BROOKDALE WORNALL PLACE.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 10/25/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 10/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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 an interview on 10/15/24 this facility failed to document all the fire extinguishers being checked monthly and to have them all maintained annually. The facility census was 41. This potentially affected 41 of 41 residents. Observation on 10/15/24 at 2:35 P.M. showed the fire extinguisher in the 5th floor life enrichment room had not been inspected since the year 2020. During an interview on 10/15/24 at 2:35 P.M. the maintenance person stated he/she did not think anyone even knew it was in there, since there is one outside in the hallway. 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 SYJC11 If continuation sheet 1 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility 's entire plan shall be provided to the local jurisdiction 's emergency management director. W/I This regulation is not met as evidenced by: Class Ill Based on record review and an interview on 10/15/24 this facility failed to provide documentation a request was made for consultation and assistance annually from a local fire unit. The facility census was 41. This potentially affected 41 of 41 residents. Record review on 10/15/24 at 3:20 P.M. showed no documentation asking for and/or receiving consultation and assistance annually from a local fire unit. During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she would make the request online via the KCFD Request Form and seek fire drill assistance with their next day time fire drill. 19 CSR 30-86.022(5)(B)(1 - 10) Fire Drill/Evacuation Plan Requirements Fire Drills and Emergency Preparedness. (B) The plan shall include, but is not limited to, the following: 1. Aphased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to total building evacuation. This phased response part of the plan shall be consistent with the Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 PRINTED: 10/25/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 direction of the local fire unit or state fire marshal and appropriate for the fire or emergency; 2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and a floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge; 3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building; 4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks; 5. Procedures for the safety and comfort of residents evacuated; 6. Staffing assignments; 7. Instructions for staff to call the fire department or other outside emergency services; 8. Instructions for staff to call alternative resource(s) for housing residents, if necessary; 9. Administrative staff responsibilities; and 10. Designation of a staff member to be responsible for accounting for all residents ' whereabouts. II/III This regulation is not met as evidenced by: Class III Based on record review and an interview on 10/15/24 this facility failed to produce a written plan or have knowledge for the proper use and response to area of refuge usage in an emergency. 19 CSR 30-86.022 (5)(B) The facility census was 41. This potentially affected 41 of 41 residents. Record review on 10/15/24 at 3:20 P.M. showed no procedures for testing, maintaining, responding to, or using the area of refuge's communication system. Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 PRINTED: 10/25/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET BROOKDALE WORNALL PLACE KANSAS CITY, MO 64114 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 3 During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she would have to look into the area of refuge procedures and how to maintain the system. 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/III This regulation is not met as evidenced by: Class III Based on record review and an interview on 10/15/24 this facility failed to produce documentation of at least 12 fire drills being conducted within the last year, the facility further failed to produce documentation of at least one fire drills being conducted on each shift every three months within the last year. The facility census was 41. This potentially affected 41 of 41 residents. Record review on 10/15/24 at 3:20 P.M. showed 7 fire drills being conducted on the first shift, 2 fire drills being conducted on the second shift and 3 fire drills being conducted on the third shift. During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she would be Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 (X2) MULTIPLE CONSTRUCTION PRINTED: 10/25/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/15/2024 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 4 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 sure to start alternating them to a different shift each month. 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. A two- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing of the exit stairway, attendants ' work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states AREA OF REFUGE IN CASE OF FIRE" and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable; 6. Asign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge; 7. Emergency lighting for the area of refuge; and 8. The total area of the areas of refuge on a floor " Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 PRINTED: 10/25/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 12 PRINTED: 10/25/2024 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 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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) BROOKDALE WORNALL PLACE Continued From page 5 shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II This regulation is not met as evidenced by: Class II Based on observations and an interview on 10/15/24 this facility is housing residents on floors that do not have accessible exits to grade and failed to have areas of refuge that meet all the requirements of 19 CSR 30-86.022 (7) (D) sections 1-8. The facility census was 41. This potentially affected 41 of 41 residents. Observations during the 10/15/24 walk through of the fire safety portion of the licensure inspection showed in each area of refuge no signage to identify which floor and stairwell area a person was in. During an interview on 10/15/24 at 12:47 P.M. the maintenance person stated it' s possible the signs were removed when the halls were painted. Observation on 10/15/24 at 12:41 P.M. showed the area of refuge intercom by Room 454, covered over with clear tape and a cotton pad then tapped over it to stop noise from being heard out of it. This was removed immediately. During an interview on 10/15/24 at 12:41 P.M. the Director of Engineering said he/she didn ' t know who would have taped over it. