ST ANTHONY'S.

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 ST ANTHONY'S (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 08/28/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 08/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST 68TH STREET KANSAS CITY, MO 64131 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check Fire Extinguishers. (D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure check. II/III This regulation is not met as evidenced by: Class Ill Based on observations and an interview on 8/22/24 this facility failed to maintain all of their fire extinguishers in accordance with NFPA 10, 1998 edition. The facility census was 46. This potentially affected 46 of 46 residents. Observations during the fire safety inspection walk-through on 8/22/24 noted April 2024 was the last monthly fire extinguishers check that was done on the fire extinguisher tags. During an Interview on 8/22/24 at 11:27 A.M. with the interim Maintenance Director indicated there was some confusion on whether they or an extinguisher company was supposed to be checking them. 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 0V7511 If continuation sheet 1 of 10 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: 1010 EAST 68TH STREET KANSAS CITY, MO 64131 ST ANTHONY'S (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility 's entire plan shall be provided to the local jurisdiction 's emergency management director. W/I This regulation is not met as evidenced by: Class Ill Based on record review and an interview on 8/22/24 this facility failed to provide documentation a request was made for consultation and assistance annually from a local fire unit. The facility census was 46. This potentially affected 46 of 46 residents. Record review on 8/22/24 at 2:44 P.M. showed no documentation asking for and/or receiving consultation and assistance annually from a local fire unit. During an interview on 8/22/24 at 2:44 P.M., the assistant Executive Director did not know if a request had ever been made. A follow up email to multiple people at the facility on 8/26/24 at 10:49 A.M. asking if one had been requested, received no responses back as well. 19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees Fire Safety Training Requirements. (A) The facility shall ensure that fire safety training is provided to all employees: 1. During employee orientation; 2. At least every six (6) months; and 3. When training needs are identified as a result Missouri Department of Health and Senior Services STATE FORM 6899 0V7511 PRINTED: 08/28/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/22/2024 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 10 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: 1010 EAST 68TH STREET KANSAS CITY, MO 64131 ST ANTHONY'S (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 of fire drill evaluations. II/IIl This regulation is not met as evidenced by: Class III Based on record review and an interview on 8/22/24 this facility failed to produce documentation or records of fire safety training being conducted as outlined in 19 CSR 30-86. 022 (6) (B). The facility census was 46. This potentially affected 46 of 46 residents. Record review on 8/22/24 at 2:44 P.M. showed no documentation of any fire safety and emergency preparedness training for the staff. During an interview on 8/22/24 at 2:44 P.M., the assistant Executive Director did not know if the training was being done. 19 CSR 30-86.022(7)(A) Exits-2 per Floor-Remote/Unobstructed Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. Il This regulation is not met as evidenced by: Class II Based on observation and an interview on 8/22/24 this facility failed to insure at least two (2) unobstructed exits remote from each other were maintained in the Memory Care area. The facility census was 46. This potentially affected 46 of 46 residents. Observation on 8/22/24 at 1:11 P.M. showed a Missouri Department of Health and Senior Services STATE FORM 6899 0V7511 PRINTED: 08/28/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/22/2024 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 10 PRINTED: 08/28/2024 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 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST 68TH STREET KANSAS CITY, MO 64131 (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) ST ANTHONY'S Continued From page 3 hand made bar approximately 10 foot long slid over the ends of the hand rails on the East exit of the Memory Care area obstructing the egress down the stairs to the parking lot. During an interview on 8/22/24 at 1:11 P.M., the new Maintenance Director stated he/she did not know for sure who had put the bar up. 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 II Based on observation and an interview on 8/22/24 this facility failed to ensure exit doors were not locked against egress. The facility census was 46. This potentially affected 46 of 46 residents. Observation on 8/22/24 at 12:36 P.M. showed the double horizontal fire exits delayed egress would not release when pushed and held from either side. Missouri Department of Health and Senior Services STATE FORM 6899 OV7511 If continuation sheet 4 of 10 PRINTED: 08/28/2024 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 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST 68TH STREET KANSAS CITY, MO 64131 (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) ST ANTHONY'S Continued From page 4 Observation on 8/22/24 at 12:43 P.M. showed the one side of the double smoke / fire doors for the 300 hall would not open back up with the handle or push bar when it was closed. During an interview on 8/22/24 at 12:43 P.M. the new Maintenance Director stated he/she would have to see what it would take to adjust the doors so they will open properly as designed. 