WESTBURY SENIOR LIVING THE.

PRINTED: 11/08/2024 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 32666 B. WING 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 550 STONE VALLEY PARKWAY COLUMBIA, MO 65203 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) WESTBURY SENIOR LIVING, THE 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications 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: Class II Based on record review and interview during a fire safety inspection on February 7, 2024 the facility failed to insure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative at least annually. Thorough visual inspections and physical testing of the fire alarm systems components must occur weekly, monthly, quarterly, semi-annually, annually, every five and ten years according to NFPA statndards. The facility census was 60. This deficiency affects 60 of 60 residents as well as all employees. Records review at 3:20 P.M. showed no annual inspection had been done on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. The last semi-annual alarm test was performed on October 17, 2023. During an interview at 4:30 P.M. the Administrator stated the annual had been performed the week prior, but they had not recieved any paperwork proof. She emailed the testing company with no reply during the inspection . Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 OLVa11 If continuation sheet 1 of 4 PRINTED: 11/08/2024 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 32666 B. WING 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 550 STONE VALLEY PARKWAY COLUMBIA, MO 65203 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) WESTBURY SENIOR LIVING, THE 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. Il This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on February 7, 2024 the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being used for trash. The facility census was 60. This deficiency affects 60 of 60 residents. Observation through out the fire inspection showed more than twenty two unapproved plastic wastebaskets in use throughout the building. The following rooms were noted with one to three violations each during the inspection. Rooms in ALF wing: 101, 106, 115, 116, 120, 121, 124, 129, 131, 133, 141, 144 Rooms in memory care wing: 2, 14, 16 During an interview at 4:30 P.M. the administrator expressed her appologies and stated she would get the issue taken care of. 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 Missouri Department of Health and Senior Services STATE FORM 6899 OLVQ11 If continuation sheet 2 of 4 PRINTED: 11/08/2024 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 32666 B. WING 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 550 STONE VALLEY PARKWAY COLUMBIA, MO 65203 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) WESTBURY SENIOR LIVING, THE Continued From page 2 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 February 7, 2024 the facility failed to properly maintain the buildings electrical wiring to not cause a safety or fire hazard. The facility census was 60. This deficiency affects 60 of 60 residents. 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. 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 construction. All facilities shall have wiring Missouri Department of Health and Senior Services STATE FORM 6899 OLVQ11 If continuation sheet 3 of 4 PRINTED: 11/08/2024 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 32666 B. WING 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 550 STONE VALLEY PARKWAY COLUMBIA, MO 65203 (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) WESTBURY SENIOR LIVING, THE Continued From page 3 inspected every two (2) years by a qualified electrician. Arecords review begining at 3:20 P.M. showed no current two year electrical wiring inspection documentation could be produced. The last electrical inspection was performed on 10-27-21. During an interview at 4:30 P.M. the administrator stated she would see that the inspection was scheduled as soon as possible. Missouri Department of Health and Senior Services STATE FORM 6899 OLVQ11 If continuation sheet 4 of 4 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).