GRAND ROYALE, THE.

PRINTED: 07/24/2024 FORM APPROVED 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: (X3) DATE SURVEY COMPLETED 03086N B. WING 07/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2900 NE KENDALLWOOD PKWY GLADSTONE, MO 64119 NAME OF PROVIDER OR SUPPLIER GRAND ROYALE, THE PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-86.022(11)(D) Sprinkler System, Res. A2272 Impaired, Single-Story Sprinkler Systems. (D) Single-story assisted living facilities that provide care to one (1) or more residents with a physical, cognitive, or other impairment that prevents the individual from safely evacuating the facility with minimal assistance shall install and maintain an approved sprinkler system in accordance with NFPA 13R, 1999 edition. I/II This regulation is not met as evidenced by: Class Il. Based on observation and interview on 7/22/24, facility fails to maintain an approved sprinkler system in accordance with NFPA 13R, 1999 edition. The facility census is twenty-three (23). This deficiency affects twenty-three (23) of twenty-three (23) residents. Observation at 1:52 p.m. of the 500's hall ceiling outside the Mechanical and Utility Rooms shows a gap between the sprinkler head escutcheon trim ring and surrounding drywall. Observation at 2:34 p.m. in Room B508 shows a sprinkler head that is missing the sprinkler head metal surround trim ring. Observation at 3:15 p.m. in the hallway outside Room B705 shows a sprinkler head that has its sprinkler head metal surround trim ring loosely hanging. Observation at 3:29 p.m. in the bathroom closet of Room B711 shows a sprinkler head with a loose metal surround trim ring, creating a gap in the drywall. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROYIDER/SUPPLJER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE PUD QA ava MAM AYIA Gi WZ We STATE FORM Ca a) OPIX11 If continuation sheet '1 of 6 PRINTED: 07/24/2024 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 03086N — 07/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2900 NE KENDALLWOOD PKWY GLADSTONE, MO 64119 (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) GRAND ROYALE, THE Continued From page 1 In an interview with the Director of Social Services at 5:15 p.m., she/he said the facility will notify the maintenance director to have repairs made ASAP. 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. II This regulation is not met as evidenced by: Class Il. Based on observation and interview on 7/22/24, facility fails to ensure only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. The facility census is twenty-three (23). This deficiency affects twenty-three (23) of twenty-three (23) residents. Observation of Room B502 at 1:57 p.m. showed one (1) non-compliant waste basket being used for trash purposes. Observation of Room B501 at 2:07 p.m. showed one (1) non-compliant waste basket being used for trash purposes. Observation of Room B504 at 2:14 p.m. showed five (5) non-compliant waste baskets being used for trash purposes. Observation of Room B507 at 2:24 p.m. showed one (1) non-compliant waste basket being used for trash purposes. Observation of Room B508 at 2:33 p.m. showed one (1) non-compliant waste basket being used for trash purposes. Observation of Room B601 at 2:49 p.m. showed one (1) non-compliant waste basket being used Missouri Department of Health and Senior Services STATE FORM 6899 OPIX11 If continuation sheet 2 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 03086N NAME OF PROVIDER OR SUPPLIER GRAND ROYALE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 for trash purposes. Observation of Room B604 at 2:50 p.m. showed one (1) non-compliant waste basket being used for trash purposes. Observation of Room B608 at 2:58 p.m. showed three (3) non-compliant waste baskets being used for trash purposes. Observation of Room B607 at 3:02 p.m. showed two (2) non-compliant waste baskets being used for trash purposes. Observation of Room B704 at 3:10 p.m. showed two (2) non-compliant waste baskets being used for trash purposes. Observation of Room B705 at 3:17 p.m. showed one (1) non-compliant waste basket being used for trash purposes. Observation of Room B707 at 3:22 p.m. showed one (1) non-compliant waste basket being used for trash purposes. Observation of Room B711 at 3:29 p.m. showed two (2) non-compliant waste baskets being used for trash purposes. In an interview with the Director of Social Services at 5:15 p.m., she/he said the facility will be replacing these waste baskets with the correct type. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 OPIX11 PRINTED: 07/24/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2900 NE KENDALLWOOD PKWY GLADSTONE, MO 64119 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 03086N NAME OF PROVIDER OR SUPPLIER GRAND ROYALE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 Based on observation and interview on 7/22/24, facility fails to ensure oxygen storage shall be in accordance with NFPA 99, 1999 edition. The facility census is twenty-three (23). This deficiency affects twenty-three (23) of twenty-three (23) residents. Observation at 2:07 p.m. in Room B501 shows an oxygen concentrator in the room with no sign on the door. Observation at 2:12 p.m. in Room B507 shows four (4) oxygen cylinders that are unsupported and not in a rack or carrier. Observation at 2:17 p.m. in Room B504 shows an unsupported oxygen cylinder in the bathroom not in a rack or carrier. Observation at 2:44 p.m. in Room B602 shows an oxygen concentrator in the room with no sign on the door. In an interview with the Director of Social Services at 5:15 p.m., she/he said the facility will make more frequent sweeps of the facility to ensure oxygen cylinder safety. 19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 OPIX11 PRINTED: 07/24/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2900 NE KENDALLWOOD PKWY GLADSTONE, MO 64119 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 03086N NAME OF PROVIDER OR SUPPLIER GRAND ROYALE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II This regulation is not met as evidenced by: Class Il. Based on observation and interview on 7/22/24, facility fails to prohibit the use of portable heaters of any kind. The facility census is twenty-three (23). This deficiency affects twenty-three (23) of twenty-three (23) residents. Observation of Room B502 at 1:57 p.m. showed a Lasko model CT22840 electric air heater in the bedroom. Observation of Room B508 at 2:34 p.m. showed a Utilitech model NT15-20A/3757108 1500w ceramic heater under a desk. Observation of Room B711 at 3:29 p.m. showed an EdenPURE brand model GEN3 quartz infrared portable heater in the bedroom closet. In an interview with the Director of Social Services at 5:15 p.m., she/he said the facility will Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 OPIX11 PRINTED: 07/24/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2900 NE KENDALLWOOD PKWY GLADSTONE, MO 64119 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 6 PRINTED: 07/24/2024 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 03086N — 07/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2900 NE KENDALLWOOD PKWY GLADSTONE, MO 64119 (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) GRAND ROYALE, THE A3211) Continued From page 5 notify the maintenance person to make more frequent sweeps of the facility to prevent space heater usage. Missouri Department of Health and Senior Services STATE FORM 6899 OPIX11 If continuation sheet 6 of 6 UNABLE TO LOCATE PLAN OF CORRECTION