KINGSWOOD SENIOR LIVING.

PRINTED: 12/11/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 04152C — 12/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10000 WORNALL ROAD KANSAS CITY, MO 64114 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) KINGSWOOD 19 CSR 30-86.022(5){D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (DB) 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. IVill This regulation is not met as evidenced by: Class Ill Based on record review and an interview on 12/2/24 this facility failed to produce documentation of at least one fire drills being conducted on each shift every other month in the last year. The facility census was 54. This potentially affected 54 of 54 residents. Record review on 12/2/24 at 3:42 P.M. showed fire drills being conducted on mainly two shifts for the last year. During an interview on 12/2/24 at 3:42 P.M. the Director of Facility Operations stated earlier this year the facility had gone back to three shifts and it appears the security people that conduct the drills may not have been aware of that change. He/she stated he/she would get with security and be sure they are alternating each shift each month for all three shifts. During an interview on 12/2/24 at 3:49 P.M. the Security Officer on duty indicated he/she was never informed the facility had switched back to three shifts. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 BSS6611 lf continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 04152C NAME OF PROVIDER OR SUPPLIER 10000 WORNALL ROAD KANSAS CITY, MO 64114 KINGSWOOD SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued Fram page 1 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shail be used for trash. [I This regulation is not met as evidenced by: Class Hl Based on observations and an interview on 12/2/24 this facility failed to insure all the wastebaskets were the approved types allowed. The facility census was 54. This potentially affected 54 of 54 residents. Observations during the 12/2/24 walkthrough showed non-approved type wastebaskets in the following areas; In Room 2201 had one wastebasket, Room 2210 had one wastebasket, Room 2212 had four wastebaskets, Room 2307 had two wastebaskets, Room 2311 had two wastebaskets, Room 2312 had two wastebaskets, Room 2313 had two wastebaskets, Room 2314 had two wastebaskets, Room 2316 had two wastebaskets, Room 2415 had two wastebaskets, and Room 2421 had two wastebaskets. During an interview on 12/2/24 at 3:42 P.M. the Director of Facility Operations stated he/she would work on getting the proper wastebaskets in place, see about getting families informed and get housekeeping trained on spotting the non-approved types of wastebaskets. Missouri Department of Health and Senior Services STATE FORM 899 B96614 (X2) MULTIPLE CONSTRUCTION PRINTED: 12/11/2024 FORM APPROVED {X3} BATE SURVEY COMPLETED 12/02/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 2 of 2

PRINTED: 12/19/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X71) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 04152C B, WING —$___ 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10000 WORNALL ROAD KANSAS CITY, MO 64114 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION &s) {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) KINGSWOOD A2217 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, exquding 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. I/II This regulation is not met as evidenced by: Class It! Based on record review and interview on 11/29/23 this facility failed to produce documentation of at least one fire drills being conducted on each shift every other month in the last year. The facility census was fifty (60). This potentially affected fifty (50) of fifty (60) residents. Record review on 11/29/23 at 2:42 P.M. showed only two first shift and five second shift fire drills being conducted within the last year. During an interview on 11/29/23 at 2:42 P.M. the Director of Facility Operations said he/she was aware of it from a recent DHSS inspection and was going to work with the security department to be sure they are done on every other shift each month. 19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees Fire Safety Training Requirements. (A) The facility shall ensure that fire safety training is provided to all employees: 1. During employee orientation; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {%6) DATE Vay Watt ed tain tpt (2-2F- 2023 STATE FORM Piz Di : 6899 VDPW14 If continuation sheet 1 of 4 PRINTED: 10/09/2024 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 041526 B.WING 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 10000 WORNALL ROAD 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} KINGSWOOD A2217 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) Aminimum 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 drilis shall include a resident evacuation at least once a year. IN/IIl This regulation is not met as evidenced by: Class Ill Based on record review and interview on 11/29/23 this facility failed to produce documentation of at least one fire drills being conducted on each shift every other month in the last year. The facility census was fifty (50). This potentially affected fifty (50) of fifty (60) residents. Record review on 11/29/23 at 2:42 P.M. showed only two first shift and five second shift fire drills being conducted within the last year. During an interview on 11/29/23 at 2:42 P.M. the Director of Facility Operations said he/she was aware of it from a recent DHSS inspection and was going fo work with the security department to be sure they are done on every other shift each month. 