19 CSR 30-86.022(10)(L) Multilevel/2 Business, Const. & Fire Safety Protection from Hazards. (L) If two (2) or more levels of long-term care or two (2) different businesses are located in the same building, the entire building shall meet either the most strict construction and fire safety standards for the combined facility or the facilities shall be separated from the other(s) by two- (2-) hour fire-resistant construction. In buildings equipped with a complete sprinkler system in accordance with NFPA 13 or NFPA 13R, 1999 edition, this separation may be rated at one (1) hour. Il This regulation is not met as evidenced by: Class II Based on observation and an interview on 8/22/24 this facility failed to ensure the one-hour fire separation between levels was properly maintained. The facility census was 46. This potentially affected 46 of 46 residents. Observations on 8/22/24 during the fire safety inspection walk-through of the parking garage showed once again a couple areas that had been pecked away by birds making nests in the parking Missouri Department of Health and Senior Services STATE FORM 6899 OV7511 If continuation sheet 5 of 10 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: 1010 EAST 68TH STREET KANSAS CITY, MO 64131 ST ANTHONY'S (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 area ceiling. This fire rated blown on insulation removal by the birds, has exposed the wood framing defeating the fire rated separation. During an interview on 8/22/24 at 2:03 P.M. the new Maintenance Director stated he/she would have to see what needs to do be done to prevent the birds from destroying the insulation and exposing the wood structure. 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on observation, record reviews and an interview on 8/22/24 this facility failed to show documentation of checking and recording monthly sprinkler pressure gauge readings and valve position checks and to have the sprinkler system inspected and tested annually by a qualified person as required in accordance with NFPA 13, 1999 edition. The facility census was 46. This potentially affected 46 of 46 residents. Observation on 8/22/24 at 2:15 P.M. showed no monthly sprinkler valve check sheets in the sprinkler room or on the annual tags on the sprinkler risers. Missouri Department of Health and Senior Services STATE FORM 6899 0V7511 PRINTED: 08/28/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/22/2024 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 10 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 1010 EAST 68TH STREET ST ANTHONY'S KANSAS CITY, MO 64131 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 6 Record review on 8/22/24 at 2:44 P.M. showed no records or indication monthly valve position and pressure gauge readings were being done for the sprinklers. During an interview on 8/22/24 at 2:15 P.M. the new Maintenance Director stated he/she did not know if they had been done, but he/she indicated he/she would start checking them if not. Record review on 8/22/24 at 2:44 P.M. showed the last annual sprinkler system inspection report available was from January of 2023. During an interview on 8/22/24 at 2:44 P.M. the assistant Executive Director did not know if a more recent sprinkler inspection was available. A follow up email to multiple people at the facility on 8/26/24 at 10:49 A.M. asking if a more recent annual sprinkler system inspection had been done, received no responses back as well. 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 8/22/24 this facility failed to insure all the wastebaskets were the approved types allowed. The facility census was 46. This potentially affected 46 of 46 residents. Missouri Department of Health and Senior Services STATE FORM 6899 0V7511 (X2) MULTIPLE CONSTRUCTION PRINTED: 08/28/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/22/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 7 of 10 PRINTED: 08/28/2024 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 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST 68TH STREET KANSAS CITY, MO 64131 (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) ST ANTHONY'S Continued From page 7 Observations on 8/22/24 during the walk-through of the facility showed the following rooms having improper wastebaskets, Room 107 had one, Room 117 had one, Room 118 had one, Room 116 had one, Rooms 104 had four, Room 103 had two, Room 208 had one, Room 207 had two, Room 203 had one, Room 302 had two, Room 411 had one, Room 421 had two, Room 416 had one and the Memory Care activity area had one. During an interview on 8/22/24 at 11:31 A.M. with the interim Maintenance Director he/she stated he/she would talk to the owner and look into getting the proper wastebaskets in those rooms. 