NHC PLACE, ST PETERS MEMORY CARE.

PRINTED: 05/19/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xt) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: _* (X3) DATE SURVEY COMPLETED B. WING 29889 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE §300 EXECUTIVE CENTER PARKWAY NHC PLACE, ST PETERS MEMORY CARE SAINT PETERS, MO 63376 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D i PROVIDER'S PLAN OF CORRECTION : (x5) PREFIX } (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE i COMPLETE TAG } REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS-REFERENCED TO THE APPROPRIATE DATE { DEFICIENCY) } 4505 19 CSR 30-86.045(3)(A)(5) Individual Evacuation | A4505 Plan - In Resident ISP General Requirements. i (A) If the facility admits or retains any individual i needing more than minimal assistance due to having a physical, cognitive or other impairment i that prevents the individual from safely evacuating the facility, the facility shall: | 5, Include an individualized evacuation plan in the resident's individual service pian; {I This regulation is not met as evidenced by: | Class I Based on observation, interview, and record review, the facility failed to include an Individualized Evacuation Plan (IEP) in the resident's Individual Service Plan (ISP) for two (Residents #1 and 2) of five sampled residents. | The facility census was 35. the following: | -Resident admitted on 4/9/25; -Diagnoses included generalized muscle weakness, unspecified sequela fall, fatigue, and | unspecified convulsions. | Review of resident's progress notes from ' electronic medical records showed the following: - On 4/10/25 at 12:13 P.M., the resident was admitted from the hospital with history of clavicle (collar bone) fracture and resident ambulated with a walker; -On 4/13/25 at 8:48 P.M., resident has poor safety awareness and frequently attempts to stand and walk without assistance; -On 4/14/25 at 4:50 P.M., resident was found rea flying on the floor next to her bed, complaining of word y ( LPN QCAL eke®) Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE i | | 1. Review of Resident #1’s face sheet showed j | STATE FORM 6a99 1V4214 If conthwation sheet 1 of 19 PRINTED: 05/19/2025 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 29889 B.WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY NHC PLACE, ST PETERS MEMORY CARE SAINT PETERS, MO 63376 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (X8) 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) Continued From page 1 left arm pain with a skin tear on her left elbow; -On 4/15/25 at 9:55 A.M., x-ray results showed resident suffered an acute fracture of left humerus (arm) from unwitnessed fall on 4/14/25; -On 4/29/25 at 6:35 A.M., resident was found on the floor in his/her bedroom between the bed and recliner. The resident sustained a laceration on her forehead, resident said she was trying to reach her wheelchair. Review of the resident's Community Based Assessment (CBA) dated 4/29/25 showed the following: -Resident wandered intrusively, but becomes disruptive or aggressive upon redirection; -Resident had hallucinations and delusions impaired decision-making skills with reality disorientation; -Resident required assistance of one person in transferring; -Resident required employees to escort or to push wheelchair because of a physical limitation; -Resident required two-person assistance for transfer; -Resident required mechanical lift for transfer; -Resident had more than one fall in the last three months. Review of the resident's ISP labeled Resident Care Plan with Schedule dated 4/30/25, showed the following: -Staff should redirect resident without agitating as needed to protect rights of other residents, report increases in wandering behaviors, and report exit-seeking behavior; -Staff should report changes in behavior, utilize validation opposed to reality orientation as appropriate, and be alert to triggers which increase behaviors such as noise or crowded Missouri Department of Health and Senior Services STATE FORM 6899 1V4211 If continuation sheet 2 of 19 PRINTED: 05/19/2025 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 29889 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE §300 EXECUTIVE CENTER PARKWAY NHC PLACE, ST PETERS MEMORY CARE 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) A4505/| Continued From page 2 areas; -Staff should use calm and gentle approach, utilize validation opposed to reality orientation, and be alert to triggers which increase behaviors related to hallucinations or delusions such as noise or crowded areas; -Staff should report increasing difficulty with transfers or other safety concerns, provide transfer assistance with good technique to protect resident and care staff, and remind resident to wait for staff assistance in transfer; -There were no staff interventions identified for resident's use of a manual wheelchair; -Staff should report all fails, provide needed assistance if resident