19 CSR 30-86.022(6)(A}(1 - 3) Fire Safety Training Requirements-employees Fire Safety Training Requirements. (A) The facility shall ensure that fire safety training is provided to all employees: 1. During employee orientation; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) DATE 12/28/23 STATE FORM sao VDPW11 If continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER IDENTIFICATION NUMBER: 04152C {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING STREET ADDRESS, CITY, STATE, ZiP CODE 10000 WORNALL ROAD KINGSWOOD A2220 KANSAS CITY, MO 64114 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 2. Atleast every six (6) months; and 3. When training needs are identified as a result of fire drill evaluations. HAll This regulation is not met as evidenced by: Class Ill Based on observation, record review, and interviews on 11/29/23 this facility failed to maintain training on the use of the area of refuge and its communication system. The facility census was fifty (50). This potentially affected fifty (50) of fifty (60) residents. Observation on 11/29/23 at 1:39 P.M. showed when the area of refuge communication system was tested it failed to operate. During an interview on 11/29/23 at 1:39 PM the Director of Facility Operations said he/she was not aware of the system not working. During a phone interview on 11/29/23 at 2:42 P.M. the Administrator stated he/she could not find the area of refuge procedures or original paperwork on the system. 19 CSR 30-86.022(11})(A) Complete Sprinkler System-NFPA 13 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. III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 PRINTED: 10/09/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED 11/29/2023 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE VDPW11 if continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER IDENTIFICATION NUMBER: 04152C {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING STREET ADDRESS, CITY, STATE, ZiP CODE 10000 WORNALL ROAD KINGSWOOD A2268 KANSAS CITY, MO 64114 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Class II Based on observation, interview, and record review on 11/29/23 this facility failed to ensure the monthly pressure gauge readings and valve position checks of the sprinkler system was done as required in accordance with NFPA 13, 1999 edition. The facility census was fifty (50). This potentially affected fifty (50) of fifty (50) residents. Observation during on 11/29/23 at 1:44 P.M. showed no recent monthly sprinkler valve position and pressure gage readings being done at the main riser. A monthly record sheet that was several years old was in the room. Record review on 11/29/23 at 2:42 P.M. showed documentation of monthly sprinkler checks being conducted, but no valve positions or pressure gauge readings were recorded. During an interview on 11/29/23 at 2:42 P.M. the Director of Facility Operations said he/she would be sure to start recording the information on their sheets. 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. JAI This regulation is not met as evidenced by: Class II* Based on observations and an interview on 11/29/23 it was determined this facility had failed Missouri Department of Health and Senior Services STATE FORM 6899 PRINTED: 10/09/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED 11/29/2023 PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE VDPW11 if continuation sheet 3 of 4 Missouri STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER KINGSWOOD A3201 Department of Health and Senior Services (X1}) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 04152C {X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING KANSAS CITY, MO 64114 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 to maintain the area of refuge intercom system. The facility census was fifty (50). This potentially affected fifty (50) of fifty (60) residents. Observations during the 11/29/23 fire safety inspection walkthrough showed that none of the areas of refuge call buttons lit up when tested. Observation on 11/29/23 at 1:52 P.M. showed the main communication panel for the area of refuge on the rear side of the building inoperable and appears to have no power running to it. During an interview on 11/29/23 at 1:52 P.M. the Director of Facility Operations said he/she would get an electrician out to look at the panel, that he/she didn ' t know how long it had been down and see if any of the original paperwork and procedures were available. *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE VDPW11 PRINTED: 10/09/2024 FORM APPROVED (X3} DATE SURVEY COMPLETED 11/29/2023 STREET ADDRESS, CITY, STATE, ZiP CODE 10000 WORNALL ROAD PROVIDER'S PLAN OF CORRECTION {x5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY} if continuation sheet 4 of 4 PLAN OF CORRECTION i Provider Name: Street Address, City, Zip: Date of Survey: KINGSWOOD Assisted Living Facility 10000 WORNALL RD, KANSAS CITY, MO 64114 November 29' 2023 Provider number: O¥/S522 ID PREFIX TAG A2217 SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION DATE Fire Drills What corrective Action will be accomplished for the resident found to be affected by the deficient practice: The facility shall ensure that monthly fire drills are completed and will keep a record of all fire drills that are done. The record shail include the time/date, personnel participating, length of time the drill lasts and a narrative of any special problems or concerns. A standard form will be used to ensure that all required elements are present. All residents had the potential of being affected by the deficient practice. How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: All residents had the potential to be affected by the deficient practice during a possible fire event. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: All Patrol and maintenance staff shall receive education provided by the Director of Maintenance or his designee on proper procedures involving fire drills and the required information that shall be included to ensure that a complete fire drill has been done monthly. How does the facility plan to monitor its performance to make sure that solutions are sustained: A record of monthly fire drills will be provided to the QAPI committee monthly to review. 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. 1/13/2024 A/ 2 Gf 2024 A 2220 A2268 _| Related to Area of Refuge panel annunciator. What corrective Action will be accomplished for the resident found to be affected by the deficient practice: 1/13/2024 All Patrol and maintenance staff will receive training on the purpose and operation of the area of refuge and its communication system (the panel). The facility shall keep a record of all training that is done on the area of refuge and its communication system. The operation of the panel will be tested monthly by maintenance. During the test, maintenance will confirm that the panel is working by testing all of the alarms in the areas of refuge, North and South on all three floors in the building. During the test a maintenance staff person will verify that the panel is working at that time. The record shall include the time/date, personnel participating, which area of refuge is being tested and a narrative of any special problems or concerns. A separate form will be used to confirm the proper operation of the area of refuge panel. All residents had the potential of being affected by the deficient practice. How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: All residents had the potential to be affected by the deficient practice during a possible fire event. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: All maintenance staff shall receive education provided by the Director of Maintenance or his designee on proper procedures involving the area of refuge in the building as well as what to look for to ensure that the panel is working properly and the alarms are | functioning. How does the facility pian to monitor its performance to make sure that solutions are sustained: A record of monthly area of refuge testing will be provided to the QAPI committee monthly to review. Related to a complete Sprinkler System What corrective Action will be accomplished for the resident found to be affected by the deficient practice: The facility shall keep a record of monthly pressure gauge readings and valve position checks of the sprinkler system along with the monthly sprinkler checks. The Director of Maintenance or 1/13/2024 his designee will train all maintenance staff on the requirements for monthly checks to include the pressure gauge readings and a value position check related to the system. How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: | A3201 All residents had the potential to be affected by the deficient practice during a possible fire event. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: All Patrol and maintenance staff shall receive education provided by the Director of Maintenance or his designee on proper procedures involving the monthly sprinkler checks. How does the facility plan to monitor its performance to make sure that solutions are sustained: Arecord of monthly sprinkler testing will be provided to the QAPI committee monthly to review. Regarding the maintenance of the area of refuge system. What corrective Action will be accomplished for the resident found to be affected by the deficient practice: The facility shall keep a record of all training that is done on the area of refuge and its communication system. All Patrol and maintenance staff will receive training on the purpose and operation of the area of refuge and its communication system (the panel). The operation of the panel will be tested monthly by maintenance. During the tests, Patrol or maintenance will confirm that the panel is working by testing all the areas of refuge on 2"4, 3" and 4" floor of the building and Patrol or maintenance will verify and document that the panel is working at that time. The record shall include the time/date, personnel participating, which area of refuge is being tested and a narrative of any special problems or concerns. A separate form from the fire drill will be used to confirm the proper operation of the area of refuge panel. All residents had the potential of being affected by the deficient practice. How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: All residents had the potential to be affected by the deficient practice during a possible fire event. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice | does not recur: All Patrol and maintenance staff shall receive education provided by the Director of Maintenance or his designee on proper procedures involving the area of refuge in the building as well as what to look for to ensure that the panel is working properly. How does the facility plan to monitor its performance to make sure that solutions are sustained: A record of monthly area of refuge testing will be provided to the _ QAPI committee monthly to review. 1/13/2024