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 If continuation sheet 6 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II This regulation is not met as evidenced by: Class II Based on record review and an interview on 10/15/24 this facility failed to show proof they had activated the fire alarm system at least once each month. The facility census was 41. This potentially affected 41 of 41 residents. Record review on 10/15/24 at 3:20 P.M. showed documentation of the fire alarm being activated only 6 times in the last 12 months with fire drills. During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she activates the fire alarm during fire drills, in the future he/she indicated it will be marked accordingly on the fire drill sheet. He/she further added on the overnight drills he/she will activate the fire alarm the following day and document that on the fire drill sheets as well. 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 II Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 PRINTED: 10/25/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 12 PRINTED: 10/25/2024 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 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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) BROOKDALE WORNALL PLACE Continued From page 7 Based on observation, record review, and an interview on 10/15/24 this facility failed to do the monthly pressure gage readings and valve position checks of all sections of the sprinkler system as required in accordance with NFPA 13, 1999 edition. The facility census was 41. This potentially affected 41 of 41 residents. Observation on 10/15/24 at 1:47 P.M. showed no check sheets in the main riser room, like those that were in the stairwell sub risers. Record review on 10/15/24 at 3:20 P.M. showed no other documentation on file of checks being done for the main risers. During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she would set up a monthly check sheets like what they have in each stairwell. 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. II This regulation is not met as evidenced by: Class II Based on observation and an interview on 10/15/24 this facility failed to provide sufficient emergency lighting in all the attendants’ stations. The facility census was 41. This potentially affected 41 of 41 residents. Observation on 10/15/24 at 2:29 P.M. showed the Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 If continuation sheet 8 of 12 PRINTED: 10/25/2024 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 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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) BROOKDALE WORNALL PLACE Continued From page 8 emergency light inoperable in the 5th floor nurses station. During an interview on 10/15/24 at 2:29 P.M. the maintenance person stated he/she would be sure to get it repaired. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. II This regulation is not met as evidenced by: Class II Based on observation and an interview on 10/15/24 this facility failed to install certified flame-retardant curtains or to chemically treat them with a flame retardant. The facility census was 41. This potentially affected 41 of 41 residents. Observation on 10/15/24 at 1:13 P.M. showed curtains in Room 469 had no tags indicating they were made from flame retardant material or treated with a flame retardant. During an interview on 10/15/24 at 1:13 P.M. the maintenance person stated he/she didn ' t think they put those up. 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 Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 If continuation sheet 9 of 12 PRINTED: 10/25/2024 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 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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) BROOKDALE WORNALL PLACE Continued From page 9 wastebaskets shall be used for trash. Il This regulation is not met as evidenced by: Class II Based on observations and an interview on 10/15/24 this facility failed to insure all the wastebaskets were the approved types allowed. The facility census was 41. This potentially affected 41 of 41 residents. Observations during the fire safety inspection walkthrough on 10/15/24 showed the following rooms with non-approved wastebaskets; Room 440 had one, Room 441 had one, Room 444 had two, Room 445 had three, Room 453 had two, Room 455 had one, Room 454 had two, Room 456 had two, Room 461 had one, Room 462 had three, Room 464 had three, Room 466 had one, Room 465 had one, Room 469 had one, Room 470 had two. Room 472 had four, Room 572 had two, Room 570 had two, Room 567 had Three, Room 565 had one, Room 566 had two, Room 564 had three, Room 562 had three, Room 561 had two, Room 555 had Two, and Room 554 had Two. During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she would get with the administrator on getting the proper ones in place and he/she would review with housekeeping on what to look for when emptying the wastebaskets so these are addressed in a timelier manner. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 NFPA 99, 1999 Edition. I/II This regulation is not met as evidenced by: Class III Based on observations and an interview on 10/15/24 this facility failed to provide oxygen storage in accordance with NFPA 99, 1999 Edition. The facility census was 41. This potentially affected 41 of 41 residents. Observation on 10/15/24 at 11:35 A.M. showed in resident room 441, one oxygen bottle in use and two spare bottles. Observation on 10/15/24 at 11:46 A.M. showed in resident room 454, one oxygen bottle in use and two spare bottles. During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she would get the amount reduced to one bottle in use and one spare bottle in the residents rooms. He/she further state he/she would move the rest to the oxygen storage room and speak to the administrator about limiting the oxygen amounts being stored in a resident's room. State Statute This regulation is not met as evidenced by: Class II Based on record review, and an