MADISON SENIOR LIVING THE.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. PRINTED: 11/05/2024 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 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14001 MADISON AVENUE KANSAS CITY, MO 64145 (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) MADISON SENIOR LIVING THE 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/IIl This regulation is not met as evidenced by: Class III Based on record review and an interview on 10/24/24 this facility failed to produce documentation of at least one fire drills being conducted on each shift every three months in the last year. The facility census was 53. This potentially affected 53 of 53 residents. Record review on 10/24/24 at 1:42 P.M. showed only 8 records on file in three different books where the fire drills were conducted, four on the first shift, one on the second shift and three on the third shift. During an interview on 10/24/24 at 1:42 P.M. with the new Plant Operations Director she stated she had just started a couple weeks ago and was still trying to sort things out record wise. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 NZXW11 If continuation sheet 1 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 14001 MADISON AVENUE KANSAS CITY, MO 64145 MADISON SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 This regulation is not met as evidenced by: Class II Based on record review and an interview on 10/24/24 this facility failed to show proof the fire alarm system was activated at least once a month. The facility census was 53. This potentially affected 53 of 53 residents. Record review on 10/24/24 at 1:42 P.M. showed only 8 records on file in three different books where the fire alarm system was indicated to have been activated with the fire drills. During an interview on 10/24/24 at 1:42 P.M. with the new Plant Operations Director she stated she had just started a couple weeks ago and was still trying to sort things out record wise. 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 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 Missouri Department of Health and Senior Services STATE FORM 6899 NZXW11 PRINTED: 11/05/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/24/2024 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 7 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: 14001 MADISON AVENUE KANSAS CITY, MO 64145 MADISON SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 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 onlly 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 an interview on 10/24/24 this facility failed to ensure a fire rated separation was maintained for the attic space. The facility census was 53. This potentially affected 53 of 53 residents. Observation on 10/24/24 at 11:29 A.M. showed a fire rated attic access door in the store room across from Room 141 was left hanging open exposing the attics wood framing. During an interview on 10/24/24 at 11:29 A.M. with the new Plant Operations Director she stated she would be sure to get a ladder to close it 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 wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observations and an interview on 10/24/24 this facility failed to insure all the Missouri Department of Health and Senior Services STATE FORM 6899 NZXW11 PRINTED: 11/05/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/24/2024 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 7 PRINTED: 11/05/2024 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 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14001 MADISON AVENUE KANSAS CITY, MO 64145 (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) MADISON SENIOR LIVING THE Continued From page 3 wastebaskets were the approved types allowed. The facility census was 53. This potentially affected 53 of 53 residents. Observations on 10/24/24 during the fire safety portion of the licensure inspection showed the following rooms with the improper types of wastebaskets; Room 146 had one, Room 144 had one, Room 142 had four, Room 140 had one, Room 139 had one, Room 136 had one, Room 135 had one, Room 133 had one, Room 128 had one, Room 127 had one, Room 125 had two, Room 123 had three, Room 118 had one, Room 114 had one, Room 113 had one, Room 112 had two, Room 111 had two, Room 104 had one, Room 102 had one, Room 3 had one, Room 7 had one, Room 11 had one and Room 13 had two. During an interview on 10/24/24 at 1:42 P.M. with the new Plant Operations Director she stated she would get with the Administrator to see what needs to be done to correct all of these. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III Based on observation and interviews on 10/24/24 this facility failed to provide a proper oxygen storage room in accordance with NFPA 99. The Missouri Department of Health and Senior Services STATE FORM 6899 NZXW11 If continuation sheet 4 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 14001 MADISON AVENUE KANSAS CITY, MO 64145 MADISON SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 facility census was 53. This potentially affected 53 of 53 residents. Observation on 10/24/24 at 11:51 A.M. showed in resident room 136, 10 oxygen bottles stored and one in use. During an interview on 10/24/24 at 11:51 A.M. with the new Plant Operations Director she stated she was not aware of an oxygen storage room. During a phone interview on 10/24/24 at 2:06 P.M. with the new Plant Operations Director's supervisor. He indicated they do not provide for resident's oxygen storage, its up to the individual resident. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class II Based on observations and an interview on 10/24/24 this facility had failed to maintain the fire doors in good repair. The facility census was 53. This potentially affected 53 of 53 residents. Observation on 10/24/24 at 1:36 P.M. showed one side of the fire door by Room 1 in the memory care side not latching properly when it closed. During an interview on 10/24/24 at 1:36 P.M. with Missouri Department of Health and Senior Services STATE FORM 6899 NZXW11 PRINTED: 11/05/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/24/2024 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 7 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: 14001 MADISON AVENUE KANSAS CITY, MO 64145 MADISON SENIOR LIVING THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 the new Plant Operations Director she stated she would have to see why the latch was sticking down. 19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services STATE FORM 6899 NZXW11 PRINTED: 11/05/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/24/2024 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 6 of 7 PRINTED: 11/05/2024 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 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14001 MADISON AVENUE KANSAS CITY, MO 64145 (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) MADISON SENIOR LIVING THE Continued From page 6 Based on observation and an interview on 10/24/24 this facility failed to ensure the use of portable space heaters was prohibited. The facility census was 53. This potentially affected 53 of 53 residents. Observation on 10/24/24 at 1:10 P.M. showed a couple portable electric heaters setting on the floor in Room 117. During an interview on 10/24/24 at 1:10 P.M. with the new Plant Operations Director she stated this was one of the rooms where the electric air handlers had failed. She further stated she understood why portable heaters are not permitted and would get them removed Missouri Department of Health and Senior Services STATE FORM 6899 NZXW11 If continuation sheet 7 of 7 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)