Inspection Reports for
Addington Place of Lee‘s Summit

19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Based on observation, interview, and record review, the facility failed to report and investigate an injury of unknown origin for one sampled resident (Resident #1) and failed to investigate a bruise of unknown origin observed by the Director of Nursing; this had the potential to affect all residents.

19 CSR 30-86.047(12) EDL Requirements: The facility failed to check the Employee Disqualification List (EDL) for four sampled volunteers (Volunteers A, B, C and D). No EDL checks were found and volunteers only had a one-page questionnaire.

19 CSR 30-86.022(8)(C) Exit Sign-Illumination: Surveyor observed exit/emergency lights (EL-32 and EL-3) did not operate when the test button was pressed, potentially affecting all residents.

19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13: Missing escutcheon rings were observed at sprinkler heads (room 306 bathroom, outside room 306, and storage closet by room 306) and record review showed pictures of partial obstructions in pipes, indicating the facility failed to maintain a complete sprinkler system.

19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs: Emergency lights (EL-32 and EL-3) did not light when the test button was pressed, indicating they would not provide required battery-powered illumination.

19 CSR 30-86.047(35) Protective Oversight: The facility failed to ensure one sampled resident received protective oversight during cares; a care manager grabbed and held the resident's arm resulting in a bruise.

19 CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults: Facility failed to correct faults with the fire alarm system; inspection records showed failed or expired PS-1270 batteries and records/email indicated eight batteries remained un-replaced despite being cited in prior inspections.

19 CSR 30-86.022(17) Oxygen Storage Requirements: Oxygen equipment was observed in Room 302 but no sign was posted on the door to ensure oxygen storage requirements were met.

19 CSR 30-86.032(2) Substantially Constructed & Maintained: Observed several sprinkler escutcheon rings and heads with gaps in hallways, a slight hissing sound from the air compressor by the sprinkler riser, and a broken wall flood light mounted at ground level laying on the ground.

19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on record review and interview, the facility failed to provide documentation of monthly fire drills for the past twelve months and had records for only four months.

19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees: Based on record review and interview, the facility failed to provide documentation of required employee fire safety training upon hire and at least every six months.

19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview, the facility failed to test and maintain the complete fire alarm system semi-annually in accordance with NFPA 72 and did not have a current semi-annual fire alarm inspection report.

19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of: Based on observation and interview, unnecessary combustible materials and storage were observed in multiple areas (hallway, laundry rooms, utility closets), creating potential fire hazards and limiting access to panels/egress.

19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: Based on observation and interview, a smoke partition door near room 214 was not closing properly and required adjustment, risking smoke or fire spread between sections.

19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on observation, record review, and interview, the facility failed to maintain a complete sprinkler system; several escutcheon rings were missing and monthly sprinkler check records were incomplete.

19 CSR 30-86.022(12)(A) Emergency Lighting - locations: Based on observation and interview, emergency lighting of sufficient intensity was not provided in required locations; some emergency lights would not stay lit when tested.

19 CSR 30-86.022(17) Oxygen Storage Requirements: Based on observation and interview, oxygen cylinders and/or concentrators were observed in resident rooms without required precautionary signage on or near the doors advising that oxygen is being used inside.

19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: Based on observation and interview, a space heater built into a TV hutch was found in a resident room producing heat while in use, indicating use of a portable/unauthorized heating device.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Based on observation, record review, and interview, the facility failed to have electrical wiring inspected every two years and had hazards including a scorched GFCI outlet and exposed wiring not contained in a junction box.

19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review the facility failed to ensure that two sampled residents were free from misappropriation of their funds. Facility records and interviews showed police were notified, an employee was terminated, and criminal charges/warrants were pending.

19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Based on interview and record review, the facility failed to immediately report an allegation of resident abuse by facility staff according to their written policy, affecting two residents (Resident #1 and #2) out of three sampled residents.

19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: Based on record review and interview during the fire safety portion of the licensure inspection the facility failed to ensure a current annual fire alarm system certification was performed; record review showed the last annual inspection was 02/27/2019.

19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13: Based on observation, record review and interview during the fire safety portion of the licensure inspection the facility failed to ensure a complete sprinkler system was installed and maintained; observations found two missing sprinkler heads in a hallway and one missing head in the kitchen that were capped while repairs were pending after frozen lines.

19 CSR 30-86.022(9)(A) Fire Alarm Complete System: The facility failed to have a complete fire alarm system as required; the attendants' station had been moved and there is no manual pull station at or near the attendant's station.

19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13: The facility failed to provide documentation of required monthly sprinkler system checks; observation and record review showed no sprinkler log present in the Sprinkler/Riser Room.

19 CSR 30-86.022(12)(A) Emergency Lighting - locations: The facility failed to provide emergency lighting in the attendants' station as required; the attendants' station lacked emergency lighting after being moved.

19 CSR 30-86.022(16)(D)(3)(A - E) Locking Devices Requirements: The facility failed to provide proper signage for delayed egress doors as required; the delayed egress door by Room 414 did not display the required 'Push Until Alarm Sounds, Door Can Be Opened in 30 Seconds' sign.

19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Based on interview and record review, the facility failed to investigate an allegation of resident mistreatment by facility staff, affecting one out of three sampled residents; the facility census was 68 residents.

19 CSR 30-86.022(8)(C) Exit Sign-Illumination: The facility failed to ensure required exit signs were illuminated; the exit sign outside Room 212 failed to illuminate when tested, affecting residents.

19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to maintain a complete fire alarm system; record review showed no documentation of a semi-annual fire alarm inspection in accordance with NFPA 72.

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to ensure required self-closing doors remain closed; the laundry room door was propped open with a waste basket preventing the self-closing device from functioning.

19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps: The facility failed to ensure clothes dryers were vented to the outside; vents from two of three dryers were disconnected allowing dryers to vent directly into the laundry room.

19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13: The facility failed to maintain a complete sprinkler system; plastic storage containers were located within ten inches of a sprinkler head and a one-half inch gap was observed around an escutcheon plate.

19 CSR 30-86.022(12)(B) Emergency Lighting - Power Source: The facility failed to ensure required emergency lighting illuminated properly; emergency lights in the nurse station/medication room and the hallway outside Room 212 failed to illuminate during testing.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility failed to ensure wastebaskets were of approved metal or fire-resistant types; unapproved plastic, wire mesh or wicker wastebaskets were observed in multiple rooms.

19 CSR 30-86.022(16)(D)(3)(A - E) Locking Devices Requirements: The facility failed to ensure delayed egress magnetic locks operated properly; during a test three of four delayed egress doors failed to release on activation of the fire alarm, affecting residents in the memory care unit.