FRIENDSHIP VILLAGE ASSISTED LIVING & MEMORY CARE.

“Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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. A two- (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. A sign 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; 6. A sign 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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The facility shall maintain a record in the facility for each resident, which shall include the following: (B) A review monthly or more frequently, if indicated, of the resident ' s general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Based on observation and interview on September 26, 2023, the facility failed to supervise the use of extension cords and unapproved multi plug adapters. The facilities census on September 26, 2023 was seventy-one (71). This deficiency affects seventy-one (71) of seventy-one (71) residents. Observation on September 26, 2023 between 9:50 A.M. and 1:00 P.M. showed non-compliant plug adapters in the folowing resident rooms: 117 (2), 135 (2), 140, 153, 161, 218, 2314 During an interview at the time of discovery, the Administrtator stated he/she would remove the plug adapters. PLAN OF CORRECTION Provider/Supplier Name: Friendship Village Assisted Living & Memory Care Sunset Hills a os 12777 Village Circle Drive, Sunset Hills, MO. 63127 City, Zip: Date of Survey: September 26, 2023: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Piease accept this Plan of Correction as our Credible Allegation of Compliance: Submission of this Response and Plan of Correction is not a legal admission that a deficiency was correctly cited, and it is also not to be construed as admission against interest by Friendship Village Sunset Hills, the Administration or any employee, agents or other individuals who may draft or who may be discussed in the Response or Plan of Correction. In addition, Preparation and submission of this ‘Plan of Correction does not constitute any admission or agreement of any kind by Friendship Village Sunset Hills of the truth of any facts alleged or correctness of any conclusion set forth in this allegation by the Survey. Agency. Corrective Action #1: Trash cans for resident apartments shall be UL-or FIM- fire resistant rated wastebaskets when used for trash. A2286 Resident apartments will be inspected quarterly, using the lor20/2023 attached form, to ensure UL- or FM fire resistant wastebaskets are being used for trash disposal. Identification of other residents affected or potentially affected: All residents have the potential to be affected. Vieasures or Systemic Changes: The EVS Department will perform quarterly safety checks in all apartments, and document on form provided. Prohibited trash cans will be removed and replaced with approved UL- or FM fire resistant wastebaskets. Monitoring: The Administrator, or designee, will audit safety check forms quarterly. Corrective Action #2 Extension cords for resident apartments shall be UL approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current for the appliance used. Multi-plug adapters are prohibited. we Resident apartments will be inspected quarterly using thie’: a attached form to ensure appliances/electronics are plugged into approved extension cords according to fire safety regulations. Identification of other residents affected or potentially affected: All residents. 10/20/2023 Measures or Systemic Changes: The Maintenance Department will perform quarterly apartment safety checks, and document on form provided. Prohibited extension cords/multi-plug adapters will be removed and replaced with approved UL rated power strips/extension cords according to fire safety regulations. Monitoring: The Administrator, or designee, will audit the safety check forms 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.”

“Based on observation and interview on September 26, 2023, the facility failed to ensure all trash cans in the facility were metal, UL or FM-fire-resistant rated. The census on September 26, 2023 was seventy-one (71). This deficiency affects seventy-one (71) of seventy-one (71) residents. Observation on September 26, 2023 between 9:50 A.M. and 1:00 P.M. showed non-compliant trash cans in the following resident rooms: 218, 317 (2), 337 (plastic bottom), 340 (plastic lid and bottom) During an interview on September 26, 2023 at time of discovery, the Administrator stated he/she would have them removed.”