falls, and report increasing evidence of unsteadiness or other safety concerns; -Resident Care Plan with Schedule did not address the need for an individualized Evacuation Plan (IEP). Observation on 4/30/25 at 9:53 A.M. of the resident's room showed the following: -Resident asleep in bed under the covers; -Resident had a bandage on her forehead and a bruised eye; -Manual wheelchair in room not next to resident's bed. During interview on 4/30/25 at 4:28 P.M., Level One Medication Aide (LIMA) A said the following: -He/She primarily worked 300 and 400 halls; -He/She was not aware of any resident on the 300 or 400 halls who would require an iEP; -When asked about Resident #1's inability to transfer independently, he/she said Resident #1 would need an IEP; -He/she was not aware of a list of residents on the 300 or 400 hails who would require more Missouri Department of Health and Senior Services STATE FORM 899 1V4211 If continuation sheet 3 of 19 PRINTED: 05/19/2025 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 29889 B.WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE §300 EXECUTIVE CENTER PARKWAY 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) NHC PLACE, ST PETERS MEMORY CARE A4505 | Continued From page 3 than minimal assistance to evacuate in an emergency. Observation on 4/30/25 at 4:28 P.M., showed no easily accessible list of residents on the 300 and 400 halls who required IEPs and what specific assistance each of those residents required for safe evacuation. 2. Review of Resident #2's face sheet showed the following: -Admission date of 9/13/23; -Diagnoses included vascular dementia, painful urination, Alzheimer's disease, major depressive disorder, localized swelling in bilateral lower limbs, unsteadiness on feet, weakness, age-related cataract, and edema. Review of the resident's progress notes from electronic medical records showed the following: -On 1/1/25 (no time noted), monthly nursing note showed the resident used a wheelchair and required assistance of two to transfer; -On 1/31/25 at 3:23 P.M., resident to be discharged from hospice on 2/3/25, resident had been using a peddle Broda (special tilt in space chair) chair provided by the hospice company, and family was making plans to secure a Broda chair for resident from another source; -On 2/1/25 at 10:41 P.M., monthly nursing note showed the resident used a wheelchair and required assistance of one to transfer; -On 3/1/25 at 9:35 P.M., monthly nursing note showed the resident used a Broda wheelchair and needed assistance of one to transfer; -On 4/8/25 at 11:15 A.M., monthly nursing note showed the resident used a Broda wheelchair and needed assistance of one to transfer; Missouri Department of Health and Senior Services STATE FORM 6899 4V4211 If continuation sheet 4 of 19 PRINTED: 05/19/2025 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 29889 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY 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) NHC PLACE, ST PETERS MEMORY CARE A4505/| Continued From page 4 Review of the resident's CBA dated 3/18/25 showed the following: -Resident required regular prompting due to confusion and disorientation; -Resident wandered in public areas, -Resident had active behavioral issues or was under current treatment; -Resident experienced agitation, anxiety, and fluctuates emotionally; Resident experienced hallucinations, had delusion-impaired decision-making skills, and had reality disorientation; -Resident required assistance of one person transferring; -Resident used a manuai wheelchair. Review of the resident's ISP titled Resident Care Plan with Schedule dated 4/30/25, showed the following: -Staff should report any increase in wandering behavior or wandering pattern; Staff should document and report any behaviors; -Staff should use calm and gentle approach when resident is agitated or anxious; -Staff should use calm and gentle approach when resident is experiencing hallucinations, delusions, or reality disorientation and be alert to triggers which increase behaviors such as noise or crowded areas; -Staff should remind resident to wait for staff assistance to transfer, report increasing difficulty with transfers or other safety concerns, provide transfer assistance with good technique to protect resident and care staff: -Staff should monitor as resident self-propels in wheelchair; ~ Resident Care Pian with Schedule did not address the resident's need for an IEP. Missouri Department of Health and Senior Services STATE FORM 6899 1V4211 if continuation sheet 5 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER NHC PLACE, ST PETERS MEMORY CARE (x4) ID PREFIX TAG A4505 IDENTIFICATION NUMBER: 29889 (X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 08/19/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 During interview on 4/30/25 at 4:26 P.M., LIMA B said the following: -He/She worked on the 100 and 200 halls; -Most residents on the 100 and 200 halls would need some assistance; -Resident #4 would need assistance to transfer; -Resident #2 would need assistance as he/she used a a Broda wheelchair and could not transfer or move the wheelchair by his/herself, -He/She was aware IEPs were listed for some residents on the daily census sheet, but was not aware of any written instruction for each resident's IEP on the 100 and 200 hails. Observation on 4/30/25 at 4:26 P.M. showed no easily accessible list of residents on the 100 and 200 halls who required iEPs and what specific assistance each of those residents required for safe evacuation. 