PETTIS COUNTY ASSISTED LIVING, LLC.
PETTIS COUNTY ASSISTED LIVING, LLC is Ranked in the bottom 5% of Missouri memory care with 49 DHSS citations on record; last inspected Nov 2025.
A large home, reviewed on public record.
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Compared to 28 Missouri facilities with a similar number of beds.
Care · 36-month window. Higher percentile = better performance on inspection record. Source: Missouri Dept. of Health and Senior Services · Section for Long-Term Care Regulation.
Rankings based on 36-month DHSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · FREE
PETTIS COUNTY ASSISTED LIVING, LLC has 49 citations on record. Know the moment anything changes.
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Citation history, plotted month by month.
49 deficiencies on record. Each bar is a month with a citation.
Finding distribution
49 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to PETTIS COUNTY ASSISTED LIVING, LLC's record and state requirements.
The facility has 34 serious citations on file across all inspections — can you provide your corrective-action plan for each cited item, and show families any documentation of remediation steps taken?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
21 complaints are on file with CDSS — were any substantiated, and what remediation did the facility take in response to substantiated findings?
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The most recent inspection on 2025-05-22 found deficiencies — can you provide the deficiency notice from that visit and walk families through the corrective actions implemented?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
10 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-11-05Complaint Investigation3201 · 4 findings
“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.
“Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/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.
“Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the person, as provided in section 660.317, RSMo. Each facility shall maintain documents verifying that the background checks were requested, the date of each such request, and the nature of the response received for each such request. 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 develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/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.
2025-05-22Annual Compliance Visit2278 · 22 findings
“Based on observation and interview on May 22, 2025 the facility failed to maintain emergency lighting and exit lights in good repair and capable of operating for at least one and one-half (1 1/2) hours. The facility census was 128 This deficiency affects 128 of 128 residents. Observation at 10:55 A.M. showed the combination emergency light/exit sign in the dining room would not illuminate when the test button was pressed. Observation at 11:25 A.M. showed the combination emergency light/exit sign in hallway 200 was missing the front of the sign and the exit was not properly identified with the word "Exit". Observation at 11:50 A.M. showed the emergency light in hallway 300 would not illuminate when the test button was pressed. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue Is corrected.”
“Based on observation and interview on May 22, 2025, the facility failed to assure all resident rooms shall be neat, orderly and cleaned daily. The facility census was 128. This deficiency affects 128 of 128 residents. Observations from 10:20 A.M. until 12:33 P.M. showed several residents rooms throughout the building were not neat, orderly and cleaned on a daily basis. During an interview at 12:55 P.M., the maintenance director stated he will pass the information on to the management team. Provider/Supplier Name: City, Zip: Date of Survey: ID PREFIX TAG A1209 PLAN OF CORRECTION Pettis County Assisted Living LLC 3017 Brooking Park Avenue, Sedalia, MO 65301 5/22/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE. DEFICIENCY) This plan of correction (POC) is submitted as required under State and Federal law. This submission of POC does not constitute admission to the part of Pettis (the facility), as to the accuracy of the surveyor’s findings, nor the conclusion drawn there from. The facility’s submission of the POC does not constitute an admission on the part of the facility that the findings cited are accurate, or that the scope and severity regarding their deficiencies cited are correctly applied. The POC is intended to constitute the facility’s credible letter alleging compliance. Corrections. will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Door to resident room 326 was reinstalled to ensure a full non-louvered door swing into the room. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: COMPLETION DATE 10-06-2025 1. Administrator in-serviced Maintenance staff on regulation requiring non-louvered doors that swing into the room. 2. Maintenance director/designee will randomly audit resident room doors weekly for 3 months. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued. compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility has completed semi-annual inspection and certification of the kitchen range hood extinguishing system. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 10-06-2025 1. Administrator in-serviced Maintenance Director on semi-annual rangehood inspection and documentation retention requirements. 2. Administrator/ Designee will review the inspection reports monthly to ensure required certifications are current and filed. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Maintenance Director contacted local Fire Department to schedule annual consultation and review the emergency management plan. The emergency plan updated accordingly, The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on the requirement of annual consultation with fire marshal to review emergency management plan. 10-06-2025 2. Administrator/ Designee will audit emergency management plan monthly to ensure consultation is done at least annually. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility updated the emergency management plan 10-06-2025 with written procedures, staffing assignments, floor plans, contracts for alternative housing, and administrative roles in emergencies. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 2. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on the requirement of having a emergency management plan. 2. Administrator/ Designee will audit emergency management plan monthly to ensure to ensure written policies and procedures in place for emergencies and disasters, The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility immediately scheduled additional fire drills to ensure all shifts and requirements are met. A resident evacuation drill will be conducted on. 9/30/2025. The facility will identify other areas having the 10-06-2025 potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-service Maintenance Director to schedule and document a minimum of 12 fire drills annually, with one each shift per quarter and at least four unannounced. 2. Administrator/ Designee will review fire drill records monthly to ensure compliance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Fire drill records were updated to inciude all required elements: time, date, personnel participating, length of time to complete, and narrative of special problems. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. 10-06-2025 The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-service Maintenance Director to schedule and document a minimum of 12 fire drills annually, with one each shift per quarter and at least four unannounced. In service also provided on fire drill records to include all required elements: time, date, personnel participating, length of time to complete, and narrative of special problems. 2, Administrator/ Designee will review fire drill records monthly to ensure compliance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. All staff received immediate fire safety training. Training logs are updated. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 2. Administrator in-serviced maintenance director on to provide fire safety training to staff at hire and every six months and when additional training need identified as part of fire drills. . Administrator/ designee will review fire safety training monthly to ensure compliance. 10-06-2025 The facility will monitor the corrective actions to ensure the solutions are sustained. as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have | 10-06-2025 been affected by the alleged deficient practice: 1. Complete annual fire alarm system inspection was conducted by licensed contractor according to NFPA standards. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1, Administrator in-serviced Maintenance Director on requirement of annual complete and semi-annual fire alarm system inspection by a licensed contractor. . Administrator will review fire alarm system inspections monthly to ensure annal and semi- annual inspections ate completed. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will conduct a monthly fire alarm test by activating the system to ensure signal is transmitted to monitoring company. 10-06-2025 The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service maintenance director on requirement of conducting monthly fire alarm testing to ensure signal is transmitted to the monitoring company. 2. Administrator/ Designee will review fire system testing monthly to ensure compliance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will update fire watch policy. The policy included notifying the fire department and conducting fire watch if fire alarm system is out for more than 4 hours. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 10-06-2025 1. Administrator will in-service maintenance director on fire watch policy requirements. 2. Administrator/ Designee will review fire watch policy monthly. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: . The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Combustibles blocking resident rooms 310 and 320 and exits were immediately removed. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient 10-06-2025 practice does not occur as follows: 1. Administrator will in-service maintenance director on prohibition of unnecessary combustible storage in resident rooms and keeping exits clear. . Maintenance director/ designee will inspect rooms and exits during weekly rounds to ensure combustibles are not stored in the rooms. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued. compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 10-06-2025 1. Fire wall holes in the attic above hallway 300 were repaired. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service maintenance director to ensure smoke section partitions are intact. 2. Maintenance director/ Designee will inspect smoke partitions during monthly rounds to ensure integrity. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated, Corrections will include: The folowing was accomplished for the areas that have been affected by the alleged deficient practice: 1. Sprinkler heads repaired/replaced, paint removed, escutcheons installed, and clearance corrected on following rooms- 214, 311, 313 closet, 300 hallway and 310. . Facility will conduct a complete fire alarm system inspection. 10-06-2025 The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1, Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on maintenance of sprinkler system according NFPA 13 standards which includes- annual, semi-annual inspections, inspecting sprinkler heads and keeping 18-inch clearance from sprinkler heads. . Maintenance director/ Designee will inspect sprinkler heads during his monthly rounds to ensure they are intact and there is 18-inch clearance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Emergency lights in the dining room, 200 hallway and 300 hallways are repaired/ replaced. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: l. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make 10-06-2025 systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service maintenance director on emergency lighting requirement- battery powered light should operate for at least one and one-half hours. . Maintenance director/ Designee will inspect and test emergency lights during his monthly rounds. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will ensure all curtains are treated with flame-resistant materials. Documentation placed on file. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient 10-06-2025 practice does not occur as follows: 1. Administrator will in-service maintenance director on only using flame resistant curtains/ drapes according to NFPA 101 standards, 2. Maintenance director/ Designee will inspect curtains during his weekly rounds to ensure they are flame resistant. The facility will monitor the corrective actions to ensure the solutions are sustamed as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will have designated smoking areas. Smoking residue from room 321 and 326 is removed. Facility will counsel residents on smoking only at designated areas. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. 10-06-2025 The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Maintenance director will check for any signs of smoking at non-designated areas during weekly rounds. Education will be provided for residents as required. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1, Unapproved Waste basket in room 328 is removed and replaced by fire resistant waste basket. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by 10-06-2025 this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1, Administrator in-service maintenance director on only using fire resistant waste basket. 2. Maintenance director/ Designee will check waste baskets during his weekly rounds to ensure only fire-resistant waste baskets are used. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility posted “Oxygen” signage on the room 111 and 108 rooms. 2. Oxygen cylinders will be stored in a metal rack and “oxygen” sign will be posted on the door. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient 10-06-2025 practice does not occur as follows: 1. Facility will post “Oxygen” signage if a room has oxygen concentrator or oxygen in use. 2. Administrator in-serviced maintenance director oxygen storage requirements according to NFPA 99 regulations. . Maintenance director/ Designee will check oxygen storage requirements during his weekly rounds. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Holes in the drywalls/ ceiling are repaired on following areas-front foyer, women’s restroom, room 104, 111, 305, 313, 318, 320, 323, 304, 317, 328, 315 330, 331, 319, and 325. Area around sprinkler heads in room in the dining room and laundry room will be sealed. 2. Facility inspected the boiler and re-certified. The certification is filed. The facility will identify other areas having the potential to be affected by the same alleged deficient 10-06-2025 practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on following requirements-”
“Based on observation and interview on May 22, : 2025, the facility failed to ensure all resident rooms have a full non-louvered door that swings | into the room. The facility census was 128. This i } deficiency affects 128 of 128 residents. Observation at 12:18 P.M. showed the door for | resident room 326 removed from the hinges. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected. A2213”
“Based on record review and interview on May 22, 2025, the facility failed to complete and/or document that the range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 PETTIS COUNTY ASSISTED LIVING LLC edition. The facility census was 128. This deficiency affects 128 of the 128 residents. Record review at 12:33 P.M. showed no documentation of a semi annual inspection of the range hood and extinguishing system. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on record review and interview on May 22, 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 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PETTIS COUNTY ASSISTED LIVING LLC 128. This deficiency affects 128 of 128 residents. Record review at 12:33 P.M. showed no documentation of a Fire Department consultation or a request for a consultation on file for review. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on record review and interview on May 22, 2025 the facility failed have current written policies and procedures in place for emergencies or disasters. The facility census was 128. This deficiency affects 128 of 128 residents. Record review at 12:33 P.M. showed documentation of an outdated evacuation plan, and no current documented plan or contracts with other locations of residency for a full evacuation of the facility on file. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on record review and interview on October 8, 2025 the facility staff failed to complete and/or document that a minimum of twelve fire drills were conducted annually with at least one every three months on each shift, and at least four of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate the staff and resident response to the fire drill. The fire drills shall also include a resident evacuation at least once a year. The facilities census was 118. This deficiency affects 118 of 118 residents. Record review of the fire drill documentation for the past year showed: - A fire drill was documented on March 12, 2025 at 3:15 P.M. - Atornado drill was documented on April 2, 2025 at 9:10 A.M. Only staff participants listed. - A fire drill was documented on May 21, 2025 at 6:15 A.M. - A fire drill was documented on July 17, 2025 at 12:00 A.M. - A fire drill was documented on August 12, 2025 at 4:00 P.M. R 30112 B. WING 10/08/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PETTIS COUNTY ASSISTED LIVING LLC {A2217}| Continued From page 1 {A2217} - A fire drill was documented on September 4, 2025 10:00 A.M. During an interview at 12:30 P.M., the Regional Director stated he had searched for the missing paperwork and was not able to locate it, but was able to get back on schedule by performing and documenting fire drills for the last three months. {A2218}”
“Based on record review and interview on October 8, 2025 the facility failed to complete and/or document a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. The facilities census was 118. This deficiency affects 118 of 118 residents. Record review of the fire drill documentation for the past year showed: - A fire drill was documented on March 12, 2025 at 3:15 P.M. - Atornado drill was documented on April 2, 2025 at 9:10 A.M. Only staff participants listed. - A fire drill was documented on May 21, 2025 at 6:15 A.M. - A fire drill was documented on July 17, 2025 at PETTIS C TAG {A2218} IDENTIFICATION NUMBER: 30112 COMPLETED R 10/08/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 OUNTY ASSISTED LIVING LLC 12:00 A.M. - A fire drill was documented on August 12, 2025 at 4:00 P.M. - A fire drill was documented on September 4, 2025 10:00 A.M. During an interview at 12:30 P.M., the Regional Director stated he had searched for the missing paperwork and was not able to locate it, but was able to get back on schedule by performing and documenting fire drills for the last three months. {A2218} 6899 W74B12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE”
“Based on record review and interview on May 22, 2025, the facility failed to complete and/or document employee fire safety training upon initial hiring and at least every six months. The facility census was 128. This deficiency affects 128 of 128 residents. Record review at 12:33 P.M., showed no records on file of required employee fire safety training being completed. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on record review and interview on May 22, 2025, the facility failed to complete and/or document that the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was 128. This deficiency affects 128 out of 128 residents. Record review at 12:33 P.M. showed no records were available to show a semi-annual inspection had been performed on the fire alarm system as required by the National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on record review and interview on May 22, 2025, the facility failed to complete and/or document that the complete fire alarm system shall be tested by activating the system at least once a month to included concurrent verifications of a successful monthly transmission of the fire PETTIS COUNTY ASSISTED LIVING LLC alarm signal to their alarm monitoring company, in accordance with State of Missouri rules and regulations as well as the National Fire Protection Association (NFPA) 72, 1999 ed.. The facility census was 128. This affected 128 of 128 residents. Records review at 12:33 P.M. showed the monthly fire alarm testing was only performed and documented for the months of March and May 2025. (refer to fire drill list on inspection records) During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on record review and interview on May 22, 2025, the facility failed to have a written fire watch policy stating: When a complete fire alarm or 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PETTIS COUNTY ASSISTED LIVING LLC sprinkler system is to be out-of- service for more than four hours in a twenty-four- hour period, the facility shall immediately notify the department and the local fire authority and implement an approved fire watch in accordance with NFPA 101, 2000 edition, until the complete fire alarm system has returned to full service. The census was 128. This deficiency affects 128 of the 128 residents. Records review at 12:33 P.M. showed no records or documentation of the required fire watch policy for a fire alarm or sprinkler system outage. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on observation and interview on May 22, 2025, the facility failed to ensure the storage of unnecessary combustible materials in any part of prohibited. The facility census was 128. This deficiency affects 128 of 128 residents. 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PETTIS COUNTY ASSISTED LIVING LLC Observation at 12:06 P.M. showed the door for resident room 320 blocked with combustibles. Observation at 12:09 P.M. showed excess combustibles surrounding and blocking access or an exit way to the second bed in resident room 320. Observation at 2:15 P.M. showed the door for resident room 310 blocked with combustibles. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected.”
“Based on observation and interview on May 22, 2025, the facility failed to ensure each smoke section shall be separated by one hour fire-rated 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PETTIS COUNTY ASSISTED LIVING LLC smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 12:45 P.M. showed three holes through the fire wall in the attic, above hallway 300. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected.”
“Based on observation, record review and interview on May 22, 2025, the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was 128. This affected 128 of 128 residents. Observation at 11:25 A.M. showed a missing 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PETTIS COUNTY ASSISTED LIVING LLC escutcheon plate on the sprinkler head in room 214. Observation at 11:55 A.M. showed the sprinkler head in room 311 had paint splattered on it. Observation at 11:58 A.M. showed 18 inches of clearance was not being maintained around the sprinkler head in the storage closet of room 313. Observation at 12:11 P.M. showed a gap between the escutcheon ring and the wall in hallway 300. Observation at 12:15 P.M. showed the sprinkler head in room 310 had paint splattered on it. Record review at 12:33 P.M. showed no records were available to show a semi-annual inspection had been performed on the sprinkler system in accordance with NFPA 13, 1999 edition. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. He also stated he would see that the deficiencies were fixed.”
“Based on record review and interview on May 22, 2025, the facility failed to show documentation 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PETTIS COUNTY ASSISTED LIVING LLC that all curtains are certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. The facility census was 128. This deficiency affects 128 out of 128 residents. Records review at 12:33 P.M. showed no documented treatment for any curtains on file. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal.”
“Based on observation and an interview on May 22, 2025 the facility failed to prevent smoking only in non-designated smoking areas. The facility census was 128. This potentially affected 128 of 128 residents. Observation at 12:10 P.M. showed smoking residue, ashes and evidence of the act of smoking in room 321. 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PETTIS COUNTY ASSISTED LIVING LLC Observation at 12:18 P.M. showed smoking residue, ashes and evidence of the act of smoking in room 326. During an interview at 12:55 P.M., the maintenance director stated he will notify management of the issue.”
“Based on observation and interview on May 22, 2025, the facility failed to assure only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 12:16 P.M., showed an unapproved wastebasket in use in room 328. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue Is corrected.”
