TRUSTWELL LIVING OF RAYTOWN.

PRINTED: — Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (81) ee AND PLAN OF CORRECTION IDENTIFICATION NUMB {AS} DAIL SUIRVLY COMPLETED (%2) MULTIPLE CONS I RUC TION {£ACH NEF PENG idea BE esptamniee! BY dion’ PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE core ' Ly | | | i i A, BUILDING: _ =_ H | | | | i i | | 24297 | B. WING ngionionan | ee rrvcescrvm Re = - j A Ge utes y sping van cone Wiest Pee ‘ | ee 9110 EAST 63RD STREET | j ‘ RAYTOWN, MO 64133 | ion | SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION (x5) i 3 ' i _— i st mene ane JOMATIC 38; wat ’ conse SErceocncen td Tuc ABDPOPDIATE i DATE RIS 19 CSR 30-86.022(2)(D) Inspection Rights, No | Fire Hazard | General Reauiremenis. OR ae 2 | i I { | (D) The department shai! have the rig! t -! ' inspection of any portion of a building in which a | | i ji licensed facility is located unless the unlicensed portion is separated by two- (2-} hour fire-resistant construction. No section of the | hutilding shall present a fire hazard. l/l This regulation is not met as evidenced by: Class |I Paced an nheervatian anc intervis 2025 , the facility failed to ensure tie ps seperteora i shall have the right of inspection of any portion of | a building in which a licensed facility is located | unless the unlicensed portion is separated by two i (2) mae i ie construction, and no section i | Af thes bedltiews hall nennont a fire hazard. The | | \ a Rive 20 E facility census ; was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. | Observation at 11:25 A.M., showed dryer lint and socks in the back of the dryers and pipe in the laundry room. The excessive : ' } wer ste : | | i of the pipe causes a fire hazard. | ' During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"Will have this added to preventative maintenance check." A2214| 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation A2214 | Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to mect | potential emergencies or disasters and shall request consultation and assistance annually Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE “RA-ASo STATE FORM {f continuation sheet 1 of 23 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 TRUSTWELL LIVING OF RAYTOWN (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 07/14/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 05/20/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements. (D) The department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two- (2-) hour fire-resistant construction. No section of the building shall present a fire hazard. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on May 20, 2025 , the facility failed to ensure the department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two (2) hour fire-resistant construction, and no section of the building shall present a fire hazard. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 11:25 A.M., showed dryer lint and socks in the back of the dryers and pipe in the laundry room. The excessive dryer lint in and out of the pipe causes a fire hazard. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"Will have this added to preventative maintenance check." 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 VYZ311 If continuation sheet 1 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 from a local fire unit for review of fire and evacuation plans. If the consultation cannot be 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. I/II This regulation is not met as evidenced by: Class III Based on record review and interview on May 20, 2025, the facility failed to request consultation and assistance annually or provide documentation the consultation had been scheduled from the local fire unit for review of fire and evacuation plans. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Record review on May 20, 2025 at 12:57 P.M., showed no request for consultation with the local fire department or having one performed. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"| can't account for anything in 2024, but will work on getting it scheduled." 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/IIl This regulation is not met as evidenced by: Class III Based on record review and an interview on May 20, 2025, Facility failed to conduct one (1) fire drill every three (3) months on each shift and a full resident evacuation once a year. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Record review on May 20, 2025 at 12:57 P.M., showed only the following fire drills being conducted and recorded within the last twelve (12) months and no full evacuation: 1. January 30, 2025 - 1st shift 2. February 28, 2025 - 2nd shift 3. March - None 4. April 4, 2025 - 1st shift 4. May 18, 2025 - 1st shift During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"| can't account for anything in 2024, but we are trying to get these address." 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 and emergency lighting illuminates them. II/III This regulation is not met as evidenced by: Class III Based on observation and interview on May 20, 2025, the facility failed to ensure all required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 10:34 A.M., showed an exit sign that failed to illuminate when pressing the test button, near the exercise/workout room. Observation at 10:38 A.M., showed an exit sign that failed to illuminate when pressing the test button, outside the sprinkler riser room. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We will get it fixed." 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on May 20, 2025, the facility failed to test and maintain the complete fire alarm system in accordance with Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 NFPA 72, 1999 edition. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 11:27 A.M., showed a small circular ring missing from the bottom of a smoke detector in the laundry room's ceiling. Observation at 12:09 P.M., showed a residential smoke detector missing from its base in room 311. Record review on May 20, 2025 at 12:57 P.M., showed no record of a a semi-annual fire alarm inspection. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"| can't account for anything in 2024, but | will work on finding the paperwork or get it scheduled. | will also address smoke detector issues." Record review of the Nation Fire Protection Association (NFPA) 72 1999 Edition: 7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer 's recommendations, and shall verify correct operation of the fire alarm system. NFPA Standard: System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner, or the owner 's designated representative shall be informed of the impairment in writing within 24 hours. 1999 NFPA 72, 7-1.1.2 NFPA Standard: The owner or the owner's Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. 1999 NFPA 72, 7-1.2 Record review of Nation Fire Protection Association (NFPA) 72 1999 Edition: 7-3 Inspection and Testing Frequency: 7-3.1* Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance. Table 7-3.1 Visual Inspection Frequencies Component for Semiannually: 3. Batteries: Nickel-Cadmium Scaled Lead-Acid 4. Transient Suppressors: 5. Control Unit Trouble Signals: 7. Emergency Voice/ Alarm Communications Equipment: 8. Remote Annunciators 9. Initiation Devices: a. Air Sampling b. Duct Detectors c. Electromechanical Releasing Devices d. Fire-Extinguish System(s) or Suppression e. Fire Alarm Boxes f. Heat Detectors h. Smoke Detectors 10. Guard 's Tour Equipment: 11. Interface Equipment: 12. Alarm Notification Appliances - Supervised: 13. Supervising Station Fire Alarm Systems -Transmitters Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 23 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ASU NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 (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 Continued From page 6 DACT DART . McCulloh d. RAT 14. Special Procedures: 15. Supervising Station Fire Alarm Systems - Receivers b. DARR* c. McCulloh Systems* d. Two-Way RF Multiplex* e. RASSR* f. RARS* g. Private Microwave* 7-3.2* Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic test is performed at least weekly by remotely monitored fire alarm control unit specifically listed for application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 Testing Frequencies Component for Semiannually: 5. Batteries - Central Station Facilities a. Lead-Acid Type 1. Specific Gravity 6. Batteries - Fire Alarm Systems a. Lead-Acid Type 2. Discharge Test (30 minutes) 3. Load Voltage Test 4. Specific Gravity b. Nickel-Cadmium Type 3. Load Voltage Test d. Sealed Lead-Acid Type 3. Load Voltage Test 7. Batteries - Public Fire Alarm Reporting Systems Voltage test in accordance with Table 7-2.2, 7(a)- (f) Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 DEFICIENCY) If continuation sheet 7 of 23 PRINTED: 07/14/2025 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 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 7 a. Lead-Acid Type 4. Specific Gravity 15. Initiating Devices g. Radiant Energy Fire Detectors k. Waterflow Devices i. Valve Tamper Switches 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on May 20, 2025, The facility failed to ensure the storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 11:45 A.M., showed several storage lockers with excess storage; walkway paths impeded by storage in the locker room. Several of the areas (lockers) have floor to ceiling storage of combustibles. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We have already started on this issue and waiting ona roll-off dumpster." 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 If continuation sheet 8 of 23 PRINTED: 07/14/2025 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 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 8 Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on May 20, 2025 the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation on May 20, 2025 from 10:14 A.M. to 12:57 P.M., showed several sprinkler heads with foreign material and/or paint on them in the follow rooms and locations: Room 204 has two (2) covered with tape, Room 205 has two (2) covered with tape, Room 207 has six (6), Room 208 has one (1), Room 210 has two (2), Room 211 has two (2), Room 212 has two (2), Room 213 has five (5), Room 301 has one (1), Room 302 has two (2), Room 303 has six (6), Room 307 has four (4), Room 304 has three (3), Room 306 has two (2), One (1) outside the door to the internal Area of Rescue, Room 308 has one (1), Room 309 has five (5), Room 310 has one (1), Room 311 has one (1), Room 313 has one (1), Room 315 has one (1), Room 319 has two (2), Room 320 has eight (8), and Room 321 has two (2). Observation on May 20, 2025 at 10:42 A.M., showed a sprinkler head outside of room 204 with a open space between the escutcheon ring and Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 If continuation sheet 9 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 the ceiling. Observation on May 20, 2025 at 11:01 A.M., showed boxes stored within eighteen (18") of a sprinkler head in the kitchen storage area. Observation on May 20, 2025 at11:51 A.M., showed boxes stored within eighteen (18") of a sprinkler head in an office area. Observation on May 20, 2025 at 12:28 P.M., showed a sprinkler head in room 316 with a open space between the escutcheon ring and the ceiling. Observation on May 20, 2025 at 12:31 P.M., showed a sprinkler head in room 317 with a open space between the escutcheon ring and the ceiling. Observation on May 20, 2025 at 12:42 P.M., showed a sprinkler head outside of room 320 with a open space between the escutcheon ring and the ceiling. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"| didn't know because it wasn't in the last year's Statement of Deficiencies. But will be working to get the issues fixed." Record review of the Nation Fire Protection Association (NFPA) 25, 1992 Edition: 2-2.1.1* Sprinklers shall be visually inspected from floor level annually. Sprinklers shall be free of corrosion, obstructions of spray patterns, foreign materials, paint, and physical damage. Any automatic sprinklers shall be replaced that are painted, corroded, damaged, or loaded with foreign materials. Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 10 of 23 PRINTED: 07/14/2025 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 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 10 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 discharge in a horizontal plane more than eighteen (18") (457mm) below the sprinkler deflector in a manner to limit the 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 shall 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)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. II This regulation is not met as evidenced by: Class II Based on observation and interview on May 20, Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 If continuation sheet 11 of 23 PRINTED: 07/14/2025 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 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 11 2025, the facility failed to ensure if battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 12:27 P.M., showed an emergency light that would not illuminate when pressing the test button near the 3rd floor interior stair case door. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We will get it fixed." 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 May 20, 2025, the facility failed to ensure all the wastebaskets were only metal or UL- or FM-fire-resistant rated wastebaskets. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observations on May 20, 2025 from 10:14 A.M. to 12:57 P.M., found the following rooms with unapproved wastebaskets; Room 203 has two (2), Room 208 has two (2), Room 209 has two (2), Room 210 has one (1), Hair Salon has two (2), Room 306 has one (1), Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 If continuation sheet 12 of 23 PRINTED: 07/14/2025 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 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 12 Room 310 has two (2), Room 311 has one (1), Room 313 has two (2), Room 315 has one (1), Room 321 has one (1), Room 108 has one (1), Room 105 has two (2), Room 103 has one (1), Room 102 has three (3), Room 224 has six (6), and Room 220 has three (3). During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We just order a bunch of approved trash cans and can't explain how, but family bring the others in. We will make a contract for the residents to sign. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class Ill Based on observation and interview on May 20, 2025, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 10:49 A.M., showed an oxygen cylinder setting next to a TV that was not ina holding device in room 110. Observation at 11:05 A.M., showed thirteen (13) oxygen cylinders in room 207. These oxygen cylinders are not stored properly and exceed the Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 If continuation sheet 13 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 amount/number of cylinders allowed outside of a proper oxygen storage area. Observation at 11:13 A.M., showed five (5) medium and one (1) large oxygen cylinders stored in the closet of room 209. These oxygen cylinders are not stored properly and exceed the amount/number of cylinders allowed outside of a proper oxygen storage area. Observation at 11:39 A.M., showed three (3) oxygen cylinders not in a holding device in room 302. These oxygen cylinders are not stored properly and exceed the amount/number of cylinders allowed outside of a proper oxygen storage area. Observation at 11:42 A.M., showed seven (7) oxygen cylinders not stored properly in the storage locker room. These oxygen cylinders are not stored properly and exceed the amount/number of cylinders allowed outside of a proper oxygen storage area. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"! will go to the nurse and have a discussion with the resident regarding the amount of spare oxygen cylinders that can be in each resident's room and the proper storage and requirements." Review of the following chapters of the 1999 National Fire Protection Association (NFPA) 99, showed: 8-3.1.11 Storage Requirements 8-3.1.11.2 Storage for non-flammable gases less than 3000 ft 3 (85 m3) (a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 14 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor. (c) Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either: 1. Aminimum distance of 20 ft (6.1 m), or 2. Aminimum distance of 5 ft (1.5m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or 3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage. 19 CSR 30-86.032(2) Substantially Constructed & A3201 Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class Ill Based on observation and interview on May 20, 2025, the facility failed to maintain the building in good repair. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 10:47 A.M., showed an approximate three inch (3") by eight inch (8") hole Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 15 of 23 PRINTED: 07/14/2025 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 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 15 in the wall of the closet, by the sprinkler head, in room 206. Observation at 10:53 A.M., showed an approximate ten inch (10") by one foot (1') hole in the wall of the closet, by the sprinkler head in room 109. Observation between 10:56 A.M. and 10:59 A.M., showed the following in the facility's commercial kitchen: an approximate eight inch (8") by two and one-half foot ( 2-1/2') hole in the wall of a storage area; a ceiling tile out of place; a strip of door trim missing to the water heater area; and open spaces around pipes in the wall by water heater. Observation at 11:28 A.M., showed an approximate two and one-half foot (2-1/2') strip of drywall tape coming lose where the ceiling and wall meet in room 212. Observation at 11:36 A.M., showed an approximate two inch (2") by four inch (4") hole in the ceiling in the hair salon. Observation at 11:39 A.M., showed an approximate two and one-half foot (2-1/2') strip of drywall tape coming lose of the ceiling of room 302. Observation at 11:40 A.M., showed three (3) tiles with cut outs for wires and pipes to run through the ceiling in the first floor janitor's room. Observation at 11:49 A.M., showed an approximate two and one-half foot (2-1/2') strip of drywall tape coming lose from the ceiling and an approximate eighteen inch (18") by three inch (3") area where the drywall popcorn ceiling came Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 If continuation sheet 16 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 16 down in an office. Observation at 12:24 P.M., showed several holes and penetrations in the maintenance room on the 3rd floor. Observation at 12:27 P.M., showed a horizontal crack in the wall at the seam were the drywall meets, outside of interior stairway on the 3rd floor near the door. Observation at 12:27 P.M., showed a broken ceiling tile in the near the fire place atrium. Observation at 12:06 P.M., showed a smoke detector not mounted flush against the ceiling in room 221. Observation at 12:21 P.M., showed a smoke detector not attached to the ceiling and hanging from it wires in room 216. Observation at 12:26 P.M., showed a smoke detector not attached all the way to the ceiling in room 214. Observation at 12:27 P.M., showed a smoke detector not mounted flush against the ceiling in the hallway near the mail boxes. Observation at 12:27 P.M., showed a smoke detector not mounted flush against the ceiling in hallway by the fire place atrium on the second floor. Observation at 12:28 P.M., showed a smoke detector not mounted flush against the ceiling in the hallway near room 224. Holes, cracks, missing tiles and penetrations will Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 17 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 allow smoke, fire and toxic gases to travel to the unaffected portions of the building in the event of a fire. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We will work on getting these issues fixed." 19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 18 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 Class II Based on observation and interview on May 20, 2025 the facility failed to ensure the use of portable space heaters was prohibited. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 11:07 A.M., showed a portable electric heater sitting in the closet of Room 207. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We will take care of it." 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 Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 19 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 19 electrician. II/III This regulation is not met as evidenced by: Class II* Based on observations and an interview on May 20, 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 forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observations on May 20, 2025 at 10:52 A.M., showed a unsecured light switch located in a double receptacle box with electrical wire protruding from the junction box, without a cover plate in room 109. Testing with circuit tester/ hot stick indicated the light switch and wires were energized. Observations on May 20, 2025 at 10:53 A.M., showed the furnace power wire not secured to the furnace cabinet in room 109. At the time of discovery, the maintenance director stated, "every room is like this." Observations on May 20, 2025 at 10:55 A.M, showed a three (3) light switch junction box and outlet without cover plates, in room 108. Observations on May 20, 2025 at 10:57 A.M., showed a water heater with the power wires exposed from the junction panel, in the main kitchen. Observations on May 20, 2025 at 11:43 A.M., showed a lose outlet and junction box in the front wall of room 303. Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 20 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"The maintenance director is working on a list." *The higher classification merited due to the impact when combined with other deficiencies. 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 damage. II/Ill This regulation is not met as evidenced by: Class Ill Based on observation and interview on May 20, 2025, the facility failed prevent the improper use of power strips, extension cords and the use of multi-plug adapters. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observations on May 20, 2025 from 10:14 A.M. to 12:57 P.M., found the following rooms with improper use of power strips, unapproved extension cords, multi-plug adapters, and appliances not approved to be plugged into power strips: Room 107 has a two (2), three (3) way adapters and a oxygen concentrator plugged into Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 21 of 23 PRINTED: 07/14/2025 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 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 21 a power strip. Room 207 has two (2) extension cords and one (1), three (3) way adapter. Room 105 has a unapproved three (3) plug extension cord daisy-chained into a power strip. Room 101 has a three (3) way adapter with three (3) appliances plugged into it, an extension cord with an appliance plugged into it, and a six (6) way adapter. Room 310 has a three (3) way adapter and an unapproved extension cord. Room 218 has three (3), three (3) way adapters. Room 313 has one (1), three (3) way adapter. Room 325 has one (1), three (3) way adapter. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We will get them removed and make a contract for the residents to sign." 19 CSR 30-86.032(19) Elevator Requirements lf elevators are used, installation and maintenance shall comply with local and state codes and the National Electric Code. II/Ill This regulation is not met as evidenced by: Class III Based on observation, record review, and interview on May 20, 2025, the facility failed to have a current approved elevator inspection certification under Missouri State Regulation, 11 CSR 40-5.065. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 11:34 A.M., showed one record located in the elevator dated as expired on December 10, 2023. Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 If continuation sheet 22 of 23 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 22 Record review at 12:57 P.M., showed no current state elevator certificate documentation. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"It has been inspected and have been trying to address it, but it started before | was hired in 2024." 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. I/II This regulation is not met as evidenced by: Class III. Based on observation and interview on May 20, 2025, facility fails to keep rooms neat and orderly. The facility census was forty-seven (47). This affected forty-seven (47) of forty-seven (47) residents. Observation at 12:18 P.M., Show excessive clutter in resident room 314. This includes clothes, blankets, boxes and trash around the resident's room. Some of the exit pathways are approximately fifteen inches (15") , or less in width. The amount of clutter in this room would impede the resident's ability to exit in a timely manner during an emergency and creates an excessive fire load in the room. During an interview on May 20, 2025 at 2:22 P.M., the Executive director said,"We will address it with the resident." Missouri Department of Health and Senior Services STATE FORM 6899 VYZ311 PRINTED: 07/14/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 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 23 of 23 AMENDED PLAN OF CORRECTION Provider Name: Trustwell Living of Raytown Street Address, City, Zip: 9110 E. 63° St. Raytown, MO 64133 Date of Survey: Provider number: ID PREFIX TAG May 20, 2025 24227 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility’s credible allegation of compliance. A2202 1} The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Excess lint and socks were removed from the back of the dryers and pipe in the laundry room. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. A lint removal/visual check log has been added to the preventative maintenance binder. 3) Measures put into place to ensure that the deficient practice does not recur includes: Executive Director educated nursing staff and Maintenance Director on eliminating fire hazards due to lint build up in the laundry room. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit dryer usage weekly x4 weeks, and then bi-weekly for x2 months. The results of the audits will be presented to the leadership team during the monthly Quality improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A2214 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Executive Director scheduled a full evacuation drill - consultation with the Raytown Fire Department for July 2025. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Education provided to Maintenance Director and preventative maintenance binder updated to include drill logs. 3) Measures put into place to ensure that the deficient practice does not recur includes: Maintenance Director educated on annual requirement of a fire drill consultation with participation from the fire department. Documentation for all drills will be kept in the preventative maintenance binder. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will routinely schedule a fire drill evacuation consultation with the local fire department annually. Feedback from monthly fire drills will be presented to the leadership team during the monthiy Quality improvement meeting and brought to the fire department for review during consultations. The corrective actions will be completed on or before: 09-03-2025 A2217 1} The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Fire drills for the remainder of the year have been prescheduled so that each shift participates in a drill once per quarter. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Education provided to Maintenance Director and preventative maintenance binder updated to include detailed logs about fire drills. 3) Measures put into place to ensure that the deficient practice does not recur includes: Documentation for all drills will be kept in the preventative maintenance binder. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will routinely schedule a fire drill once per month; ensuring that each shift participates once per quarter. Feedback from monthly fire drills will be presented to the leadership team during the monthly Quality improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A2238 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Maintenance Director ordered 2 new emergency lights for the exit near the therapy room and the sprinkler room the week of June 9" 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Education provided to Maintenance Director and preventative maintenance binder updated fo include emergency light testing. 3) Measures put into place to ensure that the deficient practice does not recur includes: Executive Director educated Maintenance Director on illumination requirements. Maintenance Director will routinely test and visually inspect emergency exit lights for proper iltumination and maintain documentation of results in the preventative maintenance binder. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will test & inspect emergency exit lights 1x per month for 3 months and ongoing. Results will be presented to the leadership team during the monthly Quality improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A2249 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: -Base of smoke defector was replaced in the laundry room. -Apartment 311 had a new smoke detector installed. -Fire alarm inspection was completed 01-20-2025. The semi- annual inspection will be completed in quarter 3 (July-Sept). 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Education provided to Maintenance Director and preventative maintenance binder updated to include inspection of smoke detectors and fire alarm inspection results. 3) Measures put into place to ensure that the deficient practice does not recur includes: Maintenance Director will routinely test and visually inspect smoke detectors throughout the facility and maintain documentation of results in the preventative maintenance binder. Maintenance Director will coordinate semi-annual fire inspections with the fire vendor and maintain documentation of results in the preventative maintenance binder. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit smoke detectors 2x per month for 3 months then 1x per month ongoing. Maintenance Director/designee will also preschedule the semi- annual fire alarm inspection following the initial inspection each year. Results will be presented to the leadership team during the monthly Quality Improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A2269 1} The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: -Executive Director scheduled replacement of 63 sprinkler heads with 360 Fire Protection on 06/12/2025. -Top shelf storage in the kitchen and business office was removed. -Gaps in between sprinkler heads outside of 204 and 320 and inside 316 and 317 were filled with caulking. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Preventative maintenance binder was updated to include visual checks on sprinkler heads throughout the facility. 3) Measures put into place to ensure that the deficient practice does not recur includes: Maintenance Director/designee will routinely inspect sprinkler heads for proper installation and build up and ensure no objects are stored within 18” from the ceiling. Maintenance Director/designee will coordinate with construction vendors to ensure sprinkler heads are not sprayed, covered or painted on during renovations. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit sprinkler heads 1x per month for 3 months then 1x quarterly. Results will be presented to the leadership team during the monthly Quality improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A2257 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: A durable medical equipment vendor was called to properly dispose of the unused oxygen tanks in the locker area. Additional storage and unused items were removed from the locker area. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Preventative maintenance binder updated to include an indoor physical plant walkthrough. 3) Measures put into place to ensure that the deficient practice does not recur includes: All staff educated not to store oxygen tanks in any area that is not labeled as oxygen storage. Residents will continue to store no more than two tanks inside their apartment. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit apartments that is equal to 10% of the total occupied census, 2x for one month and 1x per month for 2 months then quarterly ongoing. Results will be presented to the leadership team during the monthly Quality Improvement meeting. The corrective actions will be completed on or before: A2278 09-03-2025 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: The bracket holding the emergency light near the stairway on the 3" floor was adjusted to allow the test button to work properly. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Preventative maintenance binder was updated to include an emergency lighting log. 3) Measures put into place to ensure that the deficient practice does not recur includes: Executive Director educated Maintenance Director on illumination requirements. Maintenance Director will routinely test and visually inspect emergency exit lights for proper illumination and maintain documentation of results in the preventative maintenance binder 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will test & inspect emergency exit lights 1x per month for 3 months and ongoing. Results will be presented to the leadership team during the monthly Quality improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A2286 1} The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Non-fire rated wastebaskets in the following areas were removed: 203, 208, 209, 210, 306, 310, 311, 315, 321, 108, 105, 103, 102, 224, 220 and the beauty salon. Approximately 200 fire rated wastebaskets were distributed to all areas in quarter 1 of 2025. Families were notified that they may not replace our fire rated wastebaskets with plastic bins. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff, and visitors have the potential to be affected by the alleged practice. Families signed an addendum of prohibited items; including but not limited to wastebaskets. 3) Measures put into place to ensure that the deficient practice does not recur includes: Executive Director to educate families on prohibited items during admission. Staff will log in the work order book when non-fire-rated wastebaskets are in use. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit apartments that is equal to 10% of the total occupied census, 2x for one month and 1x per month for 2 months then quarterly ongoing. Results will be presented to the leadership team during the monthly Quality Improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A2298 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: A durable medical equipment vendor was called to remove the additional oxygen tanks from the lockers and apartments 110, 207, 209, and 302. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff, and visitors have the potential to be affected by the alleged practice. Families signed an addendum of prohibited items; including but not limited to oxygen storage. 3) Measures put into place to ensure that the deficient practice does not recur includes: All staff were educated on the proper oxygen storage inside apartments. Staff will log in the work order book when oxygen storage inside the apartments exceeds two tanks and is without racks. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit apartments that is equal to 10% of the total occupied census, 2x for one month and 1x per month for 2 months then quarterly ongoing. Results will be presented to the leadership team during the monthly Quality Improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A3201 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: -Holes in the wall, ceiling and near sprinkler heads in the kitchen storage, in closets of 206 and 109, beauty salon, office and door trim of water heater closet were covered with sheet rock and painted. -Missing ceiling tile in the kitchen, janitor’s closet and near the fireplace on 2"¢ floor were replaced with new tile. -Open spaces around the pipes of the water heater were filled in with fire foam. -New drywall tape was put on cracks in 212, 302, bistro, and near stairway on 3° floor. -Smoke detector mounting screws were tightened near 221, 216, 214, 224, near the fireplace and mailboxes. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Preventative maintenance binder was updated to include a visual check of floors, walls, and ceiling hysical plant walkthrough). 3) Measures put into place to ensure that the deficient practice does not recur includes: Executive Director implemented a physical plant walkthrough to observe and resolve findings. Staff will log repairs in the maintenance work order book. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance director/designee will visually inspect the physical plant (indoors) for holes and cracks in the floors, walls, and ceiling 1x weekly for 3 months and ongoing. Results will be presented to the leadership team during the monthly Quality improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A3211 1} The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: The electric heater inside the closet of apartment 207 was removed. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff, and visitors have the potential to be affected by the alleged practice. Families signed an addendum of prohibited items; including but not limited to electric heaters. 3) Measures put into place to ensure that the deficient practice does not recur includes: Staff will report to Maintenance Director/Executive Director for immediate removal or log in the work order book when extension cords/power cords are not properly used. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit apartments that is equal to 10% of the total occupied census, 2x for one month and 1x per month for 2 months then quarterly ongoing. Results will be presented to the leadership team during the monthly Quality Improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A3219 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Unapproved extension cords/power cords in apartments 207, 107, 105, 101, 310, 218, 313, and 325 were removed. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff, and visitors have the potential to be affected by the alleged practice. Families signed an addendum of prohibited items; including but not limited to extension cords. 3) Measures put into place to ensure that the deficient practice does not recur includes: Staff will report to Maintenance Director/Executive Director for immediate removal or log in the work order book when extension cords/power cords are not properly used. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit apartments that is equal to 10% of the total occupied census, 2x for one month and 1x per month for 2 months then quarterly ongoing. Results will be presented to the leadership team during the monthly Quality Improvement meeting. The corrective actions will be completed on or before: 09-03-2025 A3320 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Re-inspection of the December 2024 inspection was delayed by ESSI. ESSI came out on 06-02-2025 and approved corrections for certification. Pending receipt of certificate. 2) The corrective actions for other resident(s} having potential to be affected by the same deficient practice includes: No residents have the potential to be affected by this alleged practice due to immediate correction, delayed certification and no defect with the cabin itself. 3) Measures put into place to ensure that the deficient practice does not recur includes: Business Office Manager/designee will keep a log of elevator certificate expiration dates and coordinate inspections accordingly. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the foliowing: Executive Director will review certificate/license expiration log 1x per month for three months then monthly ongoing during the Quality Improvement Meeting. 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: A3224 At the time of inspection, the Executive Director informed the resident occupying #314 that must begin cleaning apartment with an emphasis on removing unnecessary combustibles to prevent hazardous injury to __ self and staff. Resident also received this notice in writing. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff and visitors have the potential to be affected by the alleged practice. Pathway to Safety & Neat and Orderly rooms was discussed with all residents during resident council. Education provided to all staff regarding pathway to safety inside apartments. 3) Measures put into place to ensure that the deficient practice does not recur includes: Staff will report to Maintenance Director/Executive Director or log in the work order book when furniture, boxes, shelving, etc. has become an obstruction that may impede a resident's path to safety in an emergency. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance Director/designee will visually audit apartments that is equal to 10% of the total occupied census, 2x for one month and 1x per month for 2 months then quarterly ongoing. Results will be presented to the leadership team during the monthly Quality Improvement meeting. |__| The corrective actions will be completed on or before: | _09-03-2025 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: Lose outlet in 303 was tightened so that it is fixed to the wall. Cover plates in 109 and 108 unoccupied apartments were AS214 replaced and wires pushed into junction boxes Furnace power wire has been secured to furnace cabinet in 109. Power wires are no longer exposed from the junction panel on water heater in kitchen. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents, staff, and visitors have the potential to be affected by the alleged practice. All light switches have cover plates and wires are contained within junction boxes. Loose outlet plates were tightened. 3) Measures put into place to ensure that the deficient practice does not recur includes: Maintenance Director/Executive Director in-serviced all staff to log loose outlet covers and exposed wiring in the work order book to be addressed immediately. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Maintenance director/designee will visually inspect the physical plant (indoors) for loose outlet plates and exposed wiring 2x for two months then 1x monthly ongoing. Results will be presented to the leadership team during the monthly Quality Improvement meeting The corrective actions will be completed on or before: 09-03-2025 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: 12/19/2024 FORM APPROVED tment of Health and Senior Services (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: Missouri Depa STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A. BUILDING: B, WING 24227 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE $110 EAST 63RD STREET RAYTOWN, MO 64133 TRUSTWELL LIVING OF RAYTOWN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES. (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) 1D PREFIX TAS A4776 19 CSR 30-86.047(35) Protective Oversight Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. W/ll This regulation is not met as evidenced by: CLASS II Based on observation, interview and record review, the facility failed to use a gait belt during a transfer for one sampled resident (Resident #2) who required the use of a gait belt with staff assitance. On 12/4/24 Certified Medication Technician (CMT) A failed to use a gait belt while transferring the resident from wheelchair to the bed out of three sampled residents. The facility's census was 39 residents. Review on 12/4/24 Transfer/Gait Belt Policy was requested by facility staff and was not received. 