ROCKHILL MANOR ASSISTED LIVING.

PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING 19 CSR 30-86.022(8){A) Exit Sign Requirements Exit Signs. (A) Signs bearing the word EXIT in plain, legible letters shall be placed at each required exit, except at doors directly from rooms to exit passageways or corridors. Letters of all exit signs shall be at least six inches (6”) high and principle strokes three-fourths of an inch (3/4") wide, except thai letiers of internally illuminated exit signs shall not be less than four inches (4") high. lt This regulation is not met as evidenced by: Class Il Based on observation and interview on June 11, 2025 the facility failed to have signs bearing the word EXIT in plain, legible letters shall be placed at each required exit, except at doors directly from rooms to exit passageways or corridors. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 12:13 P.M., showed no exit sign located in the third floor hallway, by room 301. Observation at 12:24 P.M., showed two (2) exit signs, one (1) stating “NO EXIT", four inches (4") above another, stating "EXIT" with an arrow pointing to the right. These are located on the wall outside the elevator on the third floor. Observation at 12:24 P.M., showed an exit sign located on the third floor in the hallway by room 310, not having letters at least six inches (6") high. Observation at 1:19 P.M., showed four exit signs Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 87B411 \f continuation sheet 1 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued Fram page 1 in the north third floor hallway by the north elevator: One (1)stating, "NO EXIT”; one (1) EXIT with an arrow pointing right, one (1) hanging lit exif sign, and one (1) on the door. Observation at 1:56 P.M., showed no exit signs located in the third floor hallway, by room 319. Observation at 1:57 P.M., showed no exit signs located in the main stairway in the middle of the building, on or between third and second floor, and second and first floor. Observation at 2:00 P.M., showed no exit signs located in the second floor hallway, by room 217. Observation at 2:23 P_.M., showed an exit sign located on the third floor in the hallway by room 210, not having letters at least six inches (6") high. Observation at 2:57 P.M., showed two (2) exit signs, one (1) stating "NO EXIT”, approximately four feet (4") to the left of another, stating “EXIT* with an arrow pointing to the right, located on the wall outside the elevator on the second floor. Observation at 3:23 P.M., showed no exit signs located in the second floor hallway, by room 218. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, “We will add signs in area and address the others.” 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the Missouri Department of Health and Senior Services STATE FORM 6838 87B411 {f continuation sheet 2 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 complete fire alarm system in accordance with NFPA 72, 1999 edition. f/1 This regulation is not met as evidenced by: Class Il Based on observation and interview on May 20, 2025, the facility failed to maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 1:44 P_.M., showed a four inch (4")} by four inch (4°) junction box with red wire in it with no cover plafe in the attic by a brick wall. Observation at 3:45 P.M., showed a four inch (4°) by four inch (4°) junction box with red wire in it with no cover plate in the hallway of the maintance room, between the shop and the office. In the same hallway showed two (2) four inch (4") by two inch (2") junction boxes above the fire extinguisher with no cover plates. During an interview on June 11, 2025 at 5:19 P_M., The Assistant Administrator said, "We will address the junction boxes.” 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 3 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which ts interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as resiciential care facility | or Hl, and existing prior fo November 13, 1980, shall be exempt from this requirement. Il This regulation is not met as evidenced by: Class fl Based on observation and interview on June 11, 2025, the facility failed to ensure all hazardous areas are separated by construction of at least a one (1) hour fire-resistant rated construction. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 3:32 P.M., showed the laundry room located on the Garden Level floor, did not have a self-closing device on the door. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, "We will have it repaired.” 19 CSR 30-86.022(10)(1} Smoke Section Partitions > than 20 beds Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 4 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued From page 4 Protection from Hazards. () In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- {20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. Il This regulation is not met as evidenced by: Class Il Based on observation and interview on June 11, 2025, the facility failed to have smoke partitions shall be continuous from outside wail-to-ocutside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation from 1:38 P.M. to 1:53 P.M., showed the attic space was not separated into smoke partitions. North wing is approximately one hundred ten feet {110°} by forty-three feet (43’), Front of the building is approximately one hundred eighty-nine feet (189) by forty-three feet (43'), and the South wing is approximately one hundred ten feet (110') by forty-three feet (43'). Missouri Department of Health and Senior Services STATE FORM 6838 87B411 {f continuation sheet § of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 There is existing brick walls, but none of them extend from wall to wall completely to the roof deck. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, "We will look inte and since I've be here, have never been sited for it.” 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 requirernents that were in effect for such facilities on August 27, 2007. (Vil This regulation is not met as evidenced by: Class fl Based on observation and interview on June 11, 2025 the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation showed sprinkler heads with foreign material, corrosion, and/or paint on them in the follow rooms and locations: Observation at 12:14 P.M., showed one (1) corroded sprinkler head, in a janitor closet on the third floor just south of the fire door. Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 6 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued From page 6 Observation at 12:24 P.M., showed one (1) corroded sprinkler head, in the closet of room 303. Observation at 12:35 P.M., showed two (2) sprinkler heads, one (1) in the closet and one (1) in the room of 307. Both have escutcheon rings away from the wall and/ or ceiling. Observation at 12:36 P.M., showed one (1) sprinkler head with paint, in the bathroorn of room 308. Observation at 12:38 P.M., showed one (1} corroded sprinkler head, in room 309. Observation at 12:42 P_M., showed two (2), one (1) in the closet and one (1) in the room of 311. Observation at 12:57 P.M., showed two (2), one (1) in the closet and one (1) in the room of 312. Observation at 1:03 P.M., showed one (1) corroded sprinkler head, in room 317. Observation at 1:07 P.M., showed two (2) sprinkler heads, one (1) in the closet and one (1) in the room of room 318. Both sprinkler head have paint on them. Observation at 1:09 P.M., showed one (1) sprinkler head with paint on it, in room 319. Observation at 1:18 P.M., showed a sprinkler head without eighteen inches (18") of clearance, in the closet and one (1} that has corrosion in reom 323. Observation at 1:22 P.M., showed two (2) sprinkler heads, one (1) in the closet and one (1) Missouri Department of Health and Senior Services STATE FORM 6838 87B411 {f continuation sheet 7 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued From page 7 in the room of room 324. Both sprinkler head have paint on them. Observation at 1:25 P.M., showed one (1) sprinkler head with paint on it, in room 325. Observation at 1:29 P.M., showed two (2) sprinkler heads with paint on them, in room 328. Observation at 1:33 P.M., showed two (2) sprinkler heads with paint on them, in room 329. Observation at 1:35 P.M., showed one (1) without an escutcheon ring in room 331. Observation at 2:03 P.M., showed two (2) obstructed with lint in room 202. Observation at 2:06 P.M., showed one (1) without an escutcheon ring in the bathroom of room 203. Observation at 2:12 P.M., showed one (1) sprinkler head with paint on it, in the A/B side of room 206. Observation at 2:16 P.M., showed one (1) corroded sprinkler head, in the bathroom of room 207. Observation at 2:19 P.M., showed a sprinkler head without eighteen inches (18”) clearance in the closet of room 208. Observation at 2:21 P.M., showed one (1) corroded sprinkler head, in room 209. Observation at 2:28 P.M., showed three (3), one (1) in the bathroom that is corroded, one (1) ina closet ancl one (1) with paint on them, in the room 211. Missouri Department of Health and Senior Services STATE FORM 6838 87B411 {f continuation sheet § of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 Observation at 2:39 P.M., showed one (1) corroded sprinkler head, in the closet of room 217. Observation at 2:42 P.M., showed one (1) sprinkler head with paint on it, in the closet of room 218. Observation at 2:43 P.M., showed a sprinkler head without eighteen inches (18") clearance in the activity office on the second floor. Observation at 2:57 P.M., showed one (1) without an escuicheon ring in the hallway outside of the north elevator on the second floor. Observation at 2:58 P.M., showed one (1) sprinkler head with paint on it, in room 224. Observation at 3:00 P.M., showed one (1) corroded sprinkler head, in the closet of room 225. Observation at 3:03 P.M., showed one (1) corroded sprinkler head, in the bathroom of room 226. Observation at 3:13 P.M., showed one (1) corroded sprinkler head, in the bathroom of room 232. Observation at 3:13 P.M., showed two (2) sprinkler head with lint on thern, in room 234. Observation at 3:36 P.M., showed one (1) corroded sprinkler head, in the bathroom of room 11, of the Respite section, on the Garden Level Floor. Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 9 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 Observation at 3:37 P.M., showed one (1) missing the escutcheon ring in the bathroom of room 12 of the Respite section, on the Garden Level Floor. Observation at 3:38 P.M., showed three (3); one (1) sprinkler head missing the escutcheon ring in the bathroom and two (2) sprinkler head with paint on thern, in room 13 of the Respite section, on the Garden Level Floor. Observation at 3:39 P.M., showed one (1) sprinkler head with paint on it, of room 14 of the Respite section, on the Garden Level Floor. Observation at 3:40 P.M., showed one (1) sprinkler head with paint on it, in room 15 of the Respite section, on the Garden Level Floor. Observation at 3:43 P.M., showed one (1) sprinkler head with paint on it, in room 17 of the Respite section, on the Garden Level Floor. Observation at 4:15 P.M., showed one (1) corroded sprinkler head, in the bathroom of room 9, on the Garden Level Floor. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, "We'll be contacting the sprinkler company to replace them and address the clearance issues.” Record review of the Nation Fire Protection Association (NFPA) 13, 1999 Edition. 5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water clischarge in a horizontal plane more than eighteen (18") (457mm) below the sprinkler deflector in a manner to limit the Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 10 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued From page 10 distribution from reaching the protected hazard shall comply with 5-5.5.3. 5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be eighteen (18") (457 mm) or greater. Record review of the Nation Fire Protection Association (NFPA) 25, 1998 Edition. 2-2.1.1* The Sprinkler shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shail be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damage, loaded, or in the improper orientation. 19 CSR 30-86.022(12})(A) Emergency Lighting - locations Emergency Lighting. (A) Emergency lighting of sufficient intensify shall be provided for exits, stairs, resident corridors, and required attendants * station. II This regulation is not met as evidenced by: Class fl Based on observation and interview on June 11, 2025 the facility failed to install and maintain emergency lighting of sufficient intensity for exits, stairs, resident corridors, and required attendants’ station. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 2:54 P_M., showed a light inside Missouri Department of Health and Senior Services STATE FORM 6838 87B411 if continuation sheet 11 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued From page 11 the north stairwell by the second floor door without a light bulbs. There are no emergency lights at this location as the facility rely's on its generator to supply emergency lighting. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, “Missing buibs will be replaced." 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. {I/II This regulation is not met as evidenced by: Class fll Based on observation and interview on June 11, 2025, the facility failed to maintain the building in good repair. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 12:13 P_M., showed a space around the sprinkler pipe in the hallway at the south third floor fire door. Observation at 12:14 P.M., showed several holes/penetrations in the wall, ceiling and the floor, and where the ceiling and wall meet, in the janitor’s closet south of the fire door on the third floor. Observation at 12:18 P.M., showed a smail hole in the wall; drywall on the ceiling is bubbling; and Missouri Department of Health and Senior Services STATE FORM 6838 87B411 If continuation sheet 12 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued From page 12 a torn drywail seam in the closet of room 302. Observation at 12:24 P.M_., showed a ceiling tile missing and one (1) with a crack in it in the hallway above the NO EXIT sign on the South side of the third floor by the elevator. Observation at 12:32 P.M., showed a space around a PVC pipe in the drywail of the furnace closet room 306. Observation at 12:38 P.M., showed a space in the drywall around the sprinkler pipe in room 309. Observation at 12:54 P_M., showed an open space approximately one foot (1') by sixteen inches (16"), in the drywall where the ceiling and wall meet; exposing the sprinkler pipe behind the drywall of room 312. Observation at 12:59 P_M., showed two (2) smail holes in the drywall were fire alarm wire runs through the room; and two (2) small penetrations and a large opening around a vent pipe in the closet of room 375. Observation at 1:04 P.M., showed a gap around a sprinkler head and a section of the ceiling with water damage that created a hole approximately four inch (4") by twelve inch (12") in room 317. Observation at 1:16 P.M., showed an gap in the drywall of ceiling, around a pipe and wires in one {1} closet and a crack approximately three feet (3’) long in another closet of room 323. Observation at 1:20 P.M., showed several damaged areas consisting of: two cracks, flaking drywall/plaster and/or water damage on the ceiling and in the closet. There is an approximate Missouri Department of Health and Senior Services STATE FORM 6838 87B411 If continuation sheet 13 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 two inch (2") by two inch (2") hole in the floor by a corner and the floor has carpet missing and an unknown type of glue residue remains in room 324. Observation at 1:25 P.M., showed a hole in the ceiling where fire alarm wire runs through it and the wall paper and/or drywall is bubbling/loose from floor to ceiling outside of room 325. Observation at 1:25 P.M., showed a hole in the ceiling with fire alarm wire running through it in room 326. Observation at 1:27 P.M., showed a hole in the ceiling with fire alarm wire running through it outside of room 328. Observation at 1:29 P.M., showed gaps around two (2) sprinkler heads in recom 328. Observation at 1:54 P.M., showed a crack in the wall approximately three inches (3") down from the ceiling tiles outside of room 334. Observation at 1:55 P.M., showed a crack in the wall were the ceiling meets in the closet of room 335. Observation at 1:58 P.M., showed a hole in the wall where fire alarm wire runs through it and an opening where the sprinkler pipe is located at the south side set of fire doors on the second floor. Observation at 1:56 P.M., showed a hole in the wall with fire alarm wire runs through it above the Janitor's closet south of the fire door, on the second floor. Observation at 1:58 P.M., showed several Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 14 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 penetrations in the walls, ceiling and the floor in the janitor’s closet, south of the fire doors, on the second floor. Observation at 1:59 P.M., showed two (2) holes in the wall with fire alarm wires running through it, between the janitor's closet and room 201. Observation at 2:01 P.M., showed two (2) spot in the ceiling that need of repair in the closet of room 201 Observation at 2:02 P.M., showed a hole in the wall with fire alarm wire runs through it, in the hallway above the door of room 201. Observation at 2:06 P.M_., showed a vent fan cover with heavy lint buildup, in the bathroom of room 203. Observation ai 2:12 P.M., showed several penetrations and holes in the walls of the closet in the A/B side’s furnace room of room 206. Observation at 2:14 P.M., showed a missing vent fan cover in the bathroom and an approximate six inch (6") by two foot (2') hole in the plaster/drywall in a closet of C/D side in raom 206. Observation at 2:31 P.M., showed ceiling damage with material flaking in both sleeping areas, of room 212. Observation at 2:37 P.M_, showed ceiling damage in the room with material flaking and a closet with penetrations in roorn 216. Observation at 2:39 P.M., showed an open space around a vent pipe and drywall tape pealing ina closet. In another closet, there is an open space Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 16 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 around a sprinkler pipe and drywall is flaking from the ceiling. Two (2) holes in the wall near a resident's bed in room 217. Observation at 2:46 P.M., showed a soft spot in the floor by the window outside the bathroom door in room 221. Observation at 2:54 P.M., showed several pieces of the drywall/plasier pealing on the wall of the north outer stairwell on the second floor. Observation at 2:57 P.M., showed a ceiling tile missing in the north hallway above the fire alarm strobe light on the second floor. Observation at 3:02 P.M., showed flaking drywall/plaster on the ceiling and a penetration in the wall of the closet in room 226. Observation at 3:04 P.M., showed holes in the ceiling and wall near the wires and pipe; anda hole in the wall near the window close to the ceiling, in the second floor store. Observation at 3:13 P.M., showed a missing ceiling tile in the bathroom; cracks and holes ina closet wall in room 232. Observation at 3:30 P.M., showed an approximate six inch (6"} by six (6") hole in the wall of the furnace room in the laundry room of the Garden Level floor. Observation at 3:36 P.M., showed a wall tile missing above the sink in the bathroom of Respite room 11. Observation at 3:37 P.M., showed a crack in the drywall/plaster about one foot (1’) down from the Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 16 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 16 ceiling that extends across the wall in Respite room 12. Observation at 3:42 P.M., showed a drywall tape seam pealing where the ceiling meets the wall near the desk of Respite area. Observation at 3:42 P.M., showed a space in the drywall around a sprinkler pipe in roorn 8 on the Garden Level. Holes, cracks, missing tiles and penetrations will allow smoke, fire and toxic gases to travel to unaffected portions of the building in the event of a fire. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, “We didn't realize that it was in the condition it was in, but will address them.” 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 Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 17 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 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 wail heaters are used, adequate guards shail be provided to safeguard residenis. I/Il This regulation is not met as evidenced by: Class fl Based on observation and interview on June 11, 2025 the facility failed to ensure the use of portable space heaters was prohibited. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 3:29 P.M., showed one (1) portable electric heater under desk in the Garden Level laundry room. Observation at 3:53 P.M., showed one (1) portable electric heater by a desk in the maintance office and one (1) in the shop near a small welder. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, "All space heaters will be removed from the facility.“ 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 18 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. HAH This regulation is not met as evidenced by: Class fll Based on observations and an interview on June 11, 2025, the facility failed to install and maintain the electrical wiring in accordance with the requirements of the National Electrical Code, 1999 edition. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 1:07 P.M., showed a closet light not secured to the ceiling in room 318. Observation at 1:20 P.M., showed three (3) outlet cover plates off outlets in room 324. Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 19 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 19 Observation at 1:41 P.M., showed live wires with wire nuts not in a junction box with a cover plate in the northeast side of the attic. Observation at 1:43 P.M., showed a two inch (2") by four inch (4") junction box with no cover plate near a note on the roof that says, “LEAK 5-15-90", in the attic. Observation at 2:44 P_M., showed an outlet box not flush with the its cover plate in the hallway near room 219 on the second floor. Observation at 2:48 P.M_, showed a closet light not secured to the ceiling and hanging from its wires in the activity room kitchen on the second floor. Observation at 3:44 P.M., showed a round junction box with no cover plate, in the ceiling of the maintance rcom hallway between the office and the shop. Observation at 3:53 P.M., showed two (2), four inch (4") by four inch (4°) junction boxes with no cover plates on the ceiling in the maintance room shop. Observation at 4:02 P.M., showed wires from a shop light in a flexible metal casing, having a plug attached fo an extension cord with wires exposed at the south exit of the maintance room. Observation at 4:10 P.M., showed an outlet not flush with its cover plate in the hallway by room 8, on the Garden Level. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, "Anything Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 20 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 sited will be repaired.” 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 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 darnage. II/HI This regulation is not met as evidenced by: Class fll Based on observation and interview on June 11, 2025, the facility failed to prevent the improper use of power strips, extension cords and the use of multi-plug adapters. The facility census was one hundred and twenty-eight (128). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 12:21 P.M., showed an extension cord without a reset switch, in room 301. This extension cord has multiple items plugged into it. Observation at 12:43 P.M., showed three different residents in room 311 with improper use of power strips: One has a power strip daisy-chained to another, using a three (3) prong to a two (2) prong adapter and the power strip plugged into the wall outlet using a three (3) prong to two (2) Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 21 of 24 PRINTED: 06/25/2025 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 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING Continued Fram page 21 prong adapter; Second resident has a power strip using a three (3) prong to two (2) prong adapter plugged into the wail outlet; Third resident has a power strip plugged into a six (6) way adapter. The six (6) way adapter has six (6) items plugged into it and it is plugged into an extension cord and the extension cord has a three (3) prong to two (2) prong adapter plugged into the wall outlet. Multiple items plugged inio extension cords, Daisy-chained power strips and using three (3) prong to two (2) prong adapters are not allowed. Observation at 1:35 P.M., showed two (2) extension cords with multiple items plugged into it, in room 337. Observation at 2:10 P.M., showed a power strips having a three (3) prong to two (2) prong adapter plugged into the wail outlet in room 204. Observation at 2:19 P.M., showed two (2) approved power strips daisy-chained together in room 208. Observation at 2:41 P.M., showed an extension cord that has two (2) items plugged into it, in room 218. Observation at 2:49 P.M., showed an extension cord that has two (2) items plugged into it, in the activity room office. Observation at 3:08 P.M., showed an extension cord that has two (2) items plugged into it, in room 229. Observation at 3:12 P.M., showed two (2) extension cords with more than on item plugged into if, in room 231. Missouri Department of Health and Senior Services STATE FORM 6838 87B411 If continuation sheet 22 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 22 Observation at 3:31 P.M., showed two (2) approved power strips daisy-chained together and one of them is hanging by its cords in the Garden Level laundry room. Using three (3) prong to two (2) prong adapters eliminates the grounding of the extension cord and/or power strip. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, “We will be going room to room and replace them with appropriate cords.” 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. HANI This regulation is not met as evidenced by: Class Hl. Based on observation and interview on June 11, The facility census was one hundred and twenty-eight (123). This deficiency affects one hundred and twenty-eight (128) of one hundred and twenty-eight (128) residents. Observation at 12:26 P.M., showed excessive clutter in resident room 304. This includes: two (2) rows of shoes by the side of the bed; the other two sides of the bed have clutter approximately two (2) feet out from the bed; a closet is not containing all clothing, shoes and other belongings, as many items have breached the closet and encroached onto the room's floor Missouri Department of Health and Senior Services STATE FORM 2025, facility fails to keep rooms neat and orderly. 899 8ZB414 PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 23 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 4235 LOCUST STREET KANSAS CITY, MO 64110 ROCKHILL MANOR ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 23 space. Observation at 1:15 P.M., showed excessive clutter in resident room 321. This includes: one side of the bed has items on the floor and the other side of the bed has several shoes scattered on the floor. The shoes by the bed side will cause a tripping hazard during emergency exiting and clutter on the floor creaies a tripping hazard in addition to adcling greater fire load in the rooms. During an interview on June 11, 2025 at 5:19 P.M., The Assistant Administrator said, "We will be addressing those rooms." Missouri Department of Health and Senior Services STATE FORM 899 8ZB414 (X2) MULTIPLE CONSTRUCTION PRINTED: 06/25/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 06/11/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 24 of 24 UNABLE TO LOCATE THE ACCEPTABLE PLAN OF CORRECTION PRINTED: 10/10/2025 FORM APPROVED Missouri Department of Heaith and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDE RVSUPPLIERYCLIA (82) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R O6794C 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (28) PREFIX (EACH DEFICIENCY MUST BE PRECEQED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IBENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE CATE DEFICIENCY} ROCKHILL MANOR ASSISTED LIVING | {A2264} 19 CSR 30-86.022(10}(I) Smoke Section {A2264} | Partitions > than 20 beds Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wail and from floor-to-floor or floor-to-roof deck. All doors in this wall shal! be at least bwenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door clases automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: This deficiency is uncorrected. For prior example, refer to Statement of Deficiencies dated June 11, 2025 Based on observation and interview, the facility failed to have smoke partitions continuous from outside wall-to-outside wail and from floor-to-floor or floor-to-roof deck. The facility census was one hundred and thirty (130). This deficiency affects one hundred and thirly {130} of one hundred and thirly (130) residents. Observation on September 23, 2025 at 2:10 P.M... showed the separation walls located in the attic did not completely extend from the floor to the roof deck. This would ailow smoke to spread between Comparlments in the event of a fire. During an interview on September 23, 2025, at 2:21 P.M., the Administrator said the facility had consulted with a company to address the issue and will have it fixed and addressed no later than, Missouri Department of Haalth anc Senior Services LABORATORY DIRECTOR'S OR PROV|DER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (Xb) DATE STATE FORM ate 87B412 Hi continuation sheet 1 of 2 IZ PL Woypos PRINTED: 10/10/2625 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 R 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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) ROCKHILL MANOR ASSISTED LIVING {A2264} 19 CSR 30-86.022(10)(1) Smoke Section {A2264} Partitions > than 20 beds Protection from Hazards. (J) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wallto-outside wail and from floor-to-floor or flcor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. {I This regulation is not met as evidenced by: This deficiency is uncorrected. For prior example, refer to Statement of Deficiencies dated June 11, 2025 Based on observation and interview, the facility failed to have smoke partitions continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. The facility census was one hundred and thirty (130). This deficiency affects one hundred and thirty (130) of one hundred and thirty (130) residents. Observation on September 23, 2025 at 2:10 P.M., showed the separation walls located in the attic did not completely extend from the floor to the roof deck. This would allow smoke to spread between compartments in the event of a fire. During an interview on September 23, 2025, at 2:21 P.M., the Administrator said the facility had consulted with a company to address the issue and will have it fixed and addressed no later than, Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 8ZB412 lf continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING SUMMARY STATEMENT OF DEFICIENCIES {A2264} Continued From page 1 November 26, 2025. Missouri Department of Health and Senior Services STATE FORM {X41} PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 10/10/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: {X3} BATE SURVEY COMPLETED R 09/23/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {A2264} 6839 lf continuation sheet 2 of 2 8ZB412 PLAN OF CORRECTION —— Provider /Supplier Name: Rockhill Manor Assisted living ALF 1 Street Address, wae 4235 Locust St. Kansas City Mo 64110 City, Zip: 9/23/25 —__mowoersumuerenwommemenmuneer | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | A2264 |: 19 CSR 30-86.022(10)(I) Smoke Section Partitions | Rockhill has engaged a contractor to install 20-minute fire rated doors in the attic to create a smoke partition that extend from wall to wall and floor to roof deck. The construction had been delayed due to confusion on the need to move a gas line as well as ventilation systems, after clarification from the fire inspector it was determined that those systems would not need to be moved. Rockhill will have the contractor complete the smoke 11/26/2025 partition and place 20 minute rated fire/smoke proof door with a self-closing device. The assistant administrator will work with the contractor to ensure that this is completed no later than November 26", 2025. The assistant administrator will complete yearly inspections to ensure that the smoke partition remains in compliance. Date of Survey: The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the pian of correction being submitted on this form. TPL yin

PRINTED: 10/29/2024 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 Cc 06794C — 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 (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) ROCKHILL MANOR ASSISTED LIVING 19 CSR 30-86.022(7)(E) Locked Exit Doors Exits, Stairways, and Fire Escapes. (E) If it is necessary to lock exit doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door from inside the building. Only one (1) lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA 101 shall be permitted, provided that not more than one (1) such device is located in any egress path. Self-locking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. Il This regulation is not met as evidenced by: Class Il. Based on observation, interview and record review, the facility failed to maintain the doors to the south exit on the 3rd floor and the 2nd floor unlocked so that special knowledge, (knowledge of the code) would not be needed to open those doors and failed to re-apply with the State Agency (SA) for the exception regarding the exit locks. This practice potentially affected 119 residents who resided in the Assisted Living Facility (ALF) I. The facility census was 119 residents. 1. Review of the exceptions letter dated 11/19/18 form the Section for Long Term Care Regulation (SLCR) showed: The exceptions approval to 19CSR30-86.022 (7) (E) regarding locked exit doors applicable for both the ALF #06794C and ALF II 06794 is approved or four (4) years. You are required to comply with the stipulation that follow: If it is necessary to lock exit doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door from Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 8XJJ11 If continuation sheet 1 of 3 PRINTED: 10/29/2024 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 Cc 06794C — 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 (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) ROCKHILL MANOR ASSISTED LIVING Continued From page 1 inside the building. Only one (1) lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA 101 shall be permitted, provided that not more than one (1) such device is located in any egress path. Self-locking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. 