“Based on observation and interview on May 22, 2025, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 10:40 A.M., showed an oxygen concentrator in use in room 111 with no signage posted outside the entry to the room. Observation at 10:47 A.M., showed an oxygen concentrator in use in room 108 with no signage posted outside the entry to the room. Observation at 11:08 A.M., showed 15 oxygen cylinders in storage inside the med room. These cylinders were not enclosed in a cabinet or noncombustible room meeting regulations listed in NFPA 99, 8-3.1.11.2. Signage was not posted outside the entry to the room. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected.”
“Based on observation and interview on March 22, 2025 the facility failed to ensure the building was being maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. The facility census was 128. This deficiency affects 128 of the 128 residents. Observation at 10:25 A.M. showed a hole in the drywall ceiling, in the front foyer, with wiring for the security camera ran through the drywall. Observation at 10:26 A.M. showed a hole in the drywall ceiling, in the front foyer, over the door to the women's restroom. Observation at 10:34 A.M. showed a hole in the drywall ceiling, in the restroom of room 104. Observation at 10:40 A.M. showed a hole in the drywall behind the door of room 111. Observation at 11:00 A.M. showed the sprinkler head in the dining room needed to be sealed around. Observation at 11:05 A.M. showed the sprinkler head in the laundry room needed to be sealed around. Observation at 11:52 A.M. showed a hole in the wall in the restroom of room 305. Observation at 11:58 A.M. showed two holes in the wall, near the baseboard, in room 313. Observation at 11:59 A.M. showed peeling ceiling finishes in room 313. 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PETTIS COUNTY ASSISTED LIVING LLC Observation at 12:04 P.M. showed a hole in the wall in room 318. Observation at 12:08 P.M. showed peeling ceiling finishes in room 320. Observation at 12:10 P.M. showed a hole in the wall in hallway 300 near room 323. Observation at 12:10 P.M. showed a hole in the drywall near a coax cord in room 304. Observation at 12:14 P.M. showed a hole in the wall in room 317. Observation at 12:15 P.M. showed eight holes in the walls in room 328. Observation at 12:16 P.M. showed two holes in the wall in room 315. Observation at 12:18 P.M. showed a hole in the wall in room 330. Observation at 12:19 P.M. showed the drywall seam on the ceiling in room 331 was separating. Observation at 12:19 P.M. showed a hole in the wall in room 319. Observation at 12:25 P.M. showed the drywall seam on the ceiling in room 325 was missing the drywall tape. Observation at 11:27 A.M. showed the state certification for the boiler was expired. During an interview at 12:55 P.M., the maintenance director stated he will see that the issues are corrected. 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PETTIS COUNTY ASSISTED LIVING LLC *Higher classification merited due to the impact when combined with other deficiencies.”
“Based on observation, record review and interview on May 22, 2025, the facility failed to assure that the 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 PETTIS COUNTY ASSISTED LIVING LLC electrician. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 11:01 A.M. showed the electrical plug, near the ceiling in the dining room was not secured in place and was protruding from the wall. Observation at 11:03 P.M. showed the light switch cover and two outlet covers were missing inside the laundry room. Observation at 11:08 A.M. showed a missing outlet cover in the bathroom of the medical room. Observation at 11:21 A.M. showed a missing outlet cover in room 212. Observation at 12:13 P.M. showed a broken junction box cover in room 319. Observation at 12:16 P.M. showed a missing Junction box cover in room 324. Record review at 12:33 P.M. showed no documentation of a biennial wiring inspection by a qualified electrician on file for review. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. He also stated he would see that the issues are corrected.”
“Based on observation and interview on March 22, 2025 the facility failed to ensure 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. The facility census was 128. This deficiency affects 128 of the 128 residents. Observation at 10:48 A.M. showed the refrigerator in room 108 was plugged into a power strip and not directly into the wall outlet. Observation at 10:48 A.M. showed a unapproved multi plug adaptor in use powering a power strip, as well as a unapproved extension cord in room 108. Observation at 11:14 A.M. showed an unapproved extension cord in use in room 211. Observation at 11:21 A.M. showed an unapproved extension cord in use in room 212. 6899 W74B11 COMPLETED 05/22/2025 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PETTIS COUNTY ASSISTED LIVING LLC Observation at 11:37 A.M. showed an unapproved multi plug adaptor in use in room 221 as well as the refrigerator not plugged directly into the wall outlet. Observation at 11:41 A.M. showed piggy backing of a powerstrip and unapproved extension cord into a second power strip. Observation at 12:12 P.M. showed the refrigerator in room 327 was plugged into a power strip and not directly into the wall outlet. Observation at 12:16 P.M. showed an unapproved extension cord in use in room 324. Observation at 12:19 P.M. showed piggy backing of one (1) powerstrip into another powerstrip in room 319. Observation at 12:21 P.M. showed an unapproved extension cord in use in room 305. Observation at 12:26 P.M. showed an unapproved extension cord in use in room 309. During an interview at 12:55 P.M., the maintenance director stated he will see that the issues are corrected.”
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PRINTED: 06/09/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (%2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30112 B. WING 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE TTIS COUNTY ASSISTED LIVING LLC PE STE NG SEDALIA, MO 65304 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES : iD i PROVIDER'S PLAN OF CORRECTION (x8) PREFIX | {EACH DEFICIENCY MUST BE PRECEDED BY FULL : PREFIX i {EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} } TAG CROSS-REFERENCED TO THE APPROPRIATE | DATE ; DEFICIENCY) I] A1208| 19 CSR 30-86.012(9) Nonlouvered Resident | Room Door Facilities shall provide resident rooms with a full nonlouvered door that swings into the room. Facilities formerly licensed as residential care facilities It and existing prior to November 13, | 1980, are exempt from this requirement. II This regulation is not met as evidenced by: Class |] i} i } t i q i i | Based on observation and interview on May 22, : 2025, the facility failed to ensure all resident rooms have a full non-louvered door that swings | into the room. The facility census was 128. This i } deficiency affects 128 of 128 residents. Observation at 12:18 P.M. showed the door for | resident room 326 removed from the hinges. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected. A2213 19 CSR 30-86.022(4)(C) Range Hood Certification | Range Hood Extinguishing Systems. : (C)- The range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. {VIII | | \ This regulation is not met as evidenced by: Class III Based on record review and interview on May 22, : 2026, the facility failed to complete and/or , document that the range hood and its _ extinguishing system shall be certified at least ; twice annually in accordance with NFPA 96, 1998 Missouri Department of Health and Senior Servicas TITLE t heb W74B11 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 06/09/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1209 19 CSR 30-86.012(9) Nonlouvered Resident Room Door Facilities shall provide resident rooms with a full nonlouvered door that swings into the room. Facilities formerly licensed as residential care facilities Il and existing prior to November 13, 1980, are exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview on May 22, 2025, the facility failed to ensure all resident rooms have a full non-louvered door that swings into the room. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 12:18 P.M. showed the door for resident room 326 removed from the hinges. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected. 19 CSR 30-86.022(4)(C) Range Hood Certification Range Hood Extinguishing Systems. (C) The range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. II/IIl This regulation is not met as evidenced by: Class Ill Based on record review and interview on May 22, 2025, the facility failed to complete and/or document that the range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 W74B11 If continuation sheet 1 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 edition. The facility census was 128. This deficiency affects 128 of the 128 residents. Record review at 12:33 P.M. showed no documentation of a semi annual inspection of the range hood and extinguishing system. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 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 interview on May 22, 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 128. This deficiency affects 128 of 128 residents. Record review at 12:33 P.M. showed no documentation of a Fire Department consultation or a request for a consultation on file for review. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 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, 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; Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 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 interview on May 22, 2025 the facility failed have current written policies and procedures in place for emergencies or disasters. The facility census was 128. This deficiency affects 128 of 128 residents. Record review at 12:33 P.M. showed documentation of an outdated evacuation plan, and no current documented plan or contracts with other locations of residency for a full evacuation of the facility on file. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 4 the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/Ill This regulation is not met as evidenced by: Class III Based on record review and interview on May 22, 2025 the facility staff failed to complete and/or document that a minimum of twelve fire drills were conducted annually with at least one every three months on each shift, and at least four of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate the staff and resident response to the fire drill. The fire drills shall also include a resident evacuation at least once a year. The facilities census was 128. This deficiency affects 128 of 128 residents. Record review of the fire drill records for the past year showed: - A fire drill was completed on March 12, 2025 at 3:15 P.M. - A Tornado drill was completed on April 2, 2025 at 9:10 A.M. Only staff participants listed. - A fire drill was completed on May 21, 2025 at 6:15 A.M. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. Missouri Department of Health and Senior Services STATE FORM 6899 W74B11 If continuation sheet 5 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 5 19 CSR 30-86.022(5)(E) Fire Drill Records Fire Drills and Emergency Preparedness. (E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. Ill This regulation is not met as evidenced by: Class III Based on record review and interview on May 22, 2025 the facility failed to complete and/or document a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. The facilities census was 128. This deficiency affects 128 of 128 residents. Record review of the fire drill records for the past year showed: - A fire drill was completed on March 12, 2025 at 3:15 P.M. No participants listed. - A Tornado drill was completed on April 2, 2025 at 9:10 A.M. Only staff participants listed. - A fire drill was completed on May 21, 2025 at 6:15 A.M. No participants listed. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees Missouri Department of Health and Senior Services STATE FORM 6899 W74B11 If continuation sheet 6 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 6 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/III This regulation is not met as evidenced by: Class III Based on record review and interview on May 22, 2025, the facility failed to complete and/or document employee fire safety training upon initial hiring and at least every six months. The facility census was 128. This deficiency affects 128 of 128 residents. Record review at 12:33 P.M., showed no records on file of required employee fire safety training being completed. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 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: Missouri Department of Health and Senior Services STATE FORM 6899 W74B11 If continuation sheet 7 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 7 Class II Based on record review and interview on May 22, 2025, the facility failed to complete and/or document that the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was 128. This deficiency affects 128 out of 128 residents. Record review at 12:33 P.M. showed no records were available to show a semi-annual inspection had been performed on the fire alarm system as required by the National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. 1/II This regulation is not met as evidenced by: Class II Based on record review and interview on May 22, 2025, the facility failed to complete and/or document that the complete fire alarm system shall be tested by activating the system at least once a month to included concurrent verifications of a successful monthly transmission of the fire Missouri Department of Health and Senior Services STATE FORM 6899 W74B11 If continuation sheet 8 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 alarm signal to their alarm monitoring company, in accordance with State of Missouri rules and regulations as well as the National Fire Protection Association (NFPA) 72, 1999 ed.. The facility census was 128. This affected 128 of 128 residents. Records review at 12:33 P.M. showed the monthly fire alarm testing was only performed and documented for the months of March and May 2025. (refer to fire drill list on inspection records) During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 19 CSR 30-86.022(9)(H) Fire Alarm System Out of Service > than 4hrs Complete Fire Alarm Systems. (H) When a complete fire alarm system is to be out-of- service for more than four (4) hours in a twenty-four- (24-) hour period, the facility shall immediately notify the department and the local fire authority and implement an approved fire watch in accordance with NFPA 101, 2000 edition, until the complete fire alarm system has returned to full service. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on May 22, 2025, the facility failed to have a written fire watch policy stating: When a complete fire alarm or Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 sprinkler system is to be out-of- service for more than four hours in a twenty-four- hour period, the facility shall immediately notify the department and the local fire authority and implement an approved fire watch in accordance with NFPA 101, 2000 edition, until the complete fire alarm system has returned to full service. The census was 128. This deficiency affects 128 of the 128 residents. Records review at 12:33 P.M. showed no records or documentation of the required fire watch policy for a fire alarm or sprinkler system outage. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 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 22, 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 128. This deficiency affects 128 of 128 residents. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 Observation at 12:06 P.M. showed the door for resident room 320 blocked with combustibles. Observation at 12:09 P.M. showed excess combustibles surrounding and blocking access or an exit way to the second bed in resident room 320. Observation at 2:15 P.M. showed the door for resident room 310 blocked with combustibles. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected. 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class II Based on observation and interview on May 22, 2025, the facility failed to ensure each smoke section shall be separated by one hour fire-rated Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 11 smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 12:45 P.M. showed three holes through the fire wall in the attic, above hallway 300. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the 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, record review and interview on May 22, 2025, the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was 128. This affected 128 of 128 residents. Observation at 11:25 A.M. showed a missing Missouri Department of Health and Senior Services STATE FORM 6899 W74B11 If continuation sheet 12 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 12 escutcheon plate on the sprinkler head in room 214. Observation at 11:55 A.M. showed the sprinkler head in room 311 had paint splattered on it. Observation at 11:58 A.M. showed 18 inches of clearance was not being maintained around the sprinkler head in the storage closet of room 313. Observation at 12:11 P.M. showed a gap between the escutcheon ring and the wall in hallway 300. Observation at 12:15 P.M. showed the sprinkler head in room 310 had paint splattered on it. Record review at 12:33 P.M. showed no records were available to show a semi-annual inspection had been performed on the sprinkler system in accordance with NFPA 13, 1999 edition. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. He also stated he would see that the deficiencies were fixed. 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 Missouri Department of Health and Senior Services STATE FORM 6899 W74B11 If continuation sheet 13 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 Based on observation and interview on May 22, 2025 the facility failed to maintain emergency lighting and exit lights in good repair and capable of operating for at least one and one-half (1 1/2) hours. The facility census was 128 This deficiency affects 128 of 128 residents. Observation at 10:55 A.M. showed the combination emergency light/exit sign in the dining room would not illuminate when the test button was pressed. Observation at 11:25 A.M. showed the combination emergency light/exit sign in hallway 200 was missing the front of the sign and the exit was not properly identified with the word "Exit". Observation at 11:50 A.M. showed the emergency light in hallway 300 would not illuminate when the test button was pressed. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue Is corrected. 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 record review and interview on May 22, 2025, the facility failed to show documentation Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 14 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 that all curtains are certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. The facility census was 128. This deficiency affects 128 out of 128 residents. Records review at 12:33 P.M. showed no documented treatment for any curtains on file. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. 19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/III This regulation is not met as evidenced by: Class III Based on observation and an interview on May 22, 2025 the facility failed to prevent smoking only in non-designated smoking areas. The facility census was 128. This potentially affected 128 of 128 residents. Observation at 12:10 P.M. showed smoking residue, ashes and evidence of the act of smoking in room 321. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 15 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 Observation at 12:18 P.M. showed smoking residue, ashes and evidence of the act of smoking in room 326. During an interview at 12:55 P.M., the maintenance director stated he will notify management of the issue. 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. Il This regulation is not met as evidenced by: Class II Based on observation and interview on May 22, 2025, the facility failed to assure only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 12:16 P.M., showed an unapproved wastebasket in use in room 328. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue Is corrected. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 16 This regulation is not met as evidenced by: Class Ill Based on observation and interview on May 22, 2025, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 10:40 A.M., showed an oxygen concentrator in use in room 111 with no signage posted outside the entry to the room. Observation at 10:47 A.M., showed an oxygen concentrator in use in room 108 with no signage posted outside the entry to the room. Observation at 11:08 A.M., showed 15 oxygen cylinders in storage inside the med room. These cylinders were not enclosed in a cabinet or noncombustible room meeting regulations listed in NFPA 99, 8-3.1.11.2. Signage was not posted outside the entry to the room. During an interview at 12:55 P.M., the maintenance director stated he will see that the issue is corrected. 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 II* Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 17 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 Based on observation and interview on March 22, 2025 the facility failed to ensure the building was being maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. The facility census was 128. This deficiency affects 128 of the 128 residents. Observation at 10:25 A.M. showed a hole in the drywall ceiling, in the front foyer, with wiring for the security camera ran through the drywall. Observation at 10:26 A.M. showed a hole in the drywall ceiling, in the front foyer, over the door to the women's restroom. Observation at 10:34 A.M. showed a hole in the drywall ceiling, in the restroom of room 104. Observation at 10:40 A.M. showed a hole in the drywall behind the door of room 111. Observation at 11:00 A.M. showed the sprinkler head in the dining room needed to be sealed around. Observation at 11:05 A.M. showed the sprinkler head in the laundry room needed to be sealed around. Observation at 11:52 A.M. showed a hole in the wall in the restroom of room 305. Observation at 11:58 A.M. showed two holes in the wall, near the baseboard, in room 313. Observation at 11:59 A.M. showed peeling ceiling finishes in room 313. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 18 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 Observation at 12:04 P.M. showed a hole in the wall in room 318. Observation at 12:08 P.M. showed peeling ceiling finishes in room 320. Observation at 12:10 P.M. showed a hole in the wall in hallway 300 near room 323. Observation at 12:10 P.M. showed a hole in the drywall near a coax cord in room 304. Observation at 12:14 P.M. showed a hole in the wall in room 317. Observation at 12:15 P.M. showed eight holes in the walls in room 328. Observation at 12:16 P.M. showed two holes in the wall in room 315. Observation at 12:18 P.M. showed a hole in the wall in room 330. Observation at 12:19 P.M. showed the drywall seam on the ceiling in room 331 was separating. Observation at 12:19 P.M. showed a hole in the wall in room 319. Observation at 12:25 P.M. showed the drywall seam on the ceiling in room 325 was missing the drywall tape. Observation at 11:27 A.M. showed the state certification for the boiler was expired. During an interview at 12:55 P.M., the maintenance director stated he will see that the issues are corrected. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 19 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 19 *Higher classification merited due to the impact when combined with other deficiencies. 