4. During interview on 4/30/25 at 5:46 P.M., the administrator said the following: -The Licensed Practical Nurses (LPNs) were responsible for entering resident !EP information in their service plans; -All staff were responsible to notify nursing staff of a change in resident's condition that might require an IEP; -IEPs were maintained in a folder on a bookshelf in each nursing station; -Daily census listing of IEPs should be maintained with accuracy; -IEPs with specific information regarding the evacuation needs of each resident with an IEP and the staff assigned for their evacuation should be stored in the front of the 24-hour Book for each nurses station in which staff did daily charting and communication. Missouri Department of Health and Senior Services STATE FORM 6868 SAINT PETERS, MO 63376 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE 1V4211 DEFICIENCY) (X5) COMPLETE DATE If continuation sheet 6 of 19 PRINTED: 05/19/2025 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 29889 BLWING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREETADODRESS, CITY, STATE, ZIP CODE §300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) 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} NHC PLACE, ST PETERS MEMORY CARE Continued From page 6 19 CSR 30-86.045(3)(A)(9) Resident Evacuation Plan - Readily Available Generai Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 9. Acopy of the resident's evacuation plan shail be readily available to all staff; |I This regulation is not met as evidenced by: Class Il Based on observation, interview, and record review, the facility failed to maintain a copy of the Individual Evacuation Plans (IEPs)(a pian based on a resident's assessed abilities and needs which includes the resident's risk of resistance, need for additional staff support, consciousness, response to instructions, and response to alarms and fire drills to communicate to staff the actions required to evacuate the resident in an emergent situation) readily available to all staff for residents who required more than minimal assistance to evacuate the facility for three residents (Resident #1, #2, and #4) of five residents sampled. The facility census was 35. 1. Review of Resident #1's face sheet showed the following: -Admission date of 4/9/25; -Diagnoses included generalized muscle weakness, unspecified sequela fall, fatigue, and unspecified convulsions. Review of the resident's Community Based Missouri Department of Health and Senior Services STATE FORM 6889 1V4211 If continuation sheet 7 of 19 PRINTED: 05/19/2025 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 29889 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY NHC PLACE, ST PETERS MEMORY CARE SAINT PETERS, MO 63376 (X4) [1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) 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 i DATE DEFICIENCY) ! Continued From page 7 Assessment (CBA) dated 4/29/25 showed the following: -The resident required either a one- ora two-person transfer; -The resident required assistance to push her wheelchair due to physical limitation; -The resident required a mechanical lift for transfer. Review of the resident's Individual Service Plan (ISP) dated 4/30/25 showed staff would report increasing difficulties with transfers or other safety concerns, provide transfer assistance with good technique to protect the resident and care staff, and remind the resident to wait for staff assistance to transfer. 2. Record review of Resident #2's face sheet showed the following: -Admission date of 9/13/23; -Diagnoses included vascular dementia, painful urination, Alzheimer's disease, major depressive disorder, localized swelling in bilateral lower limbs, unsteadiness on feet, weakness, age-related cataract, and edema. Review of the resident's CBA dated 3/18/25 showed the following: -Resident required assistance of one person to transfer; -Resident used a manual wheelchair. Review of the resident's ISP dated 4/30/25 showed the following: -Staff should remind the resident to wait for staff assistance to transfer, report increasing difficulty with transfers or other safety concerns, provide transfer assistance with good technique to protect resident and care staff; Missouri Department of Health and Senior Services STATE FORM 6899 14211 if continuation sheet 8 of 19 PRINTED: 05/19/2025 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 29889 B.WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY 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) NHC PLACE, ST PETERS MEMORY CARE A4511 | Continued From page 8 -Staff should monitor as resident self-propels in wheelchair. 