WHITE OAK ASSISTED LIVING.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER WHITE OAK ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 05/06/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements. (D) The department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two- (2-) hour fire-resistant construction. No section of the building shall present a fire hazard. I/II This regulation is not met as evidenced by: Class Il. Based on observation, records review, and interview on 04/08/24, facility fails to ensure no section of the building shall present a fire hazard. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Observation at 1:16 PM, in the basement laundry room, showed a commercial gas clothes dryer with a several-inch tall yellow flame nearly escaping the combustion chamber, indicating the flame isn't adjusted properly. Above this dryer is lint buildup on the walls, ceiling, and nearby fire sprinkler head. Observation at 2:08 PM, near a downstairs office hallway, twelve portable flame can heaters, used for keeping banquet food pans heated, were laying on the ground with their wicks exposed. Photos taken. Records review online from 8:25 PM to 8:49 PM of the Alliance Laundry, model DTB50CG, dryer manual shows on page 91/94 that the flames from that laundry dryer should be blue, not yellow. During the interview with administrator, he/she Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 12QT11 If continuation sheet 1 of 12 PRINTED: 05/06/2024 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 06604C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 (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) WHITE OAK ASSISTED LIVING Continued From page 1 said the facility was told by a dryer repair person that the flame is ok. However, they plan to have it checked again. Facility plans to clean the lint, and will put the fuel cans in a fuel container cabinet. 19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check Fire Extinguishers. (D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure check. II/III This regulation is not met as evidenced by: Class Ill. Based on observation and interview on 4/08/24, facility fails to maintain fire extinguishers. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Observation at 10:11 AM showed a fire extinguisher in the foyer missing the monthly check for March 2024, Observation at 10:24 AM showed a fire extinguisher in the kitchen missing the monthly check for March 2024, Observation at 10:28 AM showed a fire extinguisher in the kitchen missing the monthly check for March 2024, Observation at 10:55 AM showed a fire extinguisher on the 2nd floor area of refuge Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 If continuation sheet 2 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 06604C NAME OF PROVIDER OR SUPPLIER 1515 WEST WHITE OAK WHITE OAK ASSISTED LIVING INDEPENDENCE, MO 64050 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 missing an annual inspection tag, Observation at 11:29 AM showed a fire extinguisher near room 35 missing an annual inspection tag, Observation at 11:41 AM showed a fire extinguisher in the elevator room near the former doctor's offices in the basement missing the monthly check for March 2024, Observation at 1:47 PM showed a fire extinguisher in the basement hallway missing an annual inspection tag, Observation at 2:07 PM showed a fire extinguisher in the basement by office #10 missing an annual inspection tag, Observation at 2:25 PM showed a fire extinguisher in the basement server room missing an annual inspection tag, Observation at 2:32 PM showed a fire extinguisher in the hair salon missing an annual inspection tag, Observation at 2:40 PM showed a fire extinguisher in the basement hallway missing an annual inspection tag, Observation at 3:52 PM showed a fire extinguisher in the top floor hallway missing an annual inspection tag. Photos taken. During the interview with administrator, he/she said the facility is aware of the issue and has already contacted a fire extinguisher company. Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 3 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER WHITE OAK ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: INDEPENDENCE, MO 64050 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class Il. Based on observation, records review, and interview on 04/08/24, facility fails to ensure proper condition of smoke partitions. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Observation at 9:57 AM showed a wet floor’ sign impeding a self-closing door between adjacent facilities. Observation at 1:37 PM showed two fire-rated doors near the loading dock hallway were propped open by wedges despite signs on the door that the door shall not be propped open. Observation at 10:44 AM showed a set of rated fire doors on the second floor by the med room have the 'smoke gap cover' hanging loose. Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 12 PRINTED: 05/06/2024 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 06604C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 (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) WHITE OAK ASSISTED LIVING Continued From page 4 Observation at 3:29 PM showed the double doors on Juniper Hall are missing the rubber 'smoke gap strip’. Photos taken. During the interview with the administrator, he/she said the facility will make repairs, and provide education to employees not to prop open required fire/smoke doors. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class Il. Based on observation, records review, and interview on 04/08/24, facility fails to inspect and maintain fire sprinkler system. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Observations from 10:16 to 10:20 AM showed five (5) dirty or dusty sprinkler heads in the kitchen. Two of those heads have gaps between the head and drywall. Observation at 10:21 AM showed one (1) dust covered sprinkler head in the kitchen freezer. Observations from 1:17 to 1:20 PM showed two (2) sprinkler heads behind the basement clothes dryers are covered in lint, and have gaps at the Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 If continuation sheet 5 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER WHITE OAK ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: INDEPENDENCE, MO 64050 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 wall. Photos taken. Records review at 6:05 PM shows the facility uses the TELS building maintenance computer program, but there is no easily discernable record of monthly sprinkler checks. During the interview with administrator, he/she said the facility will make the repairs, and will consider recording monthly sprinkler checks near the risers. 19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/III This regulation is not met as evidenced by: Class Ill. Based on observation and interview on 4/08/24, facility fails to ensure smoking shall be permitted in designated areas only. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Observation at 11:03 AM show numerous cigarette butts in a coffee can on the second floor balcony. Observation at 6:24 PM showed several cigarette butts are in the grass just outside the NW basement exit door by the parking lot. Photos Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 12 PRINTED: 05/06/2024 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 06604C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 (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) WHITE OAK ASSISTED LIVING Continued From page 6 taken. During the interview with administrator at 5:15 PM, he/she said smoking is not allowed anywhere on property. 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. Based on observation and interview on 4/08/24, facility fails to ensure oxygen storage shall be in accordance with NFPA 99, 1999 Edition. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Observation at 10:41 AM showed three (3) oxygen cylinders outside the racks in the closet of the 2nd floor shower room. Observation at 11:10 AM showed nine (9) oxygen cylinders outside the racks in room 37. Observation at 11:24 AM showed one (1) oxygen cylinder outside the rack in room 21. Observation at 11:40 AM showed one (1) oxygen cylinder outside the rack in the medication room. Observation at 11:47 AM showed one (1) oxygen cylinder unsupported in room 17. Photos taken. Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 If continuation sheet 7 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER WHITE OAK ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: INDEPENDENCE, MO 64050 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 During the interview with administrator at 5:15 PM, he/she said facility will address the issue. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class Ill. Based on observation and interview on 4/08/24, facility fails to ensure building shall be substantially constructed and shall be maintained in good repair. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Observation at 11:41 AM showed a void space access scuttle, and two holes in the drywall ceiling, left open in the med room. Observation at 1:14 PM showed two ceiling tiles missing from the laundry room ceiling. Observation at 1:17 PM showed two holes in the ceiling, around sprinkler pipes, behind the basement clothes dryers. Observation at 1:42 AM showed a hole in the ceiling of the basement bathroom near the boiler room. Observation at 1:52 PM showed an open ceiling tile in a basement tool room. Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER WHITE OAK ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: INDEPENDENCE, MO 64050 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 Observation at 1:54 PM showed two open ceiling tiles in a basement maintenance shop. Observation at 1:56 PM showed two holes in the ceiling of a basement compressor room. Observation at 2:00 PM showed an open scuttle in the basement wood shop room. Observation at 2:04 PM showed two open scuttles in the basement room #10. Observation at 2:21 PM showed a gap at the ceiling in the basement classroom near the records room. Observation at 2:24 PM showed holes in the concrete block wall at ceiling level in the basement compressor room. Observation at 2:41 PM showed holes in the drywall wall and ceiling in the classroom across from basement room four (4). Observation at 2:42 PM showed a missing ceiling tile in the basement training room. Observation at 2:43 PM showed a missing ceiling tile in the hallway across from basement room four (4). Observation at 3:37 PM showed the stairwell, near the elevator, with lightbulbs out in it making it difficult to use the stairs without a flashlight. Observation at 3:45 PM showed the stairwell, at the end of the 80s hallway, with lightbulbs out in it. Photos taken of all violations. Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 12 PRINTED: 05/06/2024 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 06604C — 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 (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) WHITE OAK ASSISTED LIVING Continued From page 9 During the interview with administrator at 5:15 PM, he/she said facility will address the issues. 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 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, records review, and interview on 04/08/24, facility fails to ensure electrical wiring shall be maintained in good repair and shall not present a safety hazard. Census is thirty-four (34). Deficiency affects thirty-four (34) of thirty-four (34). Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 If continuation sheet 10 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER WHITE OAK ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: INDEPENDENCE, MO 64050 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 Observations at 10:14 AM showed a hanging broken kitchen lightbulb with the filament and base left in the socket. Observations at 10:26 AM showed a kitchen pipe leak has caused a large puddle employees must stand in when operating a kitchen appliance with NM-WT electrical conduit submerged in this puddle. Observations at 10:58 AM showed an electrical panel near the Juniper Hall is missing a blank cover plate. Observations at 1:32 PM showed an electrical conduit coupling has come apart and is being held in place by the wiring at the ceiling level of the boiler room. Observation at 1:58 PM showed three loose wires, hanging from the ceiling of the basement compressor room, that are not terminated in a Junction box. Observation at 2:28 PM showed broken light switch in a basement storage room, and Observations at 2:35 PM showed the beauty salon had two power strips plugged into one overloaded duplex outlet along with another daisy-chained mini-power strip. Photos taken. Records review at 5:07 PM showed STACO Electrical conducted a thermal-imaging scan of electrical connections at the facility on 10/3/23. Sixteen issues were noted on the report. There is no documentation indicating if the recommended repairs were made. During the interview with administrator, he/she Missouri Department of Health and Senior Services STATE FORM 6899 12QT11 PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ee 06604C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK WHITE OAK ASSISTED LIVING INDEPENDENCE, MO 64050 PRINTED: 05/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 04/08/2024 (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 A3214 | Continued From page 11 wrote down the issues to address them. Missouri Department of Health and Senior Services STATE FORM oeee 12QT11 DEFICIENCY) If continuation sheet 12 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER PRINTED: 08/20/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 08/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 WHITE OAK ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG {A2283} 19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/III This regulation is not met as evidenced by: Class II* This deficiency remains uncorrected. For previous examples, refer to the statement of deficiencies for tag #2283 dated 04/08/24. Based on observation, records review, and interview during a reinspection revisit on 08/06/24, facility continues to fail at ensuring smoking shall be permitted in designated areas only. Census is thirty-eight (38). Deficiency affects thirty-eight (38) of thirty-eight (38) residents. Observation at 3:10 p.m. shows smoking is still occurring on the second floor balcony, where smoking had been occurring during the annual fire inspection on 04/08/24. In the same location on the second floor balcony, cigarette butts and ashes are being discarded on the outdoor carpet on this balcony, and a blue plastic flower pot is being used as a cigarette butt receptacle. In the plastic flower pot is a mix of dry leaves, dry twigs, dry foliage, wadded up toilet paper, and cigarette butts. Records review shows the facility received a violation for this same issue on 04/08/24, and has failed to correct it. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE {A2283} TITLE (X6) DATE 6899 If continuation sheet 1 of 3 12QT12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 06604C PRINTED: 08/20/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 08/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK WHITE OAK ASSISTED LIVING (x4) ID PREFIX TAG {A2283} {A3214} INDEPENDENCE, MO 64050 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 In an interview with the maintenance director at 4:15 p.m., the facility is a no-smoking campus. He/she agreed to place a "No Smoking On Balcony" sign on the door that leads to this balcony. He/she plans to address this ongoing issue with the acting administrator. *Higher classification merited of changing this Class III to a Class II violation, due to a Class III violation having not been corrected upon this reinspection revisit on 08/06/24, and due to the severity of the violation. 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 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 Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A2283} {A3214} If continuation sheet 2 of 3 oe 12QT12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER PRINTED: 08/20/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 08/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 WHITE OAK ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A3214}| Continued From page 2 This regulation is not met as evidenced by: Class II* This deficiency remains uncorrected. For previous examples, refer to the statement of deficiencies for tag #3214 dated 04/08/24. Based on records review, and interview during a reinspection revisit on 08/06/24, facility continues to fail at maintaining the electrical wiring in good repair so it shall not present a safety hazard. Census is thirty-eight (38). Deficiency affects thirty-eight (38) of thirty-eight (38) residents. Records review shows a Staco Electrical Construction infrared inspection report dated 10/03/23, listing sixteen (16) electrical issues and recommendations. In an interview with the maintenance director at 4:15 p.m., he/she said the facility has not made the repairs. *Higher classification merited of changing this Class II to a Class II violation, due to a Class III violation having not been corrected upon this reinspection revisit on 08/06/24, and due to the severity of the violation. Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A3214} If continuation sheet 3 of 3 oe 12QT12 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 09/08/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILOING: {X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 06604C B. WING 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK TE OAK AS: irl WHT AK ASSISTED LIVIN INDEPENDENCE, MO 64050 {x4} 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULO BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY, A2238) 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. + (C) All required exit signs and directional ; indicators shall be positioned so that both normal and emergency lighting illuminates thern. IWIft This regulation is not met as evidenced by: Class Ill: Based on observation and interview on 8/28/23, facility fails to keep EXIT lights fit. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Observation at 1:11 p.m.: EXIT light at end of north half is not tit. Interview with building maintenance director at 2:15 p.m.: Facility will get it fixed. 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. Wit This regulation is not met as evidenced by: Class Il: Based on records review and interview on 8/28/23, facility fails ta conduct semi-annual fire alarm testing and inspection. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Records review: Missouri Department of Health and Senior Services LABORATORY DIR! LIER REPRESENTATIVE'S SIGNATURE TITLE {X6) DATE STATE FORM M13H11 tinualian sheet 1 of 7 PRINTED: 09/08/2023 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 06604C $$$ i$ 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID 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 WHITE OAK ASSISTED LIVING 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III This regulation is not met as evidenced by: Class III: Based on observation and interview on 8/28/23, facility fails to keep EXIT lights lit. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Observation at 1:11 p.m.: EXIT light at end of north hall is not lit. Interview with building maintenance director at 2:15 p.m.: Facility will get it fixed. 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 records review and interview on 8/28/23, facility fails to conduct semi-annual fire alarm testing and inspection. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Records review: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 M13H11 If continuation sheet 1 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 06604C NAME OF PROVIDER OR SUPPLIER 1515 WEST WHITE OAK WHITE OAK ASSISTED LIVING INDEPENDENCE, MO 64050 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 1 Facility gave inspector a packet of paperwork, showing alarm system testing was done 9/3/21, 3/18/22, and 3/22/23. An alarm test should have been done around September 2022. Records review was conducted offsite on 8/30/23 at 11:30 a.m. Interview: Inspector emailed administrator, maintenance director, and corporate facilities director on 8/30/23 at 11:42 asking for semi-annual fire alarm testing documentation be submitted by close of business on 8/31/23. As of 9/5/23 at 8:17 a.m., no documentation has been received. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as Missouri Department of Health and Senior Services STATE FORM 6899 M13H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 09/08/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/28/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 2 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 06604C NAME OF PROVIDER OR SUPPLIER 1515 WEST WHITE OAK WHITE OAK ASSISTED LIVING INDEPENDENCE, MO 64050 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 2 residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II: Based on observation, records review, and interview on 8/28/23, facility fails to keep doors to hazardous areas closed, unless only kept open by an electromagnetic hold-open device connected to the fire alarm system. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Observations: 1. Main door to basement laundry area was being held open by a bedding sheets transport cart (1:31 p.m.), 2. Once bedding cart was removed, another cart (plastic tub style) prevented the door from closing (1:31 p.m.). 3. Next to a second, smaller door was a door wedge, that was not in use. The facility placed it in the trash (1:33 p.m.). Records review: Facility was cited for the same violation last year on another laundry room at the facility. Interview with building maintenance director at 2:15 p.m.: Facility taped signs on the door, and will cover this issue at the next employee training. 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Missouri Department of Health and Senior Services STATE FORM 6899 M13H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 09/08/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/28/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 3 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 06604C NAME OF PROVIDER OR SUPPLIER 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 WHITE OAK ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG ID PREFIX TAG Continued From page 3 Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II: Based on observation and interview on 8/28/23, facility fails to prevent storage of unnecessary combustible materials in any part of a building in which a licensed facility is located. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Observations from 12:46 p.m. to 1:22 p.m. in the basement halls, all of which serve as egress means: Short west hall by medical records: pallet leaned against wall, creeper wheeled cart (tripping hazard), janitor cart with trash and it's products strewn on ground near it, two doors laying against wall (storage area for spare doors is located 40 ft away), plastic cart, battery mobility chair, wheelchair, filing cabinets, and more. These items are restricting egress hall width. Center hall near "T": couch, plastic cubicle divider, seven foam chairs. Hall near Housekeeping: armoire, 15'-20' of resident items stored against wall that are either trash or in disarray, such as boxes, parts of wood furniture, a keyboard, broken picture frame, fishing rods, items in trash bags, a dresser, walker on it's side laying atop a mattress that's laying atop a recliner chair, and more. Missouri Department of Health and Senior Services STATE FORM 6899 M13H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 09/08/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/28/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 4 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 06604C NAME OF PROVIDER OR SUPPLIER 1515 WEST WHITE OAK WHITE OAK ASSISTED LIVING INDEPENDENCE, MO 64050 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 4 Hall near hair dresser: two mattresses propped against wall, dorm refrigerator, cart with four boxes from Direct Supply, broken down cardboard box. These items are the most restricting of egress width in the four hallways where issues are present. Kitchen dry foodstuffs storage room: items stacked above 18" from ceiling, preventing sprinkler heads from operating as designed. Kitchen spare equipment/serving item storage room: plastic containers, boxes, and spare dishwasher plastic racks stacked above 18" from ceiling, preventing sprinkler heads from operating as designed. Interview with corporate facilities director at 2:15 p.m.: facility will get these areas cleaned up. 19 CSR 30-86.032(2) Substantially Constructed & A3201 Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class III: Based on observation and interview on 8/28/23, facility fails to maintain the building in good repair. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Missouri Department of Health and Senior Services STATE FORM 6899 M13H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 09/08/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/28/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 5 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 06604C NAME OF PROVIDER OR SUPPLIER 1515 WEST WHITE OAK WHITE OAK ASSISTED LIVING INDEPENDENCE, MO 64050 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X4) ID PREFIX TAG Continued From page 5 Observations: 1. Medical records library, 1st floor: Several holes in the sheetrock above the medical records area, which is a high fuel load area due to the volume of records stored. (1:01 p.m.). 2. Room 26: Ceiling tiles missing, misplaced, or damaged (11:42 a.m.). Interview with corporate facilities director at 2:15 p.m.: Facility has old cast iron pipes that are several decades old, that are failing more frequently. After the holes were cut, they were left open to dry. 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 to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring Missouri Department of Health and Senior Services STATE FORM 6899 M13H11 (X2) MULTIPLE CONSTRUCTION PRINTED: 09/08/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/28/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY (x5) COMPLETE DATE If continuation sheet 6 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06604C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 09/08/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/28/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 1515 WEST WHITE OAK INDEPENDENCE, MO 64050 WHITE OAK ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 6 inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III: Based on observation, records review, and interview on 8/28/23, facility fails to ensure the electrical system shall be maintained in accordance with the requirements of the National Electrical Code. Facility census is thirty-four (34). Violation affects thirty four (34) of thirty-four (34) residents. Observations: Kitchen: Metallic electrical junction box has the cover ripped partially off, hanging by one screw, exposing the internal wires (11:50 a.m.), Room 43: GFCI near the kitchenette sink has no power (11:44 a.m.). Records review: The last 2-year electrical inspection by an electrician expired 6/23/23. Records review conducted offsite on 8/30/23 at 11:35 a.m. Interview with building maintenance director at 2:15 p.m.: Facility will make repairs. Missouri Department of Health and Senior Services STATE FORM 6899 ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY M13H11 If continuation sheet 7 of 7 | PLAN OF CORRECTION Provider Name: White Oak Assisted Living Street Address, City, Zip: Date of Survey: Provider number: ID PREFIX TAG 1515 West White Oak, Independence, MO 64050 08/28/23 PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Preparation and/or execution of this Plan of Correction does not constitute admission of agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of federal and state law. The Plan of Correction constitutes the facility’s credible allegation of compliance. The Director of Maintenance/designee inspected the exit light at the end of the north hall with repairs made as needed. Residents that reside in the facility have potential to be affected. The Administrator/designee educated the Director of Maintenance related to exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. The Director of Maintenance/designee inspected facility exit lights to ensure they were illuminating with repairs made as A2238 needed. Results of the inspection was kept in a log. The Director of Maintenance/designee will inspect facility exit lights weekly as on-going with results kept in a log. The Administrator/designee will review the inspection logs weekly times one month then monthly times one quarter. Any issues identified will result in 1:1 education by the Administrator/designee. Results will be reviewed during QAP! for evaluation and further recommendations. The Director of Maintenance/designee will ensure semi-annual A2249 fire alarm and testing will take place. COMPLETION DATE 10/4/23 10/4/23 | recommendations. | A2256 A2257 Residents that reside in the facility have potential to be affected. | The Director of Maintenance/designee had the semi-annual fire alarm test and inspection completed on 8/14/23. The Administrator/designee educated the Director of Maintenance regarding semi-annual fire alarm test and inspection. | The Director of Maintenance/designee will set up reoccurring semi-annual fire alarm testing and inspection. The Director of Maintenance/designee will log the results of the semi-annual fire alarm and testing. The Administrator/designee will review the inspection logs completed and as on-going. Any issues identified will result in 1:1 education by the Administrator/designee. Results will be reviewed during QAP! for evaluation and further The Maintenance Director inspected the main door to the basement laundry area and a second smaller door in the same area to remove props that were holding the doors open. Residents that reside in the facility have potential to be affected. The Administrator/designee educated the Director of Maintenance regarding the use of door props. The Director of Maintenance/designee will educate staff regarding door props. The Director of Maintenance/designee will audit facility doors to 10/4/23 ensure props are nat being utilized 3 times weekly for one month. Results will be kept in a log. The Administrator/designee will review the log weekly times one month. Any issues identified will result in 1:1 education by the Director of Maintenance/designee. Results will be reviewed during QAPI for evaluation and further recommendations. 10/4/23 The Director of Maintenance/designee inspected the center hall | The Director of Maintenance/designee inspected the short west | hall and removed the items that were restricting the egress hall | width. near "T’ and removed items restricting the egress hall width. | | A3201 | The Director of Maintenance/designee inspected the kitchen dry | foodstuffs storage room and removed items that were above 18” from the ceiling. The Director of Maintenance/designee inspected the kitchen spare equipment/serving items storage room and removed items that were stored above 18” from the ceiling. Residents that reside in the facility have potential to be affected. The Administrator/designee educated the Director of Maintenance, the Director Environmental Services and the Director of Dining Services regarding proper egress wall width and not stacking items above 18” from the ceiling. The Maintenance Director/designee educated staff regarding proper egress wall width and not stacking items above 18” from the ceiling. The Director of Maintenance/designee inspected the facility halls to ensure proper egress wall width were maintained with corrections made as needed. The result of the inspection was kept in a log. The Director of Maintenance/designee inspected the kitchen ensure proper nothing was stacked above 18” with corrections made as needed. The result of the inspection was kept in a log. The Director of Maintenance/designee will inspect the halls and kitchen one time per week for one month then monthly for one quarter to ensure compliance. The results of the inspection will be kept in a log. The Administrator/designee will review the inspection logs weekly times one month then monthly for one quarter. Any issues identified will result in 1:1 education by the Director of Maintenance/designee. Results will be reviewed during QAPI for evaluation and further recommendations. The Maintenance Director/designee inspected the 1* floor medical records library with repairs made to the walls as identified. The Maintenance Director/designee inspected room 26 with repairs made to the ceiling tiles as needed. Residents that reside in the facility have potential to be affected. The Administrator/designee educated the Director of Maintenance related to maintaining the building in good repair. The Maintenance Director inspected the building to ensure it is in good repair with repairs made as identified. The results of the inspection were kept in a log. 10/4/23 The Maintenance Director/designee will inspect the facility weekly for one month then monthly for one quarter along with after any construction to ensure compliance. Results of the | inspection will be kept in a log. The Administrator/designee will review the inspection logs weekly times one month then monthly for one quarter. Any issues identified will result in 1:1 education by the Director | of Maintenance/designee. | Results will be reviewed during QAPI for evaluation and further recommendations. The Director of Maintenance/designee inspected the metallic electrical junction box with repairs made as necessary. The Director of Maintenance/designee inspected room 43 with - | repairs made to the GFI outlet as needed, electrical inspection for 9/16/23. Residents that reside in the facility have potential to be affected. The Administrator/designee educated the Director of Maintenance related ensuring the electrical system shall be maintained in accordance with the requirements of the National Electrical Code. | The Director of Maintenance/designee scheduled the 2-year | I The Director of Maintenance/designee inspected the facility to 10/4/23 ensure electrical system compliance with repairs made as necessary. The result of the inspection was kept in a log. The Maintenance Director/designee will inspect the facility weekly for one month then monthly for one quarter along with after any construction to ensure compliance. Results of the inspection will be kept in a log. The Administrator/designee will review the inspection logs weekly times one month then monthly for one quarter. Any issues identified will result in 1:1 education by the Director of Maintenance/designee. Results will be reviewed during QAPI for evaluation and further recommendations. Os a 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.