1. The operator will ensure all staff are trained in the operation of the exit doors. 2. The operator will ensure the fire alarm system and the magnetic locking exit doors are tested on a monthly basis to ensure operation. The operation will ensure a record is kept of these monitoring checks. 3. The operator will ensure that resident care and services are not adversely affected in any way by the exception. If renewal of the exception to 19 CSR30-86.022 (7)(E) should be necessary, you must make a written request to the SLCR for a review of the request forty-five (45) days prior to the expiration date of November 30, 2022. 2. Observations on 4/9/24 at 1:30 P.M., with the Administrator during the fire alarm test showed the door to the fire escape from the 3rd floor, only became unlocked, when the fire alarm was activated. During an interview on 4/9/24 at 1:32 P.M., the Assistant Administrator said the facility started locking the doors to the fire escapes in the late 1990s due to resident safety related to the fire escapes and the only way to get those doors open without the fire alarm was to press in the code. Observation on 4/9/24 at 1:34 P.M., with the Administrator showed the door to the fire escape Missouri Department of Health and Senior Services STATE FORM 6899 8XJJ11 If continuation sheet 2 of 3 PRINTED: 10/29/2024 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 Cc 06794C — 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 (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) ROCKHILL MANOR ASSISTED LIVING A2229 Continued From page 2 from the 2nd floor, only became unlocked when the alarm was activated. Missouri Department of Health and Senior Services STATE FORM 6899 8XJJ11 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider Name: Rockhill Manor Assisted Living ALF-I Street Address, City, Zip: 4235 Locust St Kansas City, Mo 64110 Date of Survey: 04-09-2024 Provider number: | 06794 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE As suggested by the Section for Long-Term Care Regulation, Regulation Unit Manager, Carmen Grover-Slattery, the Administrator at Rockhill Manor has applied for a review of our southern fire doors as a required exit through the engineering consultation unit on 10/01/24 to address the concerns of 19 CSR 30-86.022 (7) (E) that were expressed in the inspection that was completed on 4-9-24. If the engineering consultation unit approves eliminating the fire escape as required exits, the Administrator, Ryan Paschen, will A2229 immediately remove the exit signs from the door and replace them with signs that state that if is not an exit. The Assistant Administrator, Vern Miller, will also revise our evacuation plan to reflect the two other exit routes that will still be available for residents to use in emergencies. The Administrator will then conduct a training to educate staff on the new procedures and evacuation routes, followed by a drill with the residents to practice the fire evacuation within two weeks of approval. 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: 01/13/2025 ; ; ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (42) MULTIPLE CONSTRUCTION Ser AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X8) DATE SURVEY A. BUILOING: : COMPLETED R-C 06794C ded er eeenetne 12/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET ROCKHILL MANOR ASSISTED LIVING KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES lo (EACH DEFICIENCY MUST BE PREGEDED BY FULL PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (5} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED 70 THE APPROPRIATE DATE DEFICIENCY) {A2229} 19 CSR 30-86.022(7)(E) Locked Exit Doors {A2229} Exits, Stairways, and Fire Escapes. (E) If itis necessary to lock exit doors, the locks shall not require the use of a key, tool, special knowledge, or effort to unlock the door fram inside the building. Only one (1) lock shall be permitted on each door. Delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA 101 shall be permitted, provided that not more than one (1) such device is located in any egress path. Self-lacking exit doors shall be equipped with a hold-open device to permit staff to reenter the building during the evacuation. Wil This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated 4/9/24. Class JI Based on observation, interview and record review, the facility failed to maintain the doors to the south exits on the 2nd and 3rd floor unlocked so that special knowledge, (knowledge of the code) would not be needed to open the doors, failed to place information with the code to open the exit doors, and failed ta inform facility staff of the code to open the south exit door on the first floor, This practice potentially affected 1214 residents who resided in the facility. The facility census was 121 residents. 1. Review of the Missouri Department of Health and Senior Services (MO DHSS) letter dated 9/20/24 showed: -This letter was sent to the facility Administrator. -The Section for Long-Term Care Regulation {SLCR) Exceptions Commitiee has reviewed your Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {X8) DATE STATE FORM eee 8xXJJ12 “g.Pl- Vaaps if continuation sheet 1 of & PRINTED: 01/13/2025 a - 5" FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2} MULTIPLE CONSTRUCTION A. BUILDING: RE (X3) DATE SURVEY COMPLETED R-C 12/30/2024 B. WING 06794C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET CK ROCKHILL MANOR ASSISTED LIVING KANSAS CITY, MO 64110 (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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) {A2229} | Continued From page 1 request for an exception to regulation 19 CSR 30-86,.022 (7)(E), regarding the locking of exit doors. | -Regulation 19 CSR 30-86.022 (7) (E) allows for the use of delayed egress locks complying with section 7.2.1.6.1 of the 2000 edition NFPA101_— Life Safety Code, provided that no more than one | (1) such device is located in any egress path.A | delayed egress locking mechanism allows for release of the lock within fifteen (15) seconds | | after the release device is pushed for at least | | | | {A2229} three (3) seconds, and the lock release can be extended to thirty (30) seconds upon approval of ; the SLCR. -While assisted living facilities are required to i have an adequate number and type of personnel ; for the proper care and protective oversight of residents and staffing patterns per shift are i referenced in regulation, these are only minimum i | fatios, and it is noted that these minimal staffing ' requirements may not meet the needs of the _ residents as outlined in the residents’ assessments and individualized service plans. -Each floor of the facility is required to have at least two (2) exits that are remote from each ‘ other and unobstructed. Review of the facility's layout showed each floor has the required two (2) remote exits. According to the request, the facility : wants to lock one (1) of the two (2) designated exits. However, if each South exit door is locked ‘and residents are denied use of that South exit ' door, the