interview on 10/15/24 this facility failed to show plans to Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 PRINTED: 10/25/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/15/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 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 PRINTED: 10/25/2024 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 10/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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) BROOKDALE WORNALL PLACE Continued From page 11 maintain current approved boiler inspection certifications under Section 11 CSR 40-2.022 - Certificates, Inspections, and Fees. The facility census was 41. This potentially affected 41 of 41 residents. Record review in the boiler room on 10/15/24 at 1:33 P.M. showed the two year certificates for all 5 boilers were getting ready to expire on 10/17/24. During an interview on 10/15/24 at 3:20 P.M. the Director of Engineering said he/she had not heard from or been in contact with anyone coming out to do the inspections to re-certify the boilers. Missouri Department of Health and Senior Services STATE FORM 6899 SYJC11 If continuation sheet 12 of 12 PLAN OF CORRECTION | This Plan of Correction (POC) Is submitted under Federal Provider Name: Brookdale Wornall Place Street Address, City, | 501 W 107" Street. Kansas City, MO 64114 Zip: Date of * = Sova: 10.15.2024 Provider number: oe ID PREFIX | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE TAG { COMPLETION ACTION SHOULD BE CROSS-REFERENCED TO THE DATE APPROPRIATE DEFICIE and State Regulations and Statue applicable to i care providers. The submission of this plan does constitute agreement by the facility that the su findings or conclusions are accurate, that thi constitute a deficiency, or that the 5 applied. This POC is intended to credible letter alleging compliance, | and will be achieved no later than the date identified in the POC. Compliar PLAN OF CORRECTION Provider Brookdale Wornall Place Name: Street Address, City, 501 W 107" Street. Kansas City, MO 64114 Zip: Date of 10.15.2024 Survey: Provider 79304 number: ID PREFIX PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE TAG ACTION SHOULD BE CROSS-REFERENCED TO THE caaiealiati APPROPRIATE DEFICIENCY) This Plan of Correction (POC) is submitted under Federal and State Regulations and Statue applicable to long term care providers. The submission of this plan does not constitute agreement by the facility that the surveyors’ findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope and severity regarding any of the deficiencies cited are correctly applied. This POC is intended to constitute the facility’s credible letter alleging compliance. Compliance has been and will be achieved no later than the last completion date identified in the POC. Compliance will be maintained as provided in the Plan of Correction. The Community will take additional measures to ensure all fire extinguishers will bear the label of the Underwriters Laboratories (UL) or the Factory Mutual (FM) Laboratories and be installed and maintained in accordance with NFPA 10, 1998 edition. A2710 Corrections will include: 10.16.2024 1. Monthly Required Fire Extinguisher Inspection completed by the community/Maintenance Director and or Designee. 2. Maintenance Director has immediately started to check and record extinguisher tags with the required monthly inspection. Extinguisher that has been overlooked on 5" floor has been immediately added to our inspection inventory list. 3. Required Inspection Log(s) will be maintained on- site; printed and electronically (TELS Management System). 4, Maintenance Director and or Designee will ensure all extinguisher tags are not physically damaged and fully charged. 5. All Safety Tasks will not be considered complete until physical and electronic copies are accounted for and stored/filed accordingly. The facility will identify other resident having the potential to be affected by the same alleged deficient practices as follows: 1. All residents will be considered at risk for this alleged deficient practice. The measures that will be put into place or systemic changes made to insure that the alleged deficiency will not occur are as follows: 1. Maintenance Director will maintain physical and electronic copies of all safety tasks and extinguisher checks/inspections. 2. Maintenance Director and or Designee will present safety checks and extinguisher completion tasks at monthly safety meetings. 3. Monthly Inspections will be sent to Executive Director and Assisted Living Director at completion for six (6) months. A. Assisted Living Director and or Designee will monitor monthly safety checks for six (6) months, proceeded by quarterly oversight. A2214 The Maintenance Director will assure that our Fire and Evacuation Plans get reviewed by our local fire unit and the approved Plan is provided to the local jurisdiction’s Emergency Management Director. A2215 11.30.2024 The Maintenance Director and AL Director will review our Fire Drill/Evacuation Plans and phased response with our local Fire Unit. Upon approval, the Facility will assure that the Plan is posted where instructed, including a Floor Plan showing the location of exits, fire alarm pull stations, fire extinguishers, and areas of refuge. 11.30.2024 The (5) Areas of Refuge communication devices in Assisted Living have since been tested. 1 call button was found defective and a service request has been made. The Facility will begin training necessary associates on the areas of refuge communication systems procedures. A2217 The Community will take additional measures to ensure the preparedness of Fire Safety and Fire Drill/Evacuation requirements. Corrections will include: 1. A minimum of twelve (12) fire drills will be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. 2. Executive Director and or designee has in-serviced Maintenance Director on required regulations for Fire Drills and Evacuations. 3. Physical and Electronic copies of all fire drills and or evacuations will be readily available at all times. Documents will be maintained by the Maintenance Director. The facility will identify other residents having the potential to be affected by the same alleged deficient practices as follows: 1. All residents will be considered at risk for this alleged deficient practice. The measures that will be put into place or systemic changes made to insure that the alleged deficiency will not occur are as follows: 1. Maintenance Director and or Designee will perform Fire Drills and or evacuation as indicated by regulations and keep physical and electronic records of each fire drill and or evacuation. 