3, Review of Resident #4’s face sheet showed the following: -Admission date of 12/26/16; -Diagnoses included Alzheimer's disease, major depressive disorder, paranoid personality disorder, anxiety disorder, other persistent mood disorders, and unspecified osteoarthritis. Review of the resident's CBA dated 2/21/25 showed the following: -Resident required assistance of 1 person transferring; and -Resident used a Broda wheelchair (tilt in space chair). Review of the resident's ISP dated 2/21/25 showed the following: -Resident is in a Broda chair so staff should push resident to and from an activity; -Staff should remind resident to wait for staff assistance to transfer, provide transfer assistance with good technique to protect resident and care staff, and report increasing difficulty with transfers or other safety concerns; -Resident ISP makes no mention of resident's IEP. 4. Review of the Daily Census Report dated 4/30/25 showed one resident, Resident #4 as currently having an IEP. 5, Observation on 4/30/25 at 4:26 P.M. of the nurses station for the 100 and 200 halls showed no easily accessible list of residents on the 100 and 200 halls who required [EPs and what specific assistance each of those residents Missouri Department of Health and Senior Services STATE FORM S299 1V4211 if continuation sheet 9 of 19 PRINTED: 05/19/2025 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 29889 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY 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) NHC PLACE, ST PETERS MEMORY CARE Continued From page 9 required for safe evacuation. Observation on 4/30/25 at 4:28 P.M. of the nurses station for 300 and 400 hails showed no easily accessible list of residents on the 300 and 400 hails who required IEPs and what specific assistance each of those residents required for safe evacuation. 6. During interview on 4/30/25 at 4:26 P.M., Level One Medication Aide (LIMA) A said the following: -He/She primarily worked the 100 and 200 hails; -Most residents on the 100 and 200 halis needed some assistance; -Resident #4 would need assistance to transfer; -Resident #2 would need assistance as he/she sits in a Broda wheelchair and cannot transfer by his/herself; -He/She was aware that IEPs were listed for some residents on the daily census sheet, but was not aware of any written instruction for each resident's IEP on the 100 and 200 halls. During interview on 4/30/25 at 4:28 P.M., LIMAB said the following: -He/She primarily worked the 300 and 400 halls; -He/She was not aware of any resident on the 300 or 400 hall who would require an IEP; -When asked about Resident #1's inability to transfer independently, he/she said that Resident #1 would need an IEP; -He/She was not aware of a list of residents on the 300 and 400 halls who would require more than minimal assistance to evacuate in an emergency. 7. During interview on 4/30/25 at 5:46 P.M., the Administrator said the following: -The Licensed Practical Nurses (LPNs) were Missouri Department of Health and Senior Services STATE FORM 6699 1V4211 If continuation sheet 10 of 19 PRINTED: 05/19/2025 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 29889 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY NHC PLACE, ST PETERS MEMORY CARE 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) Continued From page 10 responsible for entering IEP information in residents’ service plans; -All staff were responsible to notify nursing staff of a change in resident's condition that might require an IEP; -IEPs were maintained in a folder on a bookshelf at each nurses station; -A daily census listing of IEPs should be maintained with accuracy; -IEPs with specific information regarding the evacuation needs of each resident with an IEP and the staff assigned for their evacuation should be stored in the front of the 24-hour Book for each nurses station in which staff did daily charting and communication. 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. Il This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility 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 upon hire for 13 of 14 sampled employees (Dietary Server C, Receptionist D, Level One Medication Aide (LIMA) E, Licensed Practical Nurse (LPN) F, Care Partner G, Care Partner H, Receptionist |, Nurse J, LIMA K, LIMA A, Activity Director, and Director of Nursing). Additionally the facility failed to ensure that the required two-step tuberculosis screening test was Missouri Department of Health and Senior Services STATE FORM 6899 1V4211 If continuation sheet 11 of 19 PRINTED: 05/19/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 29889 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG NHC PLACE, ST PETERS MEMORY CARE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (X4) ID PREFIX TAG Continued From page 11 administered upon admission for two residents (Resident #1 and #5) of four sampled residents and the required annual screening for tuberculosis signs and symptoms was not documented for two residents (Residents #3 and #4) of four sampled residents. The facility census was 35. 