Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
60% occupied
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 12
Date: Oct 15, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Brookdale Wornall Place following a survey conducted on 10/15/2024. The visit was to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to meet multiple fire safety and emergency preparedness regulations including fire extinguisher maintenance, fire drill documentation, fire alarm testing, sprinkler system maintenance, emergency lighting, flame-resistant curtains, wastebasket approvals, oxygen storage, and boiler inspection certifications. These deficiencies potentially affected all 41 residents.
Deficiencies (12)
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to document monthly pressure checks and annual maintenance of fire extinguishers, including one on the 5th floor not inspected since 2020.
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation. The facility failed to provide documentation of annual consultation and assistance from a local fire unit for fire and evacuation plans.
19 CSR 30-86.022(5)(B)(1-10) Fire Drill/Evacuation Plan Requirements. The facility failed to produce a written plan or have knowledge of proper use and response to area of refuge in emergencies.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to produce documentation of at least 12 fire drills annually and documentation of drills on each shift every three months.
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements. The facility failed to have accessible exits, signage, communication systems, and emergency lighting for areas of refuge on floors without grade exits.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to show proof of monthly activation of the fire alarm system at least once each month.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to perform monthly pressure gauge readings and valve position checks on the sprinkler system.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The facility failed to provide sufficient emergency lighting at attendants' stations, including an inoperable light on the 5th floor nurses station.
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant. The facility failed to install certified flame-retardant curtains or treat existing curtains chemically.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were approved fire-resistant types and had numerous non-approved wastebaskets in resident rooms.
19 CSR 30-86.022(17) Oxygen Storage Requirements. The facility failed to provide oxygen storage in accordance with NFPA 99, including excess oxygen tanks in resident rooms.
State Statute A9998. The facility failed to show plans to maintain current approved boiler inspection certifications, with certificates for 5 boilers expiring soon.
Report Facts
Facility census: 41
Fire drills documented: 7
Fire drills documented: 2
Fire drills documented: 3
Fire alarm activations: 6
Boilers: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Engineering | Interviewed regarding fire drill assistance, area of refuge procedures, fire alarm system, sprinkler system, emergency lighting, oxygen storage, and boiler inspections | |
| Maintenance Director | Interviewed and responsible for fire extinguisher inspections, fire drill documentation, fire alarm system, sprinkler system, emergency lighting repairs, wastebasket compliance, oxygen storage, and boiler inspection follow-up | |
| Assisted Living Director | Involved in monitoring fire safety checks, wastebasket removal, and oxygen storage | |
| Housekeeping Director | In-serviced on safety codes related to wastebaskets and approved materials |
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 1
Date: Jul 15, 2024
Visit Reason
The inspection was conducted due to an allegation of possible resident-to-resident abuse involving two sampled residents.
Complaint Details
The visit was complaint-related due to an allegation of resident-to-resident abuse. The facility census was 34 residents at the time of the incident. The complaint was substantiated based on interviews and record review.
Findings
The facility failed to immediately investigate and report the alleged resident-to-resident abuse to the state agency. Interviews and record reviews confirmed the delay in reporting and gaps in staff awareness of reporting requirements.
Deficiencies (1)
19 CSR 30-88.010(25) requires immediate reporting of suspected resident abuse or neglect. The facility failed to promptly report an allegation of resident-to-resident abuse involving two residents.
Report Facts
Facility census: 34
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 1
Date: Oct 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with protective oversight regulations, specifically regarding timely response to resident call lights.
Findings
The facility failed to ensure call lights were answered in a timely manner for three sampled residents. Multiple call light alerts were unanswered for extended periods, indicating a deficiency in protective oversight.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to ensure call lights were answered timely for three sampled residents. Call lights were unanswered for durations ranging from 35 minutes to over three hours.
Report Facts
Facility census: 29
Call light unanswered durations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) A | Observed resetting call light pendant and pager alerts | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding call light response expectations | |
| Director of Assisted Living | Interviewed regarding call light system tracking and staff pager usage |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 11
Date: Aug 8, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a facility inspection conducted on 08/08/2023 at Brookdale Wornall Place.