2. Documentation from drill(s) and or evacuation(s) will be presented to the Executive Director or 10.16.2024 designee for three (3) months; starting immediately. Fire Drills and or Evacuations will be monitored monthly for six (6) months by the Executive Director and or designee. A2228 The (5) Areas of Refuge communication devices in Assisted Living have since been tested. 1 call button was found defective and a service request has been made. The Facility will begin training necessary associates on the areas of refuge communication systems procedures. The facility will conspicuously post signage and instructions on the use of the area during emergency conditions near the communication system as well as at the bottom of each stairway. There will be a diagram showing each location of the areas of refuge. 11.30.2024 A2251 The facility will take additional measures to ensure monthly Fire Alarm System tests are completed, documented and maintained on site; physically and electronically. Corrections will include: 1. Maintenance Director has been in-serviced by the Executive Director and or designee, on Fire Alarm System, policy and procedure of Fire Alarm System, and safety checks related to the Fire Alarm System. 2. The Community has initiated activating the Fire Alarm System for the monthly requirement. 3. The Maintenance Director has begun documentation of specific fire drill records of the fire alarm system being activated as well as on the overnight silent fire drills. The facility will identify other residents having the potential to be affected by the same alleged deficient practices as follows: 1. All residents will be considered at risk for this alleged deficient practice. The measures that will be put into place or systemic changes made to insure that the alleged deficiency will not occur are as follows: 10.16.2024 1. Maintenance Director will complete, document, and collect all data related to and reflecting the safety of the communities Fire Alarm System. 2. Maintenance Director will provide documentation to the Executive Director for three (3) months. The Maintenance Director will present and provide the details/documentation of the communities Fire Alarm System during the monthly safety community meeting. A2269 The Maintenance Director will assure that the Sprinkler System Monthly Pressure Check Log located in the Main Riser Room gets added into our routine monthly inspections 11.15.2024 A2278 The Maintenance Director will assure that all Battery Powered Lighting devices are operable. Ongoing monthly testing of all battery powered devices will continue, and logged into our building management software system. 11.15.2024 A2282 The facility will ensure that any new curtains installed in our community are pre-treated with a flame retardant. The Maintenance Director will purchase flame retardant to treat any future curtains that haven’t been pre-treated. 11.15.2024 A2286 The facility will take additional measures to ensure all wastebaskets are approved material; only metal or UL- or FN -fire-resistant rated wastebaskets for trash. Corrections will include: 1. Removal of all non-approved wastebaskets. 2. Non-approved wastebaskets were found in: Room 440 had one, Room 441 had one, Room 444 had two, Room 445 had three, Room 453 had two, Room 455 had one, Room 454 had two, Room 456 had two, Room 461 had one, Room 462 had three, Room 464 had three, Room 466 had one, Room 465 had one, Room 469 had one, 470 had one, Room 472 had four, Room 572 had two, Room 567 had three, Room 565 had one, Room 566 had two, Room 564 had three, Room 562 had three, Room 561 had two, Room 555 had two, and Room 554 had two. 3. Maintenance Director, Assisted Living, and Housekeeping Director in-serviced by Executive Director regarding Safety Codes related to Wastebaskets and approved materials. 10.16.2024 4. Assisted Living Directors has notified all residents and family/friends of need to remove non- approved wastebaskets. 5. Assisted Living Director in-serviced nursing staff regarding non-approved wastebaskets and removal of non-approved materials; for the safety of the resident and community. 6. The Maintenance Director and or designee will order proper wastebasket(s) for all resident apartments. The facility will identify other residents having the potential to be affected by the same alleged deficient practices as follows: 1. All residents will be considered at risk for this alleged deficient practice. The measures that will be put into place or systemic changes made to insure that the alleged deficiency will not occur are as follows: 1. Maintenance Director will inspect Assisted Living weekly for one month; inspection will include removal of unsafe/non-approved wastebasket(s). 2. Assisted Living Director will inspect monthly for 6 months; inspection will include removal of unsafe/non-approved wastebasket(s). Maintenance Director, Assisted Living Director and or designee will notify Executive Director of all wastebasket(s) removed from residents’ apartments and frequency of non-approved materials returning to the community. A2298 The facility will take additional measures to ensure proper and safe storage of oxygen. Corrections will include: 1. Removal of excess oxygen tanks/bottles from apartment 441 and 454. 2. Personal oxygen tanks/bottles are to be stored in oxygen approved room. 3. Maintenance Director, Assisted Living Director, and Health and Wellness Director in-serviced on proper oxygen storage and safety. 10.16.2024 4. Assisted Living Director in-serviced nursing staff regarding oxygen storage and proper care of oxygen tanks/bottles. The facility will identify other residents having the potential to be affected by the same alleged deficient practices as follows: 1. All residents will be considered at risk for this alleged deficient practice. The measures that will be put into place or systemic changes made to insure that the alleged deficiency will not occur are as follows: 1. The Maintenance Director and or designee will inspection oxygen storage in resident apartments weekly for one month. The Assisted Living Director and Health and Wellness Director will monitor monthly of all current and future oxygen storage. The facility received their 2-year Boiler Inspection that is scheduled through our building management software. A9998 The Maintenance Director will pay any Certificate fees 10.25.2024 once the inspection report is received, and assure that the documentation is posted at our boilers. 