1. Review of Dietary Server C's employee file showed the following: -Hire date 6/15/23; -First step of two-step TB test was administered on 1/3/24 with no date when the first step was read; -No documentation of a second TB test completed. Review of Receptionist D's employee file showed the following: ~Hire date 4/1/25; -First step of two-step TB test was administered on 3/27/25 and read on 3/29/25; ~No record of the second TB test completed. Review of LIMA E's employee file showed the following: -Hire date 8/20/24: -First step of two-step TB test was administered on 12/27/24 and read on 12/30/24; -No record of the second TB test completed. Review of LPN F's employee file showed the following: -Hire date 8/27/24: -First step of two-step TB test was administered on 8/26/24 and read on 8/28/24: -No record of second TB test completed. Missouri Department of Heaith and Senior Services STATE FORM 6899 14211 If continuation sheet 12 of 79 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X4) ID PREFIX Missouri Department of Health and Senior Services STATE FORM NAME OF PROVIDER OR SUPPLIER NHC PLACE, ST PETERS MEMORY CARE (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 29889 STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 Review of Care Partner G's employee file showed the following: -Hire date 3/12/25; -First step of two-step TB test was administered on 3/12/25 with no date read; -No record of the second TB test completed. Review of Care Partner H's employee file showed the following: -Hire date 12/30/24; -First step of two-step TB test was administered on 12/30/24 with no date read; -No record of the second TB test completed. Review of LIMA L's employee file showed the following: -Hire date 3/12/25; -First step of two-step TB test was administered on 3/12/25 with no date read; -No record of the second TB test completed. Review of Receptionist I's employee file showed the following: -Hire date 1/7/25; -First step of two-step TB test was administered on 1/21/25 and read on 1/24/25; -No record of the second TB test completed. Review of Nurse J's employee file showed the following: -Hire date 9/22/2017; -No record of the first or second TB test completed. Review of LIMA K's employee file showed the following: -Hire date 3/12/25; -First step of two-step TB test was administered on 3/10/25 and read on 3/12/25; 8889 1V4211 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) PRINTED: 05/19/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/30/2025 (x5) COMPLETE DATE If continuation sheet 13 of 19 PRINTED: 05/19/2025 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 29889 B.WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) 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) NHC PLACE, ST PETERS MEMORY CARE Continued From page 13 -No record of the second TB test completed. Review of LIMAA's employee file showed the following: -Hire date 11/12/24: -First step of two-step TB test was administered on 11/9/24 and read on 11/12/24; -No record of the second TB test completed. Review of the Activity Director's employee file showed the following: -Hire date 1/27/25; -First step of two-step TB test was administered on 1/22/25 and read on 1/25/25; -No record of the second TB test completed. Review of the Director of Nursing (DON)'s employee file showed the following: -Hire date 4/23/25; -First step of two-step TB test was administered on 4/11/25 and read on 4/13/25; -No record of the second TB test completed. 2. Review of Resident #1's face sheet showed admission date of 4/9/25. Review of Resident #1's electronic medical record showed no documentation of a two-step tuberculosis test upon admission to the facility. 3. Review of Resident #5's undated face sheet showed admission date of 8/29/24. Review of Resident #5's electronic medical record showed no documentation of a two-step tuberculosis test upon admission to the facility. 4. Review of Resident #3's undated face sheet showed admission date of 3/11/24. Missouri Department of Heaith and Senior Services STATE FORM 6899 1V42114 If continuation sheet 14 of 49 PRINTED: 05/19/2025 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 29889 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER ; STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY 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) NHC PLACE, ST PETERS MEMORY CARE A4724| Continued From page 14 Review of Resident #3’s electronic medical record showed the following: -Administration of first step of two step TB test on 3/11/24 and read on 3/13/24 with 0 millimeters (mm) of induration; -Administration of second step of two step TB test on 3/18/24 and read on 3/20/24 with 0 mm of induration; -No documentation of annual TB screening for signs and symptoms in the previous 12 months. 