facility has only one (1) other exit door on each floor to use. If that exit is blocked or can't be used, residents will have to rely on staff to open the South exit that is locked. Residents should be able to evacuate during any emergency, rather than rely on staff to open an exit door. Having a locked door does not ensure | residents can promptly evacuate during any | emergency. Not every emergency is fire-related, Missouri Department of Health and Senior Services STATE FORM sese 8XJJ12 ? If continuation sheet 2 of 6 PRINTED: 01/13/2025 Missouri Department of Health and Senior Services FORM APPROVED STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION pins 4 (X3) DATE SURVEY PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C —___————— 12/30/2024 06794C B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET ROCKHILL MANOR ASSISTED LIV poleiell HMING KANSAS CITY, MO 64110 (X4) ID! SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE : DATE DEFICIENCY) {42229}; Continued From page 2 {A2229} PROVIDER'S PLAN OF CORRECTION x5) | So if the South exit doors only release upon activation of a fire alarm or they have to rely on _ Staff to enter a pass code, the facility delays | resident safety for exiting promptly, especially if | the secondary exit is inaccessible for any reason. -It is the policy of the SLCR to ensure an exception can be granted without it potentially jeopardizing the health, safety, or welfare of the residents. The Exceptions Committee carefully reviewed all the information submitted and obtained a recommendation from the SLCR Region Office staff. The Committee noted several areas of concern including, but not limited to: restricting resident access to the South exit doors, level of care placement for residents exhibiting behaviors such as suicidal ideation and self-harm, staffing levels related to protective oversight, relying on staff to unlock an exit door using a pass code during an emergency, and denial of a resident's basic right to come and go from the facility from any required exit. The | Committee does not view this situation as an undue hardship for the facility operator to comply | with the regulation. Furthermore, the Committee | believes there are other options available to the ' facility to ensure the safety of its residents without locking exit doors. It is the Committee's determination that the exception cannot be granted without it potentially jeopardizing the resident and based on previous Internal Dispute , Resolution (IDR) determination that exit doors ‘ requiring the use of a key, tool, special | knowledge, or effort to unlock the door from inside the building is not permitted. . -Based on the above-mentioned reasoning, the "request for an exception to lock the South exit doors with a magnetic lock and keypad has been _ denied. Review of written communication dated 12/20/24 Missouri Department of Health and Senior Services STATE FORM Gaga BXJJ12 if continuation sheet 3 of 6 PRINTED: 01/13/2025 Pica” FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ——$——————— (X3) DATE SURVEY COMPLETED R-C B. WING 12/30/2024 06794C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET ROCKHILL MANOR ASSISTED LIVING KANSAS CITY, MO 64110 (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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE : DATE DEFICIENCY) {A2229} Continued From page 3 {A2229} : from the MO Department of Health and Senior ; Services (DHSS) Region 3 office to the facility management, stated: -The doors (to the south exits on the 2nd and 3rd floor) need to be unlocked and protective , Oversight provided so that residents did not gain | access. : - The facility needed to work on getting a door | company out sooner to repair the locks. Facilities | in the metro area have door companies that | provide quicker services than 6-10 weeks. During an interview on 12/30/24 at 9:09 A.M., the | i Administrator said: ; Facility management wanted to find out about | ' options other than just leaving the door to the i ‘ south exit unlocked. [ | -Facility management felt uncomfortable with the | doors being left unlocked because of the history of residents who jumped from the fire escape on the 3rd floor, in the past. -Facility management placed a down payment on - a bid for the installation of an exit door with a 30 - Second delay which was linked to the facility's call ' light system. : - The door installation company said the manufacturing and installation of the delayed exit door could take up to six months. { ‘ Review on 12/30/24 at 9:15 A.M. of the door installation company bid dated 10/31/24 showed a price for the manufacture and installation three doors with a delayed egress. Review on 12/30/24 at 9:17 A.M. of the facility's check stub dated 12/16/24 showed: -The facility made a down payment for the installation company to get started with the manufacturing of the new egress doors. -Note: This was 1 1/2 months after the bid was Missouri Department of Health and Senior Services STATE FORM 8899 8XJJ12 If continuation sheet 4 of 6 PRINTED: 01/13/2025 Missouri Department of Health and Senior Services ihiristiaiailanies STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R-C 12/30/2024 06794C B. WING ee NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET ROCKHILL M D SO ABRIATED LINE KANSAS CITY, MO 64110 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X85) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE ; COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE ' DATE DEFICIENCY) {A2229} . Continued From page 4 {A2229} completed. ' During an interview on 12/30/24 at 9:26 A.M., the | , Administrator said: i - MO DHSS gave the facility the option of leaving "the door to the south exit unlocked or placing the | _ code to unlock the door next to the door. _~ At that time the codes were not posted within _ proximity to the doors. ‘ Observation on 12/30/24 at 9:33 A.M., showed | the absence of a posted code within proximity of | the south exit door from the third floor, to unlock ' the south exit door from the the third floor and the - i the third floor south exit door remained locked | | when it was pushed. | Observation on 12/30/24 at 9:35 A.M., showed | the absence of a posted code within proximity of the south exit door from the second floor, to ‘ unlock the south exit door from the second floor and the second floor south exit door remained _ locked when it was pushed. During interview on 12/30/24 at 9:55 A.M. the . Shift Supervisor said: ‘ ' -He/she supervises other Certified Nurse's Aides (CNAs). -In the event of a non-fire emergency, he/she would just push the door, He/she has never had to use the code to open the south exit doors. During an interview on 12/30/24 at 9:59 A.M., | CNAA said the following: -He/she did not know the code to unlock the south exit doors. -During a non-fire emergency, he/she would just go to the rooms to get the residents out. Vlissouri Department of Health and Senior Services STATE FORM 6899 8XJJ12 if continuation sheet 5 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 06794C NAME