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 observation, record review and interview on May 22, 2025, the facility failed to assure that the 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 W74B11 If continuation sheet 20 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 electrician. The facility census was 128. This deficiency affects 128 of 128 residents. Observation at 11:01 A.M. showed the electrical plug, near the ceiling in the dining room was not secured in place and was protruding from the wall. Observation at 11:03 P.M. showed the light switch cover and two outlet covers were missing inside the laundry room. Observation at 11:08 A.M. showed a missing outlet cover in the bathroom of the medical room. Observation at 11:21 A.M. showed a missing outlet cover in room 212. Observation at 12:13 P.M. showed a broken junction box cover in room 319. Observation at 12:16 P.M. showed a missing Junction box cover in room 324. Record review at 12:33 P.M. showed no documentation of a biennial wiring inspection by a qualified electrician on file for review. During an interview at 12:55 P.M., the maintenance director stated he had searched for the paperwork and was not able to locate it. He stated it is believed the paperwork was removed from the property by the previous maintenance director upon his dismissal. He also stated he would see that the issues are corrected. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 21 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 21 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/IIl This regulation is not met as evidenced by: Class III Based on observation and interview on March 22, 2025 the facility failed to ensure 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. The facility census was 128. This deficiency affects 128 of the 128 residents. Observation at 10:48 A.M. showed the refrigerator in room 108 was plugged into a power strip and not directly into the wall outlet. Observation at 10:48 A.M. showed a unapproved multi plug adaptor in use powering a power strip, as well as a unapproved extension cord in room 108. Observation at 11:14 A.M. showed an unapproved extension cord in use in room 211. Observation at 11:21 A.M. showed an unapproved extension cord in use in room 212. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 22 of 24 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 PETTIS COUNTY ASSISTED LIVING LLC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 22 Observation at 11:37 A.M. showed an unapproved multi plug adaptor in use in room 221 as well as the refrigerator not plugged directly into the wall outlet. Observation at 11:41 A.M. showed piggy backing of a powerstrip and unapproved extension cord into a second power strip. Observation at 12:12 P.M. showed the refrigerator in room 327 was plugged into a power strip and not directly into the wall outlet. Observation at 12:16 P.M. showed an unapproved extension cord in use in room 324. Observation at 12:19 P.M. showed piggy backing of one (1) powerstrip into another powerstrip in room 319. Observation at 12:21 P.M. showed an unapproved extension cord in use in room 305. Observation at 12:26 P.M. showed an unapproved extension cord in use in room 309. During an interview at 12:55 P.M., the maintenance director stated he will see that the issues are corrected. 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 Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 W74B11 PRINTED: 06/09/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 23 of 24 PRINTED: 06/09/2025 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 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 (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) PETTIS COUNTY ASSISTED LIVING LLC Continued From page 23 Based on observation and interview on May 22, 2025, the facility failed to assure all resident rooms shall be neat, orderly and cleaned daily. The facility census was 128. This deficiency affects 128 of 128 residents. Observations from 10:20 A.M. until 12:33 P.M. showed several residents rooms throughout the building were not neat, orderly and cleaned on a daily basis. During an interview at 12:55 P.M., the maintenance director stated he will pass the information on to the management team. Missouri Department of Health and Senior Services STATE FORM 6899 W74B11 If continuation sheet 24 of 24 Provider/Supplier Name: Street Address, City, Zip: Date of Survey: ID PREFIX TAG A1209 PLAN OF CORRECTION Pettis County Assisted Living LLC 3017 Brooking Park Avenue, Sedalia, MO 65301 5/22/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE. DEFICIENCY) This plan of correction (POC) is submitted as required under State and Federal law. This submission of POC does not constitute admission to the part of Pettis (the facility), as to the accuracy of the surveyor’s findings, nor the conclusion drawn there from. The facility’s submission of the POC does not constitute an admission on the part of the facility that the findings cited are accurate, or that the scope and severity regarding their deficiencies cited are correctly applied. The POC is intended to constitute the facility’s credible letter alleging compliance. Corrections. will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Door to resident room 326 was reinstalled to ensure a full non-louvered door swing into the room. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: COMPLETION DATE 10-06-2025 1. Administrator in-serviced Maintenance staff on regulation requiring non-louvered doors that swing into the room. 2. Maintenance director/designee will randomly audit resident room doors weekly for 3 months. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued. compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility has completed semi-annual inspection and certification of the kitchen range hood extinguishing system. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 10-06-2025 1. Administrator in-serviced Maintenance Director on semi-annual rangehood inspection and documentation retention requirements. 2. Administrator/ Designee will review the inspection reports monthly to ensure required certifications are current and filed. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Maintenance Director contacted local Fire Department to schedule annual consultation and review the emergency management plan. The emergency plan updated accordingly, The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on the requirement of annual consultation with fire marshal to review emergency management plan. 10-06-2025 2. Administrator/ Designee will audit emergency management plan monthly to ensure consultation is done at least annually. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility updated the emergency management plan 10-06-2025 with written procedures, staffing assignments, floor plans, contracts for alternative housing, and administrative roles in emergencies. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 2. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on the requirement of having a emergency management plan. 2. Administrator/ Designee will audit emergency management plan monthly to ensure to ensure written policies and procedures in place for emergencies and disasters, The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility immediately scheduled additional fire drills to ensure all shifts and requirements are met. A resident evacuation drill will be conducted on. 9/30/2025. The facility will identify other areas having the 10-06-2025 potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-service Maintenance Director to schedule and document a minimum of 12 fire drills annually, with one each shift per quarter and at least four unannounced. 2. Administrator/ Designee will review fire drill records monthly to ensure compliance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Fire drill records were updated to inciude all required elements: time, date, personnel participating, length of time to complete, and narrative of special problems. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. 10-06-2025 The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-service Maintenance Director to schedule and document a minimum of 12 fire drills annually, with one each shift per quarter and at least four unannounced. In service also provided on fire drill records to include all required elements: time, date, personnel participating, length of time to complete, and narrative of special problems. 2, Administrator/ Designee will review fire drill records monthly to ensure compliance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. All staff received immediate fire safety training. Training logs are updated. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 2. Administrator in-serviced maintenance director on to provide fire safety training to staff at hire and every six months and when additional training need identified as part of fire drills. . Administrator/ designee will review fire safety training monthly to ensure compliance. 10-06-2025 The facility will monitor the corrective actions to ensure the solutions are sustained. as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have | 10-06-2025 been affected by the alleged deficient practice: 1. Complete annual fire alarm system inspection was conducted by licensed contractor according to NFPA standards. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1, Administrator in-serviced Maintenance Director on requirement of annual complete and semi-annual fire alarm system inspection by a licensed contractor. . Administrator will review fire alarm system inspections monthly to ensure annal and semi- annual inspections ate completed. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will conduct a monthly fire alarm test by activating the system to ensure signal is transmitted to monitoring company. 10-06-2025 The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service maintenance director on requirement of conducting monthly fire alarm testing to ensure signal is transmitted to the monitoring company. 2. Administrator/ Designee will review fire system testing monthly to ensure compliance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will update fire watch policy. The policy included notifying the fire department and conducting fire watch if fire alarm system is out for more than 4 hours. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 10-06-2025 1. Administrator will in-service maintenance director on fire watch policy requirements. 2. Administrator/ Designee will review fire watch policy monthly. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: . The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Combustibles blocking resident rooms 310 and 320 and exits were immediately removed. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient 10-06-2025 practice does not occur as follows: 1. Administrator will in-service maintenance director on prohibition of unnecessary combustible storage in resident rooms and keeping exits clear. . Maintenance director/ designee will inspect rooms and exits during weekly rounds to ensure combustibles are not stored in the rooms. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued. compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 10-06-2025 1. Fire wall holes in the attic above hallway 300 were repaired. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service maintenance director to ensure smoke section partitions are intact. 2. Maintenance director/ Designee will inspect smoke partitions during monthly rounds to ensure integrity. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated, Corrections will include: The folowing was accomplished for the areas that have been affected by the alleged deficient practice: 1. Sprinkler heads repaired/replaced, paint removed, escutcheons installed, and clearance corrected on following rooms- 214, 311, 313 closet, 300 hallway and 310. . Facility will conduct a complete fire alarm system inspection. 10-06-2025 The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1, Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on maintenance of sprinkler system according NFPA 13 standards which includes- annual, semi-annual inspections, inspecting sprinkler heads and keeping 18-inch clearance from sprinkler heads. . Maintenance director/ Designee will inspect sprinkler heads during his monthly rounds to ensure they are intact and there is 18-inch clearance. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Emergency lights in the dining room, 200 hallway and 300 hallways are repaired/ replaced. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: l. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make 10-06-2025 systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service maintenance director on emergency lighting requirement- battery powered light should operate for at least one and one-half hours. . Maintenance director/ Designee will inspect and test emergency lights during his monthly rounds. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1, The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will ensure all curtains are treated with flame-resistant materials. Documentation placed on file. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient 10-06-2025 practice does not occur as follows: 1. Administrator will in-service maintenance director on only using flame resistant curtains/ drapes according to NFPA 101 standards, 2. Maintenance director/ Designee will inspect curtains during his weekly rounds to ensure they are flame resistant. The facility will monitor the corrective actions to ensure the solutions are sustamed as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will have designated smoking areas. Smoking residue from room 321 and 326 is removed. Facility will counsel residents on smoking only at designated areas. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. 10-06-2025 The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Maintenance director will check for any signs of smoking at non-designated areas during weekly rounds. Education will be provided for residents as required. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1, Unapproved Waste basket in room 328 is removed and replaced by fire resistant waste basket. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by 10-06-2025 this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1, Administrator in-service maintenance director on only using fire resistant waste basket. 2. Maintenance director/ Designee will check waste baskets during his weekly rounds to ensure only fire-resistant waste baskets are used. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility posted “Oxygen” signage on the room 111 and 108 rooms. 2. Oxygen cylinders will be stored in a metal rack and “oxygen” sign will be posted on the door. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient 10-06-2025 practice does not occur as follows: 1. Facility will post “Oxygen” signage if a room has oxygen concentrator or oxygen in use. 2. Administrator in-serviced maintenance director oxygen storage requirements according to NFPA 99 regulations. . Maintenance director/ Designee will check oxygen storage requirements during his weekly rounds. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Holes in the drywalls/ ceiling are repaired on following areas-front foyer, women’s restroom, room 104, 111, 305, 313, 318, 320, 323, 304, 317, 328, 315 330, 331, 319, and 325. Area around sprinkler heads in room in the dining room and laundry room will be sealed. 2. Facility inspected the boiler and re-certified. The certification is filed. The facility will identify other areas having the potential to be affected by the same alleged deficient 10-06-2025 practice as follows: 1. All residents have the potential to be affected by this deficient practice. The facility will put measures in place and/or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator in-serviced maintenance director on following requirements- 19 CSR 30-86.032 Keeping building in good repair condition. 2. Maintenance director/ Designee will check areas of the building during his weekly rounds to ensure it is kept in good condition, and any drywall holes are patched and repaired. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 10-06-2025 1. Facility will conduct an electrical inspection. 2. Electrical plug in dining room, light switch cover and outlet covers in laundry room, med room and toom 212, junction box in room 319 and 324 are replaced. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service maintenance director on 19 CSR 30-86.032 electrical wiring maintenance and inspection. 2. Maintenance director will check electrical outlets, switches, and junction boxes during his weekly rounds to ensure they are in good condition. 3. Administrator will review electrical wiring inspection report monthly to ensure documentation is maintained. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. Facility will use only UL approved extension cords. Any unapproved adaptors, piggybacks and extensions cords will be removed. Refrigerators will be directly plugged into wall outlets. 10-06-2025 The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1. Allresidents have the potential to be affected by this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1, Administrator will in-service maintenance director on 19 CSR 30-86.032- using on UL certified extension cords and duplex receptables. 2. Maintenance director/ Designee will check extension cords during his weekly checks to ensure only UL certified extension cords are used according to 19 CSR 30-86.032. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued. compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. Corrections will include: The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. All residents’ rooms are kept neat, orderly and cleaned out regularly. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 1, All residents have the potential to be affected by 10-06-2025 this deficient practice. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. Administrator will in-service environmental services supervisor to ensure resident rooms kept neat, orderly and cleaned regularly. 2. Environmental supervisors check resident rooms during weekly rounds to ensure they are kept neat, orderly and clean. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: The Quality Assurance committee will monitor continued compliance with these corrective measures during monthly meetings. Follow-up will occur as indicated. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating thelr approval of the plan of correction being submitted on this form. PRINTED: 12/05/2025 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 R 30112 B. WING 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) PETTIS COUNTY ASSISTED LIVING LLC {A2217}, 19 CSR 30-86.022(5)(D) Fire Drill Requirements, | {A2217} Evacuation Fire Drills and Emergency Preparedness. (D) Aminimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/IIl This regulation is not met as evidenced by: Class III Based on record review and interview on October 8, 2025 the facility staff failed to complete and/or document that a minimum of twelve fire drills were conducted annually with at least one every three months on each shift, and at least four of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate the staff and resident response to the fire drill. The fire drills shall also include a resident evacuation at least once a year. The facilities census was 118. This deficiency affects 118 of 118 residents. Record review of the fire drill documentation for the past year showed: - A fire drill was documented on March 12, 2025 at 3:15 P.M. - Atornado drill was documented on April 2, 2025 at 9:10 A.M. Only staff participants listed. - A fire drill was documented on May 21, 2025 at 6:15 A.M. - A fire drill was documented on July 17, 2025 at 12:00 A.M. - A fire drill was documented on August 12, 2025 at 4:00 P.M. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 W74B12 If continuation sheet 1 of 3 PRINTED: 12/05/2025 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 R 30112 B. WING 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) PETTIS COUNTY ASSISTED LIVING LLC {A2217}| Continued From page 1 {A2217} - A fire drill was documented on September 4, 2025 10:00 A.M. During an interview at 12:30 P.M., the Regional Director stated he had searched for the missing paperwork and was not able to locate it, but was able to get back on schedule by performing and documenting fire drills for the last three months. {A2218} 19 CSR 30-86.022(5)(E) Fire Drill Records {A2218} Fire Drills and Emergency Preparedness. (E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. Ill This regulation is not met as evidenced by: Class III Based on record review and interview on October 8, 2025 the facility failed to complete and/or document a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. The facilities census was 118. This deficiency affects 118 of 118 residents. Record review of the fire drill documentation for the past year showed: - A fire drill was documented on March 12, 2025 at 3:15 P.M. - Atornado drill was documented on April 2, 2025 at 9:10 A.M. Only staff participants listed. - A fire drill was documented on May 21, 2025 at 6:15 A.M. - A fire drill was documented on July 17, 2025 at Missouri Department of Health and Senior Services STATE FORM 6899 W74B12 If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER PETTIS C (x4) ID PREFIX TAG {A2218} (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 30112 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 12/05/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED R 10/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 OUNTY ASSISTED LIVING LLC SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 12:00 A.M. - A fire drill was documented on August 12, 2025 at 4:00 P.M. - A fire drill was documented on September 4, 2025 10:00 A.M. During an interview at 12:30 P.M., the Regional Director stated he had searched for the missing paperwork and was not able to locate it, but was able to get back on schedule by performing and documenting fire drills for the last three months. Missouri Department of Health and Senior Services STATE FORM {A2218} 6899 CROSS-REFERENCED TO THE APPROPRIATE W74B12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 3 of 3
2025-01-27Complaint Investigation2218 · 6 findings
“Fire Drills and Emergency Preparedness. (E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. 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.
“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 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 screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. 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.
“Night lights shall be provided for corridors, stairways and toilet areas. 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.
“Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/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.
“Prior to or on the first day that a new employee works in the facility he or she shall receive orientation of at least two (2) hours appropriate to his or her job function. This shall include at least the following: (I) Instruction regarding working with residents with mental illness; II/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.
2024-11-21Complaint Investigation4797 · 1 finding
“The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. 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.
2024-10-29Complaint InvestigationComplaint · 1 finding
“Each resident shall be free from abuse. Abuse is the infliction of physical, sexual, or emotional injury or harm and includes verbal abuse, corporal punishment, and involuntary seclusion. I”
This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.
2024-07-12Complaint Investigation9010 · 1 finding
“Within five (5) calendar days of the discharge of a resident, the resident, his/her designee, guardian and conservator, or conservator shall be given an up-to-date accounting of the resident ' s personal funds and the balance of the funds and all personal possessions shall be returned to the resident. This requirement shall not apply for residents discharged due to death, or for residents discharged to hospitals when those residents are expected to return to the facility. The operator shall have a receipt for all funds and possessions returned to the resident, his/her designee, guardian and conservator, or conservator. II/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.