5. Review of Resident #4's face sheet showed admission date of 12/26/16. Review of Resident #4's electronic medical record showed no documentation of annual TB screening for signs and symptoms in the previous in the previous 12 months, 6. During an interview on 4/30/25 at 4:15 P.M. the Administrator said the following: -She was not aware TB screenings were not being administered completely; -It was the facility expectation that each new staff member received the first TB test prior to the first day the new employee would be in contact with the resident, the second TB test should be given two weeks after the first; -Human Resources should keep a record of all employee TB tests; -Facility LPNs were responsible for verifying that residents received the 2-step TB test upon admission and had an annual TB screening for signs and symptoms; -Nursing management was responsible for the audit, administration, and documentation of TB screening tests. Missouri Department of Health and Senior Services STATE FORM 6899 142114 if continuation sheet 15 of 19 PRINTED: 05/19/2025 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 29889 B.WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY 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) NHC PLACE, ST PETERS MEMORY CARE A4733!| Continued From page 15 A4733) 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; III This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to ensure 13 of 14 sampled employees (Dietary Server C, Receptionist D, Level One Medication Aide (LIMA) E, Licensed Practical Nurse (LPN) F, Care Partner G, Care Partner H, Receptionist !, Nurse J, LIMA K, LIMAA, Activity Director, and Director of Nursing) had a written and signed statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. The facility census was 35. 1. Review of Dietary Server C's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of June 15, 2023; -The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work ina long-term care facility and indicating any limitations. Review of Receptionist D's employee file on 4/30/25 at 3:00 P.M., showed the following: Missouri Department of Health and Senior Services STATE FORM saea 4V4211 if continuation sheet 16 of 19 PRINTED: 05/19/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 29889 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 04/30/2025 NHC PLACE, ST PETERS MEMORY CARE (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 LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 16 - Hire date of April 1, 2025; - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. Review of the LIMA E's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of August 20, 2024; - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. Review of LPN F's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of August 27, 2024; and - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. Review of Care Partner G's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of March 12, 2025; - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. Review of the Care Partner H's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of December 30, 2024; - The personnel record did not contain a statement by a licensed physician or physician's Missouri Department of Health and Senior Services STATE FORM 6899 14241 {f continuation sheet 17 of 19 PRINTED: 05/19/2025 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 29889 B. WING 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 (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 LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NHC PLACE, ST PETERS MEMORY CARE A4733} Continued From page 17 designee indicating the person could work in a long-term care facility and indicating any limitations. Review of Receptionist I's employee file on 4/30/25 at 3:00 P.M., showed the following: -~ Hire date of January 7, 2025; - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. Review of Nurse J's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of September 22, 2017; - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. Review of LIMA K's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of March 12, 2025; - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. Review of LIMAA's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of November 12, 2024: - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work ina long-term care facility and indicating any limitations. Missouri Department of Health and Senior Services STATE FORM 6899 1V4214 lf continuation sheet 18 of 19 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER NHC PLACE, ST PETERS MEMORY CARE (X4) ID PREFIX TAG A4733 Department of Health and Senior Services (X41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 29889 {X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 05/19/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 Review of the Activity Director's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of January 27, 2025; - The personne record did not contain a statement by a licensed physician or physician's designee indicating the person could work ina long-term care facility and indicating any limitations. Review of DON's employee file on 4/30/25 at 3:00 P.M., showed the following: - Hire date of April 23, 2025; - The personnel record did not contain a statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. 