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: 11/06/2023 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 Cc B.WING 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 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) BROOKDALE WORNALL PLACE A4776| 19 CSR 30-86.047(35) Protective Oversight Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. 1/II This regulation is not met as evidenced by: Class II. Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three sampled residents (Resident #1, #2, #3) out of three sampled residents. The facility census was 29 residents. Review of the Resident Call System and Door Alarm Response Policy dated 10/15 showed: -Policy Overview: -Associates should respond to resident call system alerts and door alarms in a reasonable and timely manner. --Responding to resident call system alerts. ---When responding to resident call systems alerts: ---When an associate receives a resident call system alert, he/she should respond within a timely manner. ---If the associate is unable to respond in a timely manner, he/she should request assistance from another associate. Review of the facility All Alarms Report dated 10/23/23 at 12:16 P.M. through 10/24/23 at 11:47 A.M. showed: -On 10/23/23 at: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE \ TITLE (X6) DATE A NY STATE FORM 6889 V22S11 If continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A4776 19 CSR 30-86.047(35) Protective Oversight Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident 's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II This regulation is not met as evidenced by: Class Il. Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three sampled residents (Resident #1, #2, #3) out of three sampled residents. The facility census was 29 residents. Review of the Resident Call System and Door Alarm Response Policy dated 10/15 showed: -Policy Overview: -Associates should respond to resident call system alerts and door alarms in a reasonable and timely manner. --Responding to resident call system alerts. ---When responding to resident call systems alerts: ---When an associate receives a resident call system alert, he/she should respond within a timely manner. ---If the associate is unable to respond in a timely manner, he/she should request assistance from another associate. Review of the facility All Alarms Report dated 10/23/23 at 12:16 P.M. through 10/24/23 at 11:47 A.M. showed: -On 10/23/23 at: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 V22S11 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/24/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (X6) DATE If continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 --1:02 P.M. Room 465's call light was unanswered for two hours and 22 minutes. --1:05 P.M. Room 452's call light was unanswered for one hour 23 minutes. --1:07 P.M. Room 566's call light was unanswered for 35 minutes. --1:08 P.M. Room 452's call light was unanswered for one hour 23 minutes. --2:28 P.M. Room 558's call light was unanswered one hour 18 minutes. --3:54 P.M. Room 566's call light was unanswered for three hours 37 minutes. --4:26 P.M. Room 445's call light was unanswered for two hours 44 minutes. --4:35 P.M. Room 453's call light was unanswered for two hours seven minutes. --4:36 P.M. Room 452's call light was unanswered for two hours 35 minutes. --5:14 P.M. Room 570's call light was unanswered for five hours 22 minutes. --5:32 P.M. Room 558's call light was unanswered for four hours 57 minutes. --6:09 P.M. Room 444's call light was unanswered for one hour 4 minutes. --8:17 P.M. Room 465's call light was unanswered for 58 minutes. --8:30 P.M. Room 445's call light was unanswered for one hour 7 minutes. -On 10/24/23 at: --8:32 A.M. Room 446's call light was unanswered for one hour 12 minutes. --10:27 A.M. Room 558's call light was unanswered for 52 minutes. 1. Review of the Resident #1's Admission Record showed the resident was admitted on 8/9/23 with the diagnoses of acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body) and malaise (a general feeling of discomfort, illness, Missouri Department of Health and Senior Services STATE FORM 6899 V22S11 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/24/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 or uneasiness whose exact cause is difficult to identify). Review of the resident's Physician Order Summary (POS) dated 10/24/23 showed: - To use a Sit to Stand lift as needed for transfers with two person assistance. -Transfer with two person assistance and gait belt. -Weight bearing as tolerated. During an interview on 10/24/23 at 11:18 A.M. the resident said: -He/she wears a pendant. -The pendant call people, but they are not good about it. -He/she has used the call light three time and nobody comes. -The staff are supposed to answer their call lights. 2. Review of Resident #2's Admission Record showed the resident was admitted on 1/31/23 with the diagnoses fracture of the fifth lumbar vertebra (broken bone in lower back) and respiratory failure with hypoxia. Review of the resident's POS dated 10/24/23 showed: -To admit to hospice (end of life care) with diagnosis of acute respiratory failure. -To use assistive device for mobility, may utilize wheelchair or walker as assistive device. During an interview on 10/24/23 at 11:31 A.M. the resident's family member said: -He/She called and complained because the call lights were not being answered. -The family had a sitter with the resident. Missouri Department of Health and Senior Services STATE FORM 6899 V22S11 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/24/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 3. Review of Resident #3's Admission Record showed the resident was admitted on 2/15/23 with the diagnoses unsteadiness on feet and history of transient ischemic attack (TIA- a temporary period of symptoms similar to those of a stroke). -Physical therapy evaluation and treatment as indicated. -Transfer with two person assistance, wheelchair for mobility. During an interview on 10/24/23 at 11:41 A.M. the resident said: -Sometimes it has taken over an hour to answer a call light. -It is scary to wait so long if you need them