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PRINTED: 11/26/2024 FORM APPROVED Missouri Department.of Health and Senior Services STATEMENT OF DEFICIENCIES (<4) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE-CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: Cc 30112 B, WING ——~-----— 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE PETTIS COUNTY ASSISTED LIVING LLC SEDALIA, MO 65301 (x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (Xs) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE. ACTION SHOULD BE | COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE | DEFICIENCY) A822 A802) 19 CSR 30-88.010(22) Free From Abuse Each resident shall be free from abuse. Abuse is he infliction of physical, sexual, or emotional injury of harm and includes verbal abuse, corporal punishment, and involuntary seclusion. | : This regulation is not met as evidenced by: Based on observation, interview and record _ review, facility staff failed to ensure Resident #1 and Resident #3, who were not determined to : have the capacity to consent, remained free from : sexual abuse when they were sexually abused by Resident #2. The facility census was 108, Review of the facility's Abuse and Neglect Policy, revised 06/12/24, showed abuse is the willful : infliction of injury, unreasonable confinement, : intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to rasident altercations. This also includes the deprivation by an individual, including a caretaker, of goods or services thal are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, ' cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical ‘ abuse, and mental abuse including abuse ' facilitated or enabled through the use of . technology. | Review of the facility's Capacity to Consent to i Sexual Activity Form, undated, showed staff are | directed to determine if the resident has a ! guardian. A guardian is usually the individual with | the legal responsibility for making choices on the i resident's behalf, and is the. one to provide the consent for sexual activity. Review showed if the resident has.a guardian, they are to sign the form eS wet) : 8 LUTTE ay AID un (ofa. NY {G-T- P# QiBF11 {f continuation sheet 1 of 8 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPR STATE. FORM PRINTED: 11/26/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF OEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED \ ~ c B WING 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 PETTIS COUNTY ASSISTED LIVING LLC (xayio | SUMMARY STATEMENT OF DEFICIENCIES ID i PROVIDER'S PLAN OF CORRECTION (x5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A8022 | Continued From page 1 A8022 : to give consent. . 1. Review of Resident #3'’s medical record | showed the resident was admitted on 08/01/24 : with a diagnosis schizophrenia, bipolar disorder, depressive disorder, anxiety disorder. Review showed the resident had a guardian. Review of Resident #3's progress notes, dated 10/21/24, showed the Director of Nursing (DON) went to Resident #3's room and found Resident #3 and Resident #2 in bed together. Review showed Resident #2 did not have any clothes on and was asked to get up, get dressed, and to leave the room. The DON and Resident Care { Coordinator (RCC) asked Resident #3 what was | going on and he/she said they were having sex. | Resident's #3's guardian was called, and the guardian moved the resident to another facility ; because he/she could not give consent to have | sexual activities. Review of the resident's medical record showed | : the record did not contain an assessment for the : resident's capacity to consent. : During an interview on 10/30/24 at 12:15 P.M., . the DON said Resident #2 had a history of : entering resident's rooms. The DON said | Resident #2 was found in Resident #3’s bed ; | having sex on 10/21/24 or 10/23/24. The DON | said Resident #3 was monitored hourly which is | part of the face checks they do. The DON said | Resident #3's guardian was calted and told i | him/her Resident #3 could not give consent to | have sex, The DON said the guardian moved Resident #3.to another facility shortly after being \ | notified. | | i | 2. Review of Resident #1's medical record | Missouri Department of Health and Senior Services STATE FORM Sao9 QiBF 11 If continuation sheet 2 of 8 PRINTED: 11/26/2024 FORM APPROVED Missouri Depariment of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) OATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING; COMPLETED CG B.WING 11/06/2024 NAME OF PROVIDER OR.SUPPLIER STREET ADDRESS, CITY, STATE, ZIP GODE 3017 BROOKING PARK AVENUE PETTIS COUNTY ASSISTED LIVING LLC SEDALIA, MO 65301 i x4)ID | SUMMARY STATEMENT OF DEFICIENCIES Dp PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX. | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ' TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A8022 | Continued From page 2 | A8022 { j | showed the resident admitted on 03/14/2022 with | a diagnoses of dementia and degenerative i | diseases of basal gangilia (structures deep within | the brain that are involved with movement), The resident had a legal guardian. Review of Resident #1's medical recard showed it | | did not contain a Capacity to Consent to Sexual | | | | Activity form signed by the resident's guardian. Review of the facility's investigation report, dated : 40/28/24, showed staff reported an alleged | sexual incident on 10/28/24 at 9:30 A.M. Review : showed the administrator interviewed Resident : #1 who said Resident #2 "forced" him/her to have » sex, Review showed the administrator i : interviewed Resident #2 who said it was - “consensual” sex. : Review of Resident #1's behavior notes, dated. : : 10/28/24, showed staff documented Resident #1 . reported he/she had unwanted sex with Resident ' #2. Resident #1 said Resident #2 came in his/her room and started arguing with him/her about - having sex and crawled into bed with him/her and had sex, Resident #1 said his/her medications make him/her very tired and when he/she woke i up there was feces all over the sheets. Resident | #1 was interviewed by the Sheriff's department and sent to: the hospital. , : During an interview on 10/31/24 at 1:31 P.M., : Resident #1's guardian said he/she was notified : of. the incident by the facility. The guardiari said ‘ Resident #1 takes strong medications that make him/her tired, he/she has dementia, and he/she reported to him/her waking up with feces ali over his/her sheets and he/she believed anal penetration had occurred. Resident #1's guardian ; said he/she did not sign a capacity to consent to Missouri Department of Health and Senior Services STATE FORM savy QiBF11 ifcontinuation sheet 3 of & PRINTED: 11/26/2024 7 FORM APPROVED Missouri Department.of Health and Senior Services STATEMENT OF DEFICIENCIES (X7} PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AN . . . DB PLAN OF CORRECTION IDENTIFIGATION NUMBER: A. BUILDING: COMPLETED Cc 30112 B. WING a 41/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 3017 BROOKING PARK AVENUE PETTIS COUNTY ASSISTED LIVING LLC SEDALIA, MO 65301 (x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES ID : PROVIDER'S PLAN OF CORRECTION : (x5} PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' PREFIX § (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE Tas | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS-REFERENCED TO THE APPROPRIATE i DATE } i DEFICIENCY). : | A8022} Continued From page 3 | A8022 d ij | sexual activity form for Resident #1. i During an interview on 11/04/24 at 12:00 P.M., Resident #1 said he/she does not remember when the incident happened with Resident #2, but : Resident #2 had been following him/her around ‘ ‘ for two months. Resident #1 said staff knew and | i . also knew he/she did not like Resident #2 : following him/her around. Resident #1 said | he/she and Resident #2 were not ; boyfriend/girlfriend. Resident #1 said Resident #2 : sexually abused him/her, because his/her black pants were wet and there was "stuff".on the bed i sheets. Resident #1 said he/she asked Resident #2 "What the hell happened.” Resident #2 said when he/she woke up he/she was clothed, but | doesn't remember if Resident #2 was. Resident ' #1 said Resident #2 and his/her former roommate, Resident #3, were together as boyfriend/girlfriend. 3. Review of Resident #2's medical record | showed the resident admitted on 08/02/24. The | resident did not have a legal guardian. { | | | 3 } i i | i | Review of the resident's medical record showed it | : did not contain a Capacity to Consent to Sexual | Activity form for the resident. | { | i i 1 i Review of Resident #2's facility behavior notes, dated 10/22/24 at 11:35 P.M., showed Resident #2 was found by the DON in Resident #3's bed and would not leave until he/she was informed | administration will be notified. Resident #2 was | informed he/she was not allowed physical contact : with other residents, Review showed a staff person would "periodicaily” go to the Resident : #3's room to check and make sure Resident #2 did not go back in the room. Missauri Department of Health and Senior Services STATE FORM bf09 O1BFI1 if continuation sheet 4 of 8 PRINTED: 11/26/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B.WING 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE SEDALIA, MO 65301 XID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION ; (x5) PREFIX | (EACH DEFICIENCY MUST 8& PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE 1 COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE : DEFICIENCY) : PETHS COUNTY ASSISTED LIVING LLC A8022} Continued From page 4 ; A8022 , Review of Resident #2's facility behavior notes, | dated 10/28/24 at 2:53 P.M., showed Resident #2 ' said he/she had consensual sex with Resident | #1. Both the residents were separated and an | investigation started. Resident #2 was i | interviewed by the Sheriff's department and ; placed under arrest and left with the Sheriff's deputies at approximately 2:45 P.M. on 10/28/24. During an interview on 10/29/24 at 11:36 P.M. the | local detective said he/she spake with Resident #2 who said he/she did have sex with Resident | #1 and it was consensual sex. The detective said Resident #I was not able to give consent due to his/her illness of dementia. | 4. Observation on 10/30/24 at 10:30 A.M, showed , the local Sheriff's Deputy present as the Children's Safe Place employee interviewed ; Resident #1 who said Resident #2 stalked, | harassed, and wanted him/her to do stuff with | his/her and he/she did not want to, Resident #1 | said he/she told Resident #2 he/she just wanted | to be friends and Resident #2 would get mad and | throw things, yell, and call him/her names. | Resident #1 said he/she thinks he/she talked to | staff and thinks staff talked to Resident #2. | Resident #1 said he/she and Resident #2 slept | together side by side on 10/28/24 and when | he/she. woke up there were feces stains on his/her sheets and his/her pants were wet. : Resident #1 said his/her pants were on, but were : wet and Resident #2's shirt and pants were off. : Resident #1 said his/her body “did not feel different.” Resident #1 said sex happened and he/she told Resident #2 to leave, he/she did not want that. During ah interview on 10/30/24 at 12:08 P.M., | LIMAA said on 10/28/24 at approximately 9:00 Missouri Department of Heallh and Senior Services STATE FORM ayy Q4BF11 continuation sheet 5 of 8 PRINTED: 11/26/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED ABUILDING:. . Cc B. WING 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiF CODE 3017 BROOK PETTIS COUNTY ASSISTED LIVING LLC ING PARK AVENUE SEDALIA, MO 65301 T 1 le a (M410 | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION : (x5) PREFIX | {EACH DEFICIENCY MUST BE PRECEDED BY FULL : PREEIX : (EACH CORRECTIVE ACTION SHOULD BE : COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS-REFERENCED