2. During interview on 4/30/25 at 4:15 P.M. the Administrator said the following: - She was not aware that a physical from a physician had to be done upon hire; - She will work with the facility medical director to facilitate a physician's designee to complete employee physicals. Missouri Department of Heaith and Senior Services STATE FORM 6899 SAINT PETERS, MO 63376 CROSS-REFERENCED TO THE APPROPRIATE 1V4211 PROVIDER'S PLAN OF CORRECTION {X5) {EACH CORRECTIVE ACTION SHOULD BE : COMPLETE DATE DEFICIENCY) continuation sheet 19 of 19 Provider/Supplier Name: | NHC Place St. Peters Memory Care 5300 Executive Centre Parkway St. Peters Mo 63376 Street Address, City, Zip: Apo dapper LPN, ROAL Odominist ate PROVEIEDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG TUES HEE CEE EA STG EOE CHE EERE EE WET EE] alta Residents #1, 2, and 5 were assessed by DON and determined the need for IEP. DON implemented new IEP form and completed the form for each resident. ISP,CBA, and Evaluations updated on the residents. She notified family, uploaded the new IEP form to the residents EHR, added each IEP form to the 24 hour Communication binder. The Daily Census Report has been updated to reflect the IEP’s. The Director of Nursing will be responsible for either assessing the residents or assigning the task to an appropriate nurse. These assessments will be upon admission, change of condition, and when a CBA must be completed by the regulations of the State of Missoun. All staff meetings have been hosted, and employees have bean educated on {EP’s, their locations, and who is in charge of the residents who have an IEP per the forms, NHC Place will continue to monitor the residents for need for IEP's by conducting fire drills monthly, reviewing change of conditions, staff interventions, etc. Upon admission of new residents, a Neighbor Care Card will be filled out by staff which will include if they are an IEP. See Neighbor Care Card Staff have been educated to inform DON and other nurses of resident change of 06/09/2025 conditions at all times. DON will continue to monitor monthly summaries, admissions of new residents, changes of condition. Please see new IEP form. See forms All Partner Inservice Copies of CBA’s of Residents #1, 2, 4, and 5 are in the 24 hour communication binder at the nurses station, on the most recent paper Daily Census Report. As additional IEP’s are presented, all partners will be notified at daily stand-up meetings, updates on the 24 hour communication log. Staff have been educated to revies IEP’s in the front of the communication binders and to look at the Daily Census Report for the list of IEP's. All Department Heads receive a copy of the Daily Census Report and an ADR, which will reflect the IEP change on the resident. Administrator and DON will monitor that all IEP’s are current weekly and add of subtract JEP’s as they change. See forms All Partner Inservice. LPN's have reviewed all current employees for need for TB screening; it was determined by DON to complete annual TB for all staff and restart 2 step for those partners whom their TB paperwork was missing from the files. Dietary Server C's first of the 2 step was administered on 5/29/25 and read 6/1/25, Receptionist D first of two step administered on 5/29/25 and read 6/1/25. LIMA E first of the 2 step was administered on 5/29/25 and read 5/31/25. LPN F is no longer employed by NHC Place St Peters Memory Care, Care Partner G is no longer employed by NHC St Peters Memory Care. Care Partner H first of the 2 step was administered on 5/29/25 and read 06/01/25.Lima L first of the 2 step was administered on 5/29/25 and read 06/01/25.Receptinist | first of the 2 step was administered on 5/31/25 and read 06/02/25.Nurse J first of the 2 step was administered on 06/02/25 and will be read by 06/05/25 as per the guidelines. LIMA K first of the 2 step was administered on 6/29/25 and read 06/01/25. LIMA A first of the 2 step was administered on 5/30/25 and read 06/01/25, Activity Director's first of the 2 step was administered on 5/29/25 and read 05/31/25, DON second TB was administered 04/30/25 and tead 05/02/2025. Resident 1 first of the 2 step was administered on 05/05/25 and read 05/08/25. Second was administered 05/16/25 and read 05/19/25. Resident 2 first of the 2 step was administered on 05/05/25 and read 05/08/25. Second was administered 05/16/25 and read 05/19/25. Resident 3 annual was administered 5/17/25 