1. Raview of Resident #2's undated face sheet showed he/she was admitted 9/3/13 with the following diagnosis: -Type 2 Diabetes (a chronic disease where the body either doesn't produce enough insulin or doesn't use insulin effectively, causing blood sugar levels to become too high because glucose can't enter calls properly to be used for energy). -Hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher). Review of the resident's Service Plan dated 12/4/24 showed: -The resident required physical assistance of two Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PRINTED: 12/19/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING: B. WING 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN (X4) ID PREFIX | TAG A4776 RAYTOWN, MO 64133 | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 person with transfer, and frequent rest periods. -Staff provided physical assistance with transfers as needed. -The resident used a walker. Observation on 12/4/24 at 10:01 A.M. of the resident showed: -CMT A transferred the resident by him/her self when he/she wrapped his/her arms around the resident and pulled the resident up out the wheelchair and placed the resident in his/her bed. | -CMT Adid not use a gait belt during the transfer. During an interview on 12/4/24 at 9:46 A.M. the resident said: | -He/she needed help all the time. -He/she was not able to get up on his/her own. During an interview on 12/4/24 at 10:21 A.M. CMT A said: -He/she was aware the resident could not bear weight. -He/she was suppose to use the gait belt for the resident. -He/she did not use the gait belt. -The expectation was to use a gait belt for any residents that needed it. | -He/she was trained on how and when to use a | gait belt. | During an interview on 12/4/24 at 10:46 A.M. the | Health Services Director said: | -He/she was not aware that staff had transferred the resident without a gait belt. -His/her expectation was staff to use the gait belts | when residents needed hands on transfer | assistance. | -All staff have the knowledge of what and how to | use a gait belt. Missouri Department of Health and Senior Services STATE FORM oe MZJ811 COMPLETED Cc 12/04/2024 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 3 PRINTED: 12/19/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B. WING 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5) (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) TRUSTWELL LIVING OF RAYTOWN 44776 Continued From page 2 During an interview on 12/16/24 at 1:10 P.M. Family Member B said: -The resident was not able to bear weight. -The resident needed staff during the resident transfers. -The staff have not used a gait belt for transfer of the resident when he/she has been at the facility. MO00246063 Missouri Department of Health and Senior Services. STATE FORM 6899 MZJ811 Hf continuation sheet 3 of 3 PLAN OF CORRECTION Trustwell Living of Raytown Street Address, City, Zip: December 4, 2024 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 9110 E. 63 St. Raytown, MO 64133 3) Measures put into place to ensure that the deficient practice does not recur includes: Health Service Director and Physical Therapist provided re- education to nursing staff regarding transfer safety and proper use of gait belts. A chart audit was conducted to review care plans of all residents needing transfer assistance to ensure it is documented for nursing staff to reference when providing ADL cares. 1) The corrective actions accomplished for the resident(s) found to have been affected by the deficient practice includes: The resident's care plan was updated to reflect the use of gait belts during transfers and requiring the assistance of two people when he/she cannot bear weight. 2) The corrective actions for other resident(s) having potential to be affected by the same deficient practice includes: All residents have the potential to be affected by the alleged practice. A transfer assessment was conducted for all residents and their care plans were updated as necessary. 4) The facility will monitor its performance to make sure the solutions are sustained by conducting the following: Health Service Director/designee will visually audit transfers 3x weekly x4 weeks. The results of the audits will be presented to the leadership team during the monthly Quality Assurance meeting. The corrective actions will be completed on or before: 01/13/2025 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.

NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM). 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 TRUSTWELL LIVING OF RAYTOWN (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 06/06/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 05/20/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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 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. I/II This regulation is not met as evidenced by: Class III Based on record review and an interview on 5/20/24 this facility failed to provide documentation a request had been made for consultation and assistance annually from a local fire unit. The facility census was 51. This potentially affected 51 of 51 residents. Record review on 5/20/24 at 3:44 P.M. showed no documentation asking for and/or receiving consultation and assistance annually from a local fire unit. During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she would have to talk to the administrator to see if it had been done. 19 CSR 30-86.022(5)(B)(1 - 10) Fire Drill/Evacuation Plan Requirements Fire Drills and Emergency Preparedness. (B) The plan shall include, but is not limited to, Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 B6UG11 If continuation sheet 1 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 1 the following: 1. Aphased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to total building evacuation. This phased response part of the plan shall be consistent with the direction of the local fire unit or state fire marshal and appropriate for the fire or emergency; 2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and a floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge; 3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building; 4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks; 5. Procedures for the safety and comfort of residents evacuated; 6. Staffing assignments; 7. Instructions for staff to call the fire department or other outside emergency services; 8. Instructions for staff to call alternative resource(s) for housing residents, if necessary; 9. Administrative staff responsibilities; and 10. Designation of a staff member to be responsible for accounting for all residents ' whereabouts. II/III This regulation is not met as evidenced by: Class III Based on record review and an interview on 5/20/24 this facility failed have written policies and procedures in place for emergencies or disasters. The facility census was 51. This potentially affected 51 of 51 residents. Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 2 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Record review on 5/20/24 at 3:44 P.M. showed only generic plans for the prior facility owner Bickford Senior Living. During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she would have to talk to the administrator to see if it had been done for their facility. 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. IlI/Ill This regulation is not met as evidenced by: Class II* Based on record review and an interview on 5/20/24 this facility failed to produce documentation of at least 12 fire drills being conducted within the last year, the facility further failed to produce documentation of at least one fire drills being conducted on each shift every three months within the last year. The facility census was 51. This potentially affected 51 of 51 residents. Record review on 5/20/24 at 3:44 P.M. showed only the following fire drills being conducted and recorded within the last 12 months: Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 1. June 29th, 2023. 1st shift 2. August 29, 2023 1st shift 3. August 30, 2023 1st shift 4. April 2, 2024 1st shift During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she had only been there a little less than two months and would have to talk to the administrator to see if there are any more records available. * The higher classification deficiency was selected due to the appearance of a major breakdown in the rules requirements. 19 CSR 30-86.022(5)(F) Fire Alarm Activation Requirements Fire Drills and Emergency Preparedness. (F) The fire alarm shall be activated during all fire drills unless the drill is conducted between 9 p.m. and 6 a.m., when a facility-generated predetermined message is acceptable in lieu of the audible and visual components of the fire alarm. II/Ill This regulation is not met as evidenced by: Class III Based on record review and an interview on 5/20/24 this facility failed to produce documentation of the fire alarm being activated during some of their fire drills that occurred outside the hours of 9 P.M. and6 A.M. The Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 4 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 facility census was 51. This potentially affected 51 of 51 residents. Record review on 5/20/24 at 3:44 P.M. showed no documentation the fire alarm was set off on the August 30, 2023 fire drill record. During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she had only been there a little less than two months and would have to talk to the administrator to see if there are any more records available. 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 of fire drill evaluations. II/IlI This regulation is not met as evidenced by: Class III Based on record review and an interview on 5/20/24 this facility failed to produce documentation or records of fire safety training as outlined in 19 CSR 30-86. 