TO THE APPROPRIATE : DATE | DEFICIENCY) A022 | Cantinued From page 5 A8022 | A.M., he/she found Resident #2 in Resident #1's : bed, LIMAA said he/she woke up Resident #2 - and told him/her to get up and get out of the : room. LIMAA said Resident #1 came out of the bathroom and told him/her Resident #2 had done stuff to him/her and he/she did not want it. LIMAA said Resident #2 had his/her clothes on. LIMAA said Resident #2 followed him/her around saying : "I did nothing wrong." LIMA A said when the DON ; and RCC got in, he/she reported the information | to them. ! During an interview on 10/29/24 at 10:00 A.M., : the RCC said level | medication aide (LIMA) A | sent him/her a text and said he/she found Resident #2 in Resident #1's bed. The RCC said | Resident #1 told him/her Resident #2 wanted sex, | but he/she did not want to have sex and he/she ' finally gave in. The RCC said Resident #1 said ' | | when he/she woke up there was feces all over ; : his/her bed. The RCC said Resident #1 called | _ his/her guardian and told his/ner guardian what | happened, and the guardian wanted charges pressed since Resident #1 does not have i _ cognitive ability to have consensual sex. The | RCC said the Sheriff's department was called and | after they got Resident #1's statement he/she | | was sent out to the hospital and Resident #2 was arrested. | i : During an interview on 10/29/24 at 9:45 A.M., the , Director of Nursing (DON) said on 10/28/24 at ' approximately at 9:00 A.M., he/she was doing / room checks and noticed Resident #1's bedding : was stripped off his/her bed and was on the other i | bed in the room. The DON said Resident #1 said | } | told Resident #2 he/she just wanted to be friends ; and did not want to have sex. The DON said Resident #1 said Resident #2 crawled in bed with | | ; him/her and something happened early in the | Missouri Deparimeni of Health and Senior Services STATE FORM 6a38 O1BFt1 If continuation sheet 6 of B Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {Xi} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER. OR SUPPLIER PETTIS COUNTY ASSISTED LIVING LLC (x4) ID PREFIX. | TAG A8022: PRINTED: 11/26/2024 FORM APPROVED {X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY A BUILDING: 6. WING SEDALIA, MO 65301 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL REGULATORY OR LSC IDENTIFYING INFORMATION} Continued From page 6 : mamning. The DON said Resident #1 said there > was feces all over his/her bed. The Sheriff's : department and Resident #1's guardian were called. The DON said Resident #1 was sent to the hospital to be examined on 10/28/24 after the : Sheriffs department interviewed Resident #1. : The DON said Resident #2 was arrested and was i injail. The DON said facility staff should observe : residents every hour. i During an interview on 10/29/24 at 9:27 A.M., the | administrator said he/she was made aware ! Resident #2 made Resident #1 have sex wiih | hinvher on 10/28/24 when staff told him/her. The : administrator said as soon as she was made | aware they started-an investigation and Resident | #1 Was put on one.on one and the Sheriff's | department was called on 10/28/24 at around ! 9:30 A.M, : During an interview on 11/01/24 at 2:00 P.M., the : Director of the Sexual Assault Nurse Examiner : said the nurse documented bruises on the inner ' thigh of Resident #1 which does not always indicate rape in the elderly as they often lake ’ blood thinners and can bruise easily. The nurse : alse collected swabs from Resident #1, He/She : said the results of the swabs could take up to a . year for the preliminary results to be received. : Resident #1 refused certain steps of the exam : but no lacerations, trauma, blood, or bodily fluids ' were seen externally on Resident # I. During an interview on 11/01/24 at 4:20 P.M, the » administrator said he/she was new to the facility ' and had only been the acting administrator for : about twa weeks. He/She said Resident #1 was , unable to give consent for sexual relations, | because he/she has a guardian. The | administrator said there should be a consent form Missouri Department of Health and Senior Services STATE FORM iD PREFIX TAG ; A8022 Q1BF 11 COMPLETED Cc 11/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE PROVIDER'S PLAN OF CORRECTION i («5) {EACH CORRECTIVE ACTION SHOULD BE {COMPLETE CROSS-REFERENCED TO THE APPROPRIATE : DATE DEFICIENCY) H If continuation sheet. 7 af & Missouri Department of Health and Senior Services (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING NAME OF PROVIOER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3017 BROOKING PARK AVENUE PETTIS COUNTY ASSISTED LIVING LLC SEDALIA, MO 65301 PRINTED: 11/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/06/2024 e410 SUMMARY STATEMENT OF DEFICIENCIES PD PROVIDER'S PLAN OF CORRECTION xs) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIEYING INFORMATION) ' TAG CROSS-REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) A8022; Continued From page 7 » Ag0220 signed per ihe policy she obtained from their corporate office, but he/she was unable to find a consent form for Residerit # |. During an interview on 11/5/24 at 1:45 P.M., the { administrator said he/she is unable to provide proof staff performed face checks on the night \ shift for 10/28/24 and is reviewing the camera | footage and had proof that face checks were not : done every hour by staff from the video footage i even though they documented they did them. ! The administrator said there is not a written i policy, but itis part of the Electronic Medical : Record (E-MAR) program far hourly checks be done on all residents. She said if the checks are ' not documented it will flag it like it woutd if a | medication was nat given on time. The administrator said her expectation of slaff is to do hourly face checks on all residents since it is part of the E-MAR program and staff are in-serviced on deing hourly face checks. i H | } i NOTE: At the time of the complaint investigation the violation was determined to be at an imminent danger class I level. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will | be conducted to determine if the facility is in | substantial compliance with participation | requirements. { : At the time of exit, the imminent danger was removed. M000244226 and MO00244230 ; : t i iH { } | } j i i Missouri Department of Healih and Senior Services STATE FORM Sage OiBF 14 lf continuation sheet 8 of 8 PLAN OF CORRECTION Provider/Supplier Name: Pettis County Assisted Living Street Address, City, Zi 3017 Brooking Park Ave, Sedalia Mo, 65301 ity, Zip: Date of Survey: 11/06/2024 Preparation and execution of the Plan of Correction does not constitute an admission or agreement to the allegation or conclusions set forth in the statement of Deficiencies. The Plan of Correction is prepared and executed solely because it is requested by State and Federal law. None of the actions taken by the facility pursuant to its Plan of Corrections should be considered an admission that a deficiency existed, or additional /measures should have been in place at all time of survey. PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER Co ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A8022 All residents have the potential to be affected by this 41/8/2024 deficient practice. Resident #2 was taken to jail and was issued an Po immediate discharge on 10/28/2024. All staff currently at work to be inserviced by Administrator and/or Designee immediately on completing face checks hourly and documenting it in Point of Care, ensuring that resident is safe in the facility and in room assigned to them | as policy states. All staff currently at work to be inserviced | by Abuse and Neglect Policy. All oncoming staff willbe | inserviced by Administrator and/or Designee prior to | clocking in for scheduled shift on completing face checks hourly and documenting it in Point of Care, ensuring that resident are safe in the facility and in room assigned to them as policy states before working assigned shift. All oncoming staff will be inserviced by Administrator and/or Designee prior to clocking in on the Abuse and Neglect Policy. All new hires will be inserviced in orientation upon hire on completing face checks hourly and documenting in Point of Care, ensure that resident is safe in the facility and in room assisted to them as policy states, as well as the Abuse and Neglect Policy. All in servicing will be | completed verbally by Administration and staff will sign | ____and date an inservice sheet. All residents to be educated immediately by Administrator and/or Designee on rules associated with congregating with peers. Residents will be closely monitored in common areas from 10pm-7am by adding one additional staff member. From 10pm-7am residents are only able to congregate on specific hall in common areas. Residents to be educated on only entering assigned rooms. _ The Administrator and/or Designee will review documentation in Point of Care face checks daily on completion of face check documentation in Point of Care to ensure appropriate staff documented the completion of the checks. Anything found out of compliance will be addressed immediately by Administrator. Upon facility admission, forms for sexual consent will be presented to all residents or guardians. Consent forms will be reviewed and monitored weekly at IDP meetings. Face sheets will be updated for staff to identify residents with a history of sexual misconduct. Individual Service Plans and Community Based Assessments will be updated to reflect such identification. |SP’s are available to staff in Point Click Care system. Resident #1 has been seen by Physician and Psych Services. Group and Individual therapy have been made available. Resident is closely monitored for signs and/or symptoms of anxiety and/or stress and face checked ___ hourly. __ Resident #2 has been discharged from the facility and is not allowed to be readmitted in the future. If the discharge is appealed and resident is not in protective custody, we will assign a staff member to one-on-one supervision of the resident. 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.
2024-07-10Annual Compliance Visit2269 · 10 findings
“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.
“Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. 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.
“Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. 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.
“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.
“Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. 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.
“Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/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.
“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.
“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.
“Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/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.
“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/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.
2024-05-08Complaint Investigation4776 · 1 finding
“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. 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.
2024-04-03Complaint Investigation4797 · 1 finding
“The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. 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.
2023-11-30Complaint Investigation2283 · 2 findings
“Smoking. (A) Smoking shall be permitted in designated areas only. Areas where smoking is permitted shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/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.
“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.
18 older inspections from 2018 are not shown above.
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