and read 05/20/25. Resident 4 annual was administered on 5/16/25 and read on 5/19/25, DON will be in charge keeping track of new employee TR's electronically in her calendar that the Administrator will have access. A paper reminder will also be in front of their new hire folder. DON has designated May to be the annual! TB for all employees and residents from this year moving forward. For the residents, a task completion audit will be submitted to the DON for review that the 2 step has been completed on all resident admissions. Medical Director Dr. Andrea Itzkowitz has given Authorization to Director of Nursing LPN Christine Coplin, Administrator LPN Debra Tappe, and Nursing supervisors (Current on staff at this time LPN Cassandra Coleman, LPN Ana Gonzales, LPN Leo Gonzales, and BSN Myah Eggert designees under her guidance to fill out the health form that will deem a prospective employee healthy enough to perform the duties of the respective job in ‘ 06/09/2025 06/09/2025 05/29/25 which they are applying for. Dietary Server C has filled out the form and is healthy enough to perform her duties in her job. Receptionist D has filled out the form and is healthy enough to perform her duties in her job. LIMA E has filled out the form and is healthy enough to perform her duties in her job. LPN F is no longer employed by NHC Place St. Peters Memory Care. Care Partner G is no longer employed by NHC Place Sf Peters Memory Care. Care Partner H has filled out the form and is healthy enough to perform her duties in her job, Receptionist | has filled out the form and is healthy enough to perform her duties in her job. Nurse J has filled out the form and is healthy enough to perform her duties in her job, LIMA K has filled out the form and is healthy enough to perform her duties in her job. LIMA A has filled out the form and is healthy enough to perform her duties in her job. Activities Director has filled out the form and is healthy enough to perform her duties in her job, Director Of Nursing has filled out the form and is healthy enough to perform her duties in her job. All current employees will have a copy of thelr job description and will be deemed healthy enough to perform their job duties. All prospective employees will fill out the health screen before their first day of orientation. it will be completed during their onboarding process. See Letterhead signed b 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; 09/21/2623 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 GORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED 29889 BL WING antenna 09/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES io PROVIDER'S PLAN OF CORRECTION (xs) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE i compute TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE VILLAGES OF ST PETERS MEMORY CARE 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 incorperated by reference. Facilities built between September 28, 1979 and July 1, 2005 shail be maintained in ; accordance with the requirements of the National | Electrical Cade, which was in effect at the time of the original plan approval and local codes. This rule dees not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shail not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. H/I | This regulation is not met as evidenced by: ; Class Hl Based on record review and an interview on ; 9-12-2023 this facility failed to show ; documentation the electrical wiring had been | inspected within the last two years by a qualified electrician. The facility census was thirty-two (32). | This affected thirty-two (32) of thirty-two (32) | residents. Record review showed no records of an electrical inspection being conduct in the last 2 years. The Missouri Department of Health and Senior Services TITLE j {X8) DATE sie SCNR11 if continuation sheet 1 of 2 STATE FORM PRINTED: 09/21/2023 FORM APPROVED Missouri Depariment 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 29889 B. WING 09/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5300 EXECUTIVE CENTER PARKWAY SAINT PETERS, MO 63376 (xayi0 SUMMARY STATEMENT OF DEFICIENCIES 1D i 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 VILLAGES OF ST PETERS MEMORY CARE Continued From page 1 | documentation for the last inspection provided was dated 1-18-2021. During an interview on 9-12-2023 at 12:35 P.M. with the facility director said he couldn't locate it and wasn't sure it had been completed. Missouri Department of Health and Senior Services STATE FORM 8895 SCNR11 if continuation sheet 2 of 2 PLAN OF CORRECTION The Us Wages or Sy. Peles Mewngr my Care ZAG YA | Street Address, 5 > 300 Eye cu dive Ce fal we City, Zip: “a De har S . Date of Survey: | G - \ ‘C . Po 25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: Provider/Supplier Name: 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD a CROSS-REFERENCED TO JRE APPROPRIATE DEFICIENCY} DATE 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.