M011 If continuation sheet 2 of 2 PRINTED: 04/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10 DUBRAY DRIVE SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CLARENDALE OF ST PETERS A3214) 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 fo 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. HAH This regulation is not met as evidenced by: Class Ill Based on record review and interview the facility failed to properly maintain the buildings electrical wiring. The facility census was 96. This deficiency affects 96 of 96 residents. Arecords review showed no current two year electrical wiring inspection documentation could be provided During an interview on 3-27-2925 at 11:30 A.M. the maintenance director said it was not completed and would have to schedule it. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 5OMO11 lf continuation sheet 1 of 2 PRINTED: 04/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION {X3} BATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10 DUBRAY DRIVE SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CLARENDALE OF ST PETERS Missouri Department of Health and Senior Services STATE FORM 6838 5OMO11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Clarendale of St. Peters Name: Street Address, City, Zip: 10 Dubray Drive St. Peters, MO 63376 Date of Survey: March 27%, 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER po PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE |A3214___—| A two year electrical wiring inspection will be performed witha | 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: 04/10/2024 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 03/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10 DUBRAY DRIVE SAINT PETERS, MO 63376 (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) CLARENDALE OF ST PETERS A3224 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. I/II This regulation is not met as evidenced by: Class Ill Based on observation and interview the facility failed to ensure resident rooms were neat, clean, and orderly. The facility census on 3/25/24 was 103. This affected 103 of 103 residents. Observation showed Resident Room #2221 having several card board boxes full of personal property and papers laying on the floor and furniture throughout the living room and bed room. There was personal property such as clothing and boxes on the floor piled up in and in front of the closet. these item were causing a trip hazard. During an interview on 3/25/24 at 1:00 P.M., the maintenance director said they will contact the family to help them clean, organize, and remove some of the property. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE eather Ft Lake Executive Director 4/19/2024 STATE FORM 6899 FAG611 If continuation sheet 1 of 1 PLAN OF CORRECTION Provider/Supplier Clarendale of St. Peters Name: Street Address, City, Zip: 10 DuBray Drive, St. Peters, MO 63376 Date of Survey: April 10, 2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE A3224 The Resident and family of apartment 2221 were notified that 4/15/2024 the current state of the apartment was not in regulatory compliance and needed to immediately be addressed. The family assisted the resident to clean up and remove items so the apartment was clean, tidy and not creating any tripping hazards. Environmental services, nursing, and maintenance will report further violations of this nature regarding any apartment to their direct supervisor. For the next 3 months, staff will sign off weekly that 2221 has stayed in compliance remaining neat, cleaned and organized. 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.