right away. -Thinks a lot of the calls stay on. 4. During an interview on 10/24/23 at 10:52 A.M. Licensed Practical Nurse (LPN) A said: - He/she expects call lights to be answered within 15 minutes. -If staff was assisting another resident, the resident waiting may have to wait a little longer. -It should not take an hour or longer to answer a call light. -The goal is to answer a call light in 15 minutes or less. -About two to three months ago the facility got a new call light system. -There were issues at first, but those issues were resolved. -The alerts were not going to the pagers the staff were carrying. -The alerts were not showing the resident names or pendant number. -There were communication failure notifications. -The notifications were ringing to the wrong locations. Missouri Department of Health and Senior Services STATE FORM 6899 V22S11 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/24/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Observation on 10/24/23 at 11:20 A.M. showed Certified Nursing Assistant (CNA) A: -Reset the resident's call light pendant. -He/She rechecked the pager and the alert did not clear. -He/She reset the call light pendant again. -Upon rechecking again, the pager alert did not clear. -He/She said the call light system was not working right, so he/she wasn't sure if the call light was really clear or not. During an interview on 10/24/23 at 11:48 A.M. the Director of Assisted Living said: -There were no tracking logs for the new call light system. -He/She was not aware of any concerns about the call light system. -In order to know when there is a call light going off, staff must have a pager. -There is no other way for staff to know if there was a Call light going off. -All direct care staff were required to carry a pager. -Administrative staff were responsible for ensuring call lights were being answered. -None of the Administrative staff, including the Director, were not carrying pagers. -He/She checks the system on the computer a couple of times per day to check on the call lights. -A call light could go off for an extended period of time before being checked to ensure it was answered. -He/She did not have access to review the records for the call light system beyond the last 24 hours. -He/She expected call lights to be answered in 20 to 30 minutes. -He/She prefers call lights to be answered within Missouri Department of Health and Senior Services STATE FORM 6899 V22S11 PRINTED: 11/06/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/24/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 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: 11/06/2023 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 Cc 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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) BROOKDALE WORNALL PLACE Continued From page 5 15 minutes. -Any call light not answered for more than 30 minutes was unacceptable. M0O00224217 Missouri Department of Health and Senior Services STATE FORM 6899 V22811 If continuation sheet 6 of 6 Provider Name: Street Address, City, Zip: Date of Survey: ID PREFIX TAG Provider number: A4776 PLAN OF CORRECTION Brookdale Wornall Place 501 W 107% Street, Kansas City, MO 64114 10/24/2023 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This Plan of Correction (POC) is submitted under Federal and State Regulations and Statue applicable to long term care providers. The submission of this plan does not constitute agreement by the facility that the surveyors’ findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope and severity regarding any of the deficiencies cited are correctly applied. This POC is intended to constitute the facility's credible letter alleging compliance. Compliance has been and will be achieved no later than the last completion date identified in the POC. Compliance will be maintained as provided in the Plan of Correction. The facility will take additional measures to ensure protective oversight is provided twenty-four hours a day while ensuring that call lights are answered in a timely manner. Corrections will include: 1) 2) Resident #1, #2, #3 received new (stat ordered) pendants on 10/26/2023. Community ordered a mass order (30+) pendants, from the manufacture that correlates directly with the new system installed in the community. Each Nursing staff member is required to keep a pager (pagers alert once a pendant has been pressed); The directors, moving forward will also be required to have a pager to routinely check the active alerts. The Vendor whom installed the new system, reset the network and pendant system on 10/24/2023. All staff were in-serviced by ALD, Assisted Living Director, on how to use pendants and reset pendants. All staff were in-serviced by ALD on how to use pager(s), respond to the location per pager(s), and reset set pager(s). All staff were in-serviced by ALD on timeliness of response to all resident needs and pendant alerts. All concerns and or routine findings of pendant and pager errors to be reported daily to Vendor until fixed. COMPLETION DATE 11/16/2023 The facility will identify other residents having the potential to be affected by the same alleged deficient practices as follows: 1) All residents will be considered at risk for this alleged deficient practice. The measures that have and will be put into place or systemic changes made to ensure that the alleged deficiency will not occur are as follows: 1) Daily audits of response times for 30 days; weekly audits to follow if response times are answered timely — under 30 minutes on a routine basis. 2) Random response time audits to take place on all three shifts; daily for one week, three — four times during week two, two — three times during week three, one to two times during week four. 3) Random response time audits to take place minimum one time per shift per month. 4) Findings of all audits to be submitted monthly to Executive Director. 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: 08/24/2023 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 29304 $$$ i$ 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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 BROOKDALE WORNALL PLACE 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 III Based on observation and an interview on 8/8/23 the facility failed to document all the fire extinguishers being checked monthly. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observations during the fire safety inspection walkthrough on 8/8/23 showed the fire extinguishers were not being checked monthly During an interview on 8/8/23 at 11:10 A.M. the new Maintenance Director stated he/she would immediately start check and recording on the extinguisher tags the monthly checks to ensure they are not physically damaged and are fully charged. 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM ea98 PD5M11 If continuation sheet 1 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29304 NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE 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 1 the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/IIl This regulation is not met as evidenced by: Class III Based on record review and interview on 8/8/23 the facility failed to produce documentation of at least 12 fire drills being conducted within the last year, the facility further failed to produce documentation of at least one fire drills being conducted on each shift every three months within the last year. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Record review on 8/8/23 at 3:55 P.M. showed no fire drill records available for the year of 2022, four first shift fire drills, one second shift fire drill, and two third shift fire drills for 2023. During an interview on 8/8/23 at 3:55 P.M. the new Maintenance Director stated he/she had not been able to find the prior maintenance director's records and he/she further stated he/she would be sure to rotate fire drills on each shift each month. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. 1/II Missouri Department of Health and Senior Services STATE FORM 6899 PD5M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 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 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29304 NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE 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 2 This regulation is not met as evidenced by: Class II Based on record review and an interview on 8/8/23 the facility failed to show proof they had activated the fire alarm system at least once each month. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Record review on 8/8/23 at 3:55 P.M. showed no record of the fire alarm system being activated each month. During an interview on 8/8/23 at 3:55 P.M. the new Maintenance Director stated he/she would start documenting specifically on fire drill records the fire alarm system was activated and on the overnight silent fire drills, start testing it the following day and documenting it on the overnight fire drill records. 19 CSR 30-86.022(10)(G) Door Devices - Self/Auto closing Protection from Hazards. (G) All doors providing separation between floors shall have a self-closing device attached. If the doors are to be held open, electromagnetic hold-open devices shall be used that are interconnected with either an individual smoke detector or a complete fire alarm system. II This regulation is not met as evidenced by: Class II Based on observation and an interview on 8/8/23 Missouri Department of Health and Senior Services STATE FORM 6899 PD5M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 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 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29304 NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE 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 the facility failed to ensure the doors providing separation between levels were only held open with devises that would allow them to close if the fire alarm system activated. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observation on 8/8/23 at 11:39 A.M. showed the north stairwell fire separation door that leads into the parking garage was wide open with the door closer pulled off allowing air flow through the stairwell preventing the individual entry doors into the stairwell from each level from closing properly. Observation on 8/8/23 at 1:26 P.M. showed the Sth floor entry door into the stairwell that leads to the parking garage would not latch when closed. During an interview on 8/8/23 at 11:39 A.M. the new Maintenance Director stated he/she would have to check each separation door to ensure they all work properly. 19 CSR 30-86.022(10)(J) Smoke Section Partitions < than 20 beds Protection from Hazards. (J) In all facilities that were initially licensed on or prior to December 31, 1987, and all facilities licensed for twenty (20) or fewer beds prior to August 28, 2007, each smoke section shall be separated by a one- (1-) hour fire-rated smoke partition that extends from the inside portion of an exterior wall to the inside portion of an exterior wall and from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and Missouri Department of Health and Senior Services STATE FORM 6899 PD5M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 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 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29304 NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE 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 4 through interstitial structural and mechanical spaces. Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspending ceiling system where the following conditions are met: The ceiling system forms a continuous membrane, a smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling and the space above the ceiling is not used as a plenum. Smoke partition doors 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 II Based on observation and interview on 8/8/23 the facility failed to insure the smoke stop partition doors would properly close during fire alarm activation. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observation on 8/8/23 at 10:53 A.M. showed the fire door by Room 440 sticking and not fully closing. During an interview on 8/8/23 at 10:53 A.M. the new Maintenance Director stated he/she would get the doors fixed so they do not stick and ensure they will close properly. 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Missouri Department of Health and Senior Services STATE FORM 6899 PD5M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 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 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29304 NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET BROOKDALE WORNALL PLACE KANSAS CITY, MO 64114 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 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on observations and an interview on 8/8/23 the facility failed to do the monthly pressure gage readings and valve position checks of the sprinkler system as required in accordance with NFPA 13, 1999 edition. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observations during the fire safety inspection walkthrough on 8/8/23 showed no records at the risers for monthly sprinkler valve position and pressure gage checks being done on the main sprinkler riser or the stairwell sub risers since November of 2022. During an interview on 8/8/23 at 10:40 P.M. the new Maintenance Director stated he/she would set up new monthly check sheets in each riser area and start recording the information again. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. Missouri Department of Health and Senior Services STATE FORM 6899 PD5M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 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 11 PRINTED: 08/24/2023 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 29304 $$$ i$ 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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 BROOKDALE WORNALL PLACE Continued From page 6 (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 II Based on observations and an interview 8/8/23 the facility failed to insure all the wastebaskets were the approved types allowed. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observations during the fire safety inspection walkthrough on 8/8/23 showed the following rooms with non-approved wastebaskets; Room 445 had two, Room 451 had three, Room 452 had one, Room 456 had one, Room 461 had one, Room 464 had two, Room 466 had two, Room 467 had two, Room 469 had two, Room 570 had two, Room 565 had two, Room 562 had two, Room 566 had two, Room 564 had one, and Room 551 had one. During an interview on 8/8/23 at 11:12 A.M. the new Maintenance Director stated he/she would get with the administrator on getting the proper ones in place and he/she would review with housekeeping on what to look for when emptying the wastebaskets so these are addressed in a timelier manner. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/IIl Missouri Department of Health and Senior Services STATE FORM oeee PD5M11 If continuation sheet 7 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29304 NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE 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 7 This regulation is not met as evidenced by: Class III Based on observation and interview on 8/8/23 the facility failed to provide oxygen storage in accordance with NFPA 99, 1999 Edition. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observation on 8/8/23 at 11:01 A.M. showed in resident room 444, seven large oxygen bottles, six medium oxygen bottles, one oxygen bottle in use and a concentrator. During an interview on 8/8/23 at 11:01 A.M. the new Maintenance Director stated he/she would get this amount reduced to one bottle in use and one spare bottle. He/she further state he/she would move the rest down to the oxygen storage room and speak to the administrator about limiting the oxygen amounts being stored in a resident's room. 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 II Missouri Department of Health and Senior Services STATE FORM 6899 PD5M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 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 8 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 29304 NAME OF PROVIDER OR SUPPLIER 501 WEST 107TH STREET BROOKDALE WORNALL PLACE KANSAS CITY, MO 64114 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 8 Based on observation and interview on 8/8/23 the facility had failed to properly maintain an exit door. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observation on 8/8/23 at 12:51 P.M. showed the panic hardware loose and about to fall off on the exit door by Room 474 inside the area of refuge. During an interview on 8/8/23 at 12:51 P.M. the new Maintenance Director stated he/she would get the panic hardware resecured immediately. 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 PD5M11 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 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 9 of 11 PRINTED: 08/24/2023 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 29304 $$$ i$ 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 (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 BROOKDALE WORNALL PLACE Continued From page 9 inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class II* Based on record review and an interview 8/8/23 the 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-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Record review on 7/13/22 (last year) showed 2018 was the last time an electrical inspection was done at this facility. Record review on 8/8/23 at 3:55 P.M. also showed no new electrical inspections available. During an interview on 8/8/23 at 3:55 P.M. the new Maintenance Director stated he/she would have to call his supervisor about getting one done. The higher classification was merited due to the potential effect on the residents. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served Missouri Department of Health and Senior Services STATE FORM oeee PD5M11 If continuation sheet 10 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 29304 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 08/24/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/08/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 501 WEST 107TH STREET KANSAS CITY, MO 64114 BROOKDALE WORNALL PLACE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/Ill This regulation is not met as evidenced by: Class III Based on observation and an interview on 8/8/23 the facility failed to prevent extension cords from being used with more than one electrical item plugged into it. The facility census was thirty-three (33). This potentially affected thirty-three (33) of thirty-three (33) residents. Observation on 8/8/23 at 2:15 P.M. showed in Room 567 a white utility type extension cord with multiple items plugged into it. During an interview on 8/8/23 at 2:15 P.M. the new Maintenance Director stated he/she would get a power strip to replace the extension cord 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 PD5M11 If continuation sheet 11 of 11 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).