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 8/22/24 this facility failed to maintain the building in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. The facility census was 46. This potentially affected 46 of 46 residents. Observations on 8/22/24 during the walk-through of the facility showed Rooms 112 and 313 with mechanically blocked open doors (door wedges). Most rooms already have magnetic door holds that easily release with a slight tug. All these doors were originally constructed with door Missouri Department of Health and Senior Services STATE FORM 6899 OV7511 If continuation sheet 8 of 10 PRINTED: 08/28/2024 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 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST 68TH STREET KANSAS CITY, MO 64131 (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) ST ANTHONY'S Continued From page 8 closers in place to help protect the resident (evacuation) corridors and areas of refuge from the effects of fire. NOTE: NFPA 101 does permit these types of doors to be held open with friction type holders that release with a simple pull on the door handle. During an interview on 8/22/24 at 11:52 A.M. with the interim Maintenance Director he/she stated he/she did not know why all the rooms did not have magnetic holds, but would see about getting the two found switched over. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III Missouri Department of Health and Senior Services STATE FORM 6899 OV7511 If continuation sheet 9 of 10 PRINTED: 08/28/2024 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 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1010 EAST 68TH STREET KANSAS CITY, MO 64131 (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) ST ANTHONY'S Continued From page 9 This regulation is not met as evidenced by: Class III Based on record review and an interview on 8/22/24 this facility failed to show documentation the electrical wiring had been inspected within the last year by a qualified electrician. The facility census was 46. This potentially affected 46 of 46 residents. Record review on 8/22/24 at 2:44 P.M. showed no records of an electrical inspection being done. During an interview on 8/22/24 at 2:44 P.M., the assistant Executive Director did not know if the electrical inspection had been done. A follow up email to multiple people at the facility on 8/26/24 at 10:49 A.M. asking if one had been done, received no responses back as well. Missouri Department of Health and Senior Services STATE FORM 6899 OV7511 If continuation sheet 10 of 10 PLAN OF CORRECTION Provider/Supplier Name: St. Anthony’s Senior Living Street Address, a os 1000 E. 68" Street, Kansas City, MO. 64131 City, Zip: Date of Survey: 8/22/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER iD PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE . All fire extinguishers will be checked in September. This will be a monthly work order in TELS that will alert maintenance staff to do monthly checks. The Executive Director or Assistant Executive Director will monitor as needed and report issues at the monthly safety meeting. The Assistant Executive Director has reached out to the Fire Department to set up an annual consultation by 11/19/24. This will be TELS on as an annual work order to alert staff to set up the consultation. The Executive Director or Assistant Executive Director will monitor as needed and report issues at the monthly safety committee meeting. Fire procedure fs part of the new employee orientation. It is reviewed and on a check list. Care Academy has training on disaster preparedness and an in-service is provided every 6 months for staff as well. The Executive Director or Assistant Executive Director will monitor as needed and report issues at the monthly safety meeting. 11/19/24 41/19/24 11/19/24 A2220 The bar that was across the stairway was removed by maintenance. When doing the safety rounds the safety committee will ensure the exit is unobstructed and report any issues monthly at the safety committee meeting. Maintenance fixed/adjusted the double horizontal fire exits delayed egress so they would release when pushed and held from the other side. They also fixed/adjusted the double fire doors on the 300 hall would open back up with the handle and push bar when it was closed. TELS will not produce a monthly work order to have all fire doors checked for proper functioning. Maintenance tech. or director will report any issues at the monthly safety meeting. A general contractor has been hired to repair the damage caused by the birds. When doing safety rounds the safety committee will ensure the fire insulation is in good repair and report issues monthly at the safety committee meeting The monthly sprinkler valve checks is on TELS which will create a monthly work order fo alert the maintenance department to do A2268 the checks. C&C group was contracted to complete the annual sprinkler inspection and will provide documentation by 11/19/2024. This is on TELS and will make a work order for 11/19/24 A2222 11/19/24 A2229 11/19/24 A2267 11/19/24 i i i \ | i j 1 i 3 maintenance staff to alert them it needs to be done. The reports will be uploaded into TELS so staff will know where to find them. The Executive Director or Assistant Executive Director will monitor as needed and report issues at the monthly safety meeting. Maintenance department removed all improper wastebaskets. Nursing staff and housekeeping staff will be in-serviced on improper wastebaskets and will remove any they find. Safey Committee will monitor on monthly rounds and report any issues at the monthly meeting. Maintenance staff removed all improper door wedges. Magnetic door holds were purchased and will be installed by 11/19/2024. Safety committee will monitor on monthly rounds and report any issues at the monthly meeting. Jeremy Electrical was contracted to do an inspection every two years. This was last completed on 9/29/23 and is attached as exhibit A. This has been added to TELS which will produce a work order to alert maintenance that this needs to be completed. Results will be uploaded to TELS so everyone knows where the report is located. 11/19/24 11/19/24 11/19/24 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.