Findings
The facility failed to meet multiple fire safety and maintenance regulations including fire extinguisher checks, fire drills, fire alarm system tests, door device functionality, smoke section partitions, sprinkler system maintenance, wastebasket compliance, oxygen storage, exit door maintenance, electrical wiring inspections, and extension cord usage. These deficiencies potentially affected all 33 residents present at the time of inspection.
Deficiencies (11)
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to document monthly fire extinguisher checks as required, potentially affecting 33 residents.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to document at least 12 fire drills annually and one drill per shift every three months, potentially affecting 33 residents.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to show proof of monthly fire alarm system activation, potentially affecting 33 residents.
19 CSR 30-86.022(10)(G) Door Devices - Self/Auto closing. The facility failed to ensure doors providing separation between floors closed properly upon fire alarm activation, potentially affecting 33 residents.
19 CSR 30-86.022(10)(J) Smoke Section Partitions < than 20 beds. The facility failed to ensure smoke stop partition doors closed properly during fire alarm activation, potentially affecting 33 residents.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to perform monthly pressure gauge and valve position checks on the sprinkler system since November 2022, potentially affecting 33 residents.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility used non-approved wastebaskets in multiple rooms, potentially affecting 33 residents.
19 CSR 30-86.022(17) Oxygen Storage Requirements. The facility failed to provide oxygen storage in accordance with NFPA 99, 1999 Edition, potentially affecting 33 residents.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to properly maintain an exit door, potentially affecting 33 residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to show documentation of electrical wiring inspection within the last two years, potentially affecting 33 residents.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles. The facility failed to prevent extension cords from being used with more than one electrical item plugged in, potentially affecting 33 residents.
Report Facts
Facility census: 33
Fire drills required annually: 12
Fire drills per shift every three months: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed multiple times regarding deficiencies and corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 9, 2023
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a state survey conducted at Brookdale Wornall Place.
Findings
The facility failed to meet staffing ratio requirements and did not ensure proper assessment and respectful treatment of residents, including a resident who fell and was injured. The facility also failed to ensure dignity and respect for residents, with documented incidents of staff being rude and disrespectful.
Deficiencies (2)
19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety: The facility failed to ensure adequate staffing to meet resident care needs, evidenced by improper assessment and handling of a resident who fell and was injured.
19 CSR 30-88.010(29) Dignity/Privacy: The facility failed to treat a resident with dignity and respect, as a Level One Medication Aide was rude and disrespectful while assisting a resident after a fall.
Report Facts
Facility census: 27
Facility census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| L1MA A | Level One Medication Aide | Named in findings related to resident fall and dignity/privacy violations |
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 2
Date: Nov 8, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to proper care per individualized service plans and reporting of abuse or neglect in the assisted living facility.
Findings
The facility failed to ensure proper care for a resident with aggressive behaviors related to alcohol use and failed to immediately report and investigate an allegation of resident abuse by a staff member. The facility census was 34 residents at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to ensure one resident's individualized service plan included goals or guidance for managing alcohol use and aggressive behaviors.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed. The facility failed to immediately report and investigate an allegation of resident abuse by a Level 1 Medication Aide.
Report Facts
Facility census: 34
Sampled residents: 5
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 7
Date: Jul 13, 2022
Visit Reason
The inspection was conducted to identify deficiencies related to fire extinguishers, sprinkler systems, emergency lighting, wastebaskets, electrical wiring, elevator requirements, and boiler inspections at Brookdale Wornall Place.
Findings
Multiple deficiencies were found including failure to document and maintain fire extinguisher checks, incomplete sprinkler system maintenance, emergency lights not in good repair, use of non-approved wastebaskets, lack of electrical wiring inspection documentation, missing elevator inspection certifications, and absence of current boiler inspection certificates. These issues potentially affected all 46 residents