OF PROVIDER OR SUPPLIER ROCKHILL MANOR ASSISTED LIVING {X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 01/13/2025 eo cee KANSAS CITY, MO 64110 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {A2229} Continued From page 5 During an interview on 12/30/24 at 10:05 A.M., the Activity Director said: i -He/she did not know the code. ! -During a non-fire emergency, he/she would use | the other two staircases to evacuate. | During an interview on 12/30/24 at 10:14 A.M., Resident #2 said he/she would use the south exit | door and he/she was not given access to the code to the south exit doors. | During an interview on 12/30/24 at 10:16 AM., Resident #3 said he/she would use the south exit : | | door from his/her floor and he/she was not given | access to the code to unlock the south exit doors. | ' During an interview on 12/30/24 at 10:22 A.M., . Resident #4 said he/she has not had access to : the code to unlock the south exit doors and | his/her room was closest to the center stairwell. | During an interview on 12/30/24 at 11:04 A.M., | the Administrator said: ~- He/she found out in July 2024 that the previous exception was not approved. - The current Plan of Correction (POC) was submitted in November 2024 and the facility management was in process of working towards accomplishing what was stated in the POC. Missouri Department of Health and Senior Services STATE FORM i ID PREFIX TAG {A2229} 6889 8X12 STREET ADDRESS, CITY, STATE, ZIP CODE 4235 LOCUST STREET PROVIDER'S PLAN OF CORRECTION FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 12/30/2024 (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 6 of 6 AMENDED PLAN OF CORRECTION Provider Name: Rockhill Manor Assisted Living Street Address, 4235 Locust Street _ | nee Kansas City, Missouri 64110 _ | Date of Survey: December 30, 2024 | Provider number: 06794C (ID PREFIXTAG | PROVIDER'S PLAN OF CORRECTION: [EACH CORRECTIVE ACTION | COMPLETION a ___A2229 —a _— __ +-——_—} ‘one: _—ac en. SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICI ENCY) _ from inside th e ieee ‘nd ree 3rd Floor affecting 121 recigenbal A at corrective actions will be undertaken for those January 16, iting the_afternoon a commu ity ouncil was heldto_| cf tee a E = tC glitinn pie Te mei Hoes caine a code that is posted at each door to inlock the doors. The residen were told tha t the pla : ed with ith it i Ober af U Oncs o arm tim 0 OVA | ee I amt + eri hati opine 6 FYE hg E 9 att here being an emerven ea: Rae How will Rockhill Manor identify other residents having | January 16 e potential to be affected by the samedeficient __—s|_—« 2025 practice All residents will be educated on the operation on of the 30 second 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. EP ngs PLAN OF CORRECTION Provider Name: Rockhill Manor Assisted Living Street Address, City, Zip: 4235 Locust Street Kansas City, Missouri 64110 Date of Survey: December 30, 2025 Provider number: 06794C 1D PREFIX TAG PROVIDER’ 'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2229 (cont) | delayed egress doors and how to operate them if the need arises. en The staff will engage the residents in educationtoallowthemto | | e the doors and again egress if necessary in a non-fire Sere ee, |__emergena iii a Capea gs ; an al Be hel apa) What measures will be put in place or what systematic changes Rockhi# Manor will make to ensure that the deficient practice do not recur? sy ae The re-engineered doors will be installed during the week of January 27th Jan 29,2024 | sid Periodic testing of the doors will be conducted by staff. Ifthere are | Spring 2025 | any issues noted, they will be addressed. ns ee | ier | | The testing will be under the purview of the Administrator. She will ensure that the doors are fully operational and continue in good ae a fae ieee 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. PLAN OF CORRECTION Provider Name: Rockhill Manor Assisted Living Street Address, 4235 Locust Street City, Zip: Kansas City, Missouri 64110 Date of Survey: December 30, 2024 Provider number: 06794C ID PREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE _A2229 [cont)| What education will be done with staff, and if so, who wi ' Completing it? The contractor performing the installation will do February 2025 do all staff bye groups of Sta 4 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: 09/24/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA {X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 06794C B.WING 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 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} ROCKHILL MANOR ASSISTED LIVING A3214 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, 1989 edition, National Fire Protection Association, inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. IV/HI This regulation is not met as evidenced by: Class Ill Based on record review and an interview on 4/3/24 this facility failed to show documentation the electrical wiring had been inspected within the last two years by a qualified electrician. The facility census was 116. This potentially affected 116 of 116 residents. Record review on 4/3/24 at 3:27 P.M. showed the last electrical inspection had expired on 9/16/23. During an interview on 4/3/24 at 3:27 P_M. with the assistant administrator he/she said he/she Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) DATE STATE FORM sao 301TH If continuation sheet 1 of 2 PRINTED: 09/24/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA {X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 06794C B.WING 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 4235 LOCUST STREET KANSAS CITY, MO 64110 (X4) 1D 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} ROCKHILL MANOR ASSISTED LIVING A3214 Continued From page 1 saw it had expired the other day and had scheduled the electrician to come but he was backed up and not able to make it out yet. Missouri Department of Health and Senior Services STATE FORM 5899 3C1T14 if continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Rockhill Manor Assisted Living Name: Street Address, City, Zip: 4235 Locust St Kansas City Mo 64110 Date of Survey: 4/3/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 06794C ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The Fire Marshall came to the facility on 4/3/24 to complete his fire inspection. The electrical inspection had expired on 9/16/23. The assistant administrator had already discovered the expired electrical inspection and had contacted Superior Electric to complete the inspection. They were able to come to the facility A3214 and perform the inspection on 4/12/24. At that time some minor issues were identified and were placed on the schedule to be repaired. Those were repaired on 04/26/24 and final approval was given. The assistant administrator, and administrator will also set a calendar reminder two months prior to the expiration of the wiring inspection to ensure that it is completed on time before it expires in the future. 4/12/24 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. RR he 4/2-6/2*]