022 (6) (B). The facility census was 51. This potentially affected 51 of 51 residents. Record review on 5/20/24 at 3:44 P.M. showed no documentation of any fire safety and emergency preparedness training for the staff. This is necessary to ensure the staff is aware of and how to respond during any potential fire Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 emergencies. During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she had only been there a little less than two months and would have to talk to the administrator to see if there are any more records available. 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. Atwo- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing of the exit stairway, attendants ' work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states AREA OF REFUGE IN CASE OF FIRE" and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable; " Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 6. Asign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge; 7. Emergency lighting for the area of refuge; and 8. The total area of the areas of refuge on a floor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II This regulation is not met as evidenced by: Class II Based on observations, record review,and an interview on 5/20/24 this facility is housing residents on floors that do not have accessible exits at grade and failed to have areas of refuge that meet all the requirements of 19 CSR 30-86.022 (7) (D) sections 1-8. The facility census was 51. This potentially affected 51 of 51 residents. Observations during the 5/20/24 walk through of the fire safety portion of the licensure inspection showed ' 1. No signage at the entrance of some of these areas indicating "Area of Refuge in Case of Fire" with the international symbol of accessibility. 2. No signage at the bottom of the exit stairways identifying and showing the location of each area of refuge. 3. No instructions on the use of the area of refuge and identification of the actual location of each area of refuge by the intercoms. 4. No Map(s) and location identifiers at the main communication panel on the first-floor entry way for the areas of refuge. 5. No written procedures on how to respond to the area of refuge or usage of the intercom system. Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 6. No audible signal at the main communication panel on the first-floor entry way. During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she would have to talk to the administrator to see if there is a written procedure available and see about getting everything identified and working correctly. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II This regulation is not met as evidenced by: Class Il Based on record review and an interview on 5/20/24 this facility failed to produce documentation of the fire alarm being activated at least once a month over the last 12 months. The facility census was 51. This potentially affected 51 of 51 residents. Record review on 5/20/24 at 3:44 P.M. showed documentation the fire alarm system was only activated in June of 2023, Sept of 2023, and April of 2024 with the fire drills. During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she had only been there a little less than two months and would have to talk to the administrator to see if there are any more records available. 19 CSR 30-86.022(10)(H) Smoke Sections Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 8 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 Protection from Hazards. (H) All facilities shall be divided into at least two (2) smoke sections with each section not exceeding one hundred fifty feet (150') in length or width. If the floor 's dimensions do not exceed seventy-five feet (75') in length or width, a division of the floor into two (2) smoke sections will not be required. Il This regulation is not met as evidenced by: Class II Based on observation and an interview on 5/20/24 this facility failed to ensure the smoke sections were divided on every level. The facility census was 51. This potentially affected 51 of 51 residents. Observation on 5/20/24 at 11:51 A.M. showed the smoke doors were both blocked open on the first floor that separates and protects the stairwell to and from the second floor. Observation on 5/20/24 at 12:04 P.M. showed the one hour rated smoke separation door by Room 112 was totally missing the latch from the frame. Observation on 5/20/24 at 1:32 P.M. showed the one hour rated smoke separation door by Room 305 would not fully close and latch as it was designed. During an interview on 5/20/24 at 11:51 A.M. the maintenance director stated he/she would be sure these doors were kept closed and put-up signage indicating they must be kept closed as well. Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 9 of 17 PRINTED: 06/06/2024 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 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 9 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, an interview and record review on 5/20/24 this facility failed to ensure the monthly pressure gage readings and valve position checks of the sprinkler system was done and recorded as required in accordance with NFPA 13, 1999 edition. The facility census was 51. This potentially affected 51 of 51 residents. Observation on 5/20/24 at 12:11 P.M. showed no monthly sprinkler valve and pressure gage checks recording sheet hanging in the sprinkler room. Record review on 5/20/24 at 3:44 P.M. showed no documentation of monthly sprinkler valve and pressure gage checks being done. During an interview on 5/20/24 at 12:11 P.M. the maintenance director stated he/she would be sure to start checking and recording this information monthly. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 If continuation sheet 10 of 17 PRINTED: 06/06/2024 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 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 10 Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on observation and an interview on 5/20/24 this facility failed to maintain the sprinkler system in accordance with the applicable edition of NFPA 13R. The facility census was 51. This potentially affected 51 of 51 residents. Observation on 5/20/24 at 1:29 P.M. showed outside Room 304 an eschusheon ring hanging on the edge of the sprinkler deflector. During an interview on 5/20/24 at 1:29 P.M the maintenance director stated he/she would get it put back in place. 19 CSR 30-86.022(12)(A) Emergency Lighting - locations Emergency Lighting. (A) Emergency lighting of sufficient intensity shall be provided for exits, stairs, resident corridors, and required attendants ' station. II This regulation is not met as evidenced by: Class II Based on observations and an interview on 5/20/24 this facility failed to maintain all the emergency lights in good repair. The facility census was 51. This potentially affected 51 of 51 Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 If continuation sheet 11 of 17 PRINTED: 06/06/2024 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 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 11 residents. Observations during the 5/20/24 walk through of the fire safety portion of the licensure inspection showed the following emergency lights not working; on the third floor outside the stairs (tabs broke off), outside Room 214, the second floors back hall way, outside Room 311, outside Room 305, and outside Room 318. Many others were observed to have very weak light output when tested. During an interview on 5/20/24 the maintenance director stated he/she would find the dedicated circuit breaker for the emergency lights to confirm which ones were not working or staying lit for the 90 minutes they are required to work and replace or repair them as needed. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. || This regulation is not met as evidenced by: Class II Based on observations and an interview on 5/20/24 this facility failed to provide documentation some residents curtains were either certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. The facility census was 51. This potentially affected 51 of 51 residents. Observations during the 5/20/24 walk through of Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 If continuation sheet 12 of 17 PRINTED: 06/06/2024 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 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 12 the fire safety portion of the licensure inspection showed the following rooms with curtains that showed no labeling to indicate they were flame retardant material; in Room 201 and in Room 303. During an interview on 5/20/24 the maintenance director stated he/she would see about getting the curtains treated with a flame retardant or have them removed. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FI-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 5/20/24 the facility failed to ensure all the wastebaskets were the approved types allowed. The facility census was 51. This potentially affected 51 of 51 residents. Observations on 5/20/24 during the fire safety inspection walkthrough found the following rooms with improper wastebaskets; Room 111 had two, Room 110 had one, Room 109 had one, Room 106 had one, Room 103 had one, Room 101 had three, Room 225 had one, Room 223 had two, Room 220 had two, Room 218 had two, Room 217 had one, Room 214 had four, Room 213 had two, Room 204 had one, Room 303 had one, Room 327 had one, Room 325 had one, Room 324 had one, Room 319 had one, Room 317 had one and Room 326 had one. Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 If continuation sheet 13 of 17 PRINTED: 06/06/2024 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 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 13 During an interview on 5/20/24 the maintenance director stated he/she would get with the administrator and see about getting the proper ones. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III Based on observation and an interview on 5/20/24 this facility failed to provide a proper oxygen storage room and limit oxygen storage within a resident’ s room in accordance with NFPA 99, 1999 Edition. The facility census was 51. This potentially affected 51 of 51 residents. Observation on 5/20/24 at 12:46 P.M. showed 3 spare bottles and one with the regulator attached free standing in Room 102. During an interview on 5/20/24 at 12:46 P.M. the maintenance director stated this resident had just moved out, but he/she would get the oxygen properly racked, see about establishing an oxygen storage room and be sure in the future residents are only limited to one bottle in use and one spare. 19 CSR 30-86.032(10) Heaters-Approved Label, A3211 Venting, No Portable Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 If continuation sheet 14 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 In newly licensed facilities or if a new heating system is installed in an existing licensed facility, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foregoing requirements are applicable to residential care facilities. In assisted living facilities, the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outside wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. For all facilities, oil or gas heating appliances shall be properly vented to the outside and the use of portable heaters of any kind is prohibited. If approved wall heaters are used, adequate guards shall be provided to safeguard residents. I/II This regulation is not met as evidenced by: Class II Based on observation and an interview on 5/20/24 this facility failed to ensure the use of portable space heaters was prohibited. The facility census was 51. This potentially affected 51 of 51 residents. Observation on 5/20/24 at 1:37 P.M. showed a portable electric heater setting on the floor in the extra bedroom in Room 218. Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 15 of 17 PRINTED: 06/06/2024 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 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 (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) TRUSTWELL LIVING OF RAYTOWN Continued From page 15 During an interview on 5/20/24 at 1:37 P.M. the maintenance director stated he/she would get it removed and let the administrator know. 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 This regulation is not met as evidenced by: Class III Based on observations, record review, and an interview on 5/20/24 this facility failed to install and maintain the electrical wiring in accordance with the requirements of the National Electrical Code, 1999 edition, and to show documentation Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 If continuation sheet 16 of 17 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: 9110 EAST 63RD STREET TRUSTWELL LIVING OF RAYTOWN RAYTOWN, MO 64133 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 16 the electrical wiring had been inspected within the last two years by a qualified electrician The facility census was 51. This potentially affected 51 of 51 residents. Observations during the 5/20/24 walk through of the fire safety portion of the licensure inspection showed every furnace / air handler was in an unlocked closet within the resident's rooms and the high voltage Romex wire running to the furnace / air handlers was not enclosed in conduit or a greenfield protective covering with a wiring connector as it entered the furnace / air handler. During an interview on 5/20/24 the maintenance director stated many of the units are being replace and he/she would double check with an electrician on the wiring concern. Record review on 5/20/24 at 3:44 P.M. showed no documentation of an electrical inspection being done within the last two years. During an interview on 5/20/24 at 3:44 P.M. the maintenance director stated he/she would have to talk to the administrator to see if it had been done and if not get one scheduled. Missouri Department of Health and Senior Services STATE FORM 6899 B6UG11 PRINTED: 06/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2024 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 17 of 17

PRINTED: 01/09/2024 . . FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY A. BUILDING: COMPLETED Cc 6. WING 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRUSTWELL LIVING OF RAYTOWN $110 EAST 63RD STREET RAYTOWN, MO 64133 (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) 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: . PHeose ace atlacheol Based on interview and record review, the facility staff failed to ensure the required two step TD ; tuberculosis (TB - a communicable disease that | lan Go p Cosy vedh@n, affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for two of three sampled employees. The facility census was 50 residents. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) two (2)-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two years. A policy for TB testing was requested but not received. 1. Review of Cook A’s personnel file showed: -Date of hire 5/18/23. -The one step TB test was administered on Missouri Department of Health and Senior Services . Lab TORY DIRECTOR'S OR PI ER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6) OATE ob fash ( J Executive Direc 3-19-2009 STATE FORM 6899 PRPE11 \f continualion sheet 1 of 2 PRINTED: 01/09/2024 ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES j (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B. WING 01/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9110 EAST 63RD STREET RAYTOWN, MO 64133 {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) f TRUSTWELL LIVING OF RAYTOWN | Continued From page 1 9/6/23 and read on 9/8/23 as negative. -The second step TB test was administered on 9/26/23 and read on 9/28/23 as negative. 2. Review of Caregiver A's personnel file showed: -Date of hire 6/15/23.. -The one step TB test was administered 7/14/23 and read on 7/16/23 as negative. -The second step TB test was administered 8/10/23 and read on 8/12/23 as negative. During an interview on 1/5/24 at 1:30 P.M., the Administrator said: -A two-siep TB test must be done upon hire. -The first step must be performed and read before any staff worked in the facility. -Employees must have a TB test completed annually. -He/she was not aware the employees did not have current TB tests. -All employees should have current TB tests. -He/she was responsible for TB testing and these should have been completed. Missouri Department of Health and Senior Services STATE FORM 6e99 PRPE11 If continuation sheet 2 of 2 PLAN OF CORRECTION Provider Name: Trustwell Living of Raytown Street Address: 9110 E. 63” Street Raytown, MO 64133 Date of Survey: 1/5/2024 Provider number: 24227 ID Prefix TAG Provider’s Plan of Correction A4724 At time of pre-employment offer of employment each prospective employee will be screened and tested for TB using the 2-step method to with the initial test being completed prior to first day of work and 2" step being completed within 3 weeks of the initial reading. The Administrative Nurse will administer TB testing, unless the employee or prospective employee is sent to an approved work related employee service provider to provide this service. The Executive Director has educated the Administrative Nurse to the Guidelines and timelines for pre-employment compliance with the initial TB testing to be completed prior to first work day within the facility, as well as follow-up and timeline for 2"° step to be within the 3 weeks time-line for compliance with the Missouri State Regulations. The Business Office Manager has been educated as the to requirement that no employee begin in-house employment within the community until the results of the initial TB test have been read and recorded appropriately with negative findings or appropriate referral and follow-up to provide compliance with negative TB reading. The Executive Director will be responsible for review of new employees for compliance with initial testing and compliance prior to approval for employee to begin working assignments in the community. The Divisional Director of Nursing will review compliance with TB testing protocol on a quarterly basis and report Quality Assurance findings to the Executive Leadership Team to ensure infection control protocols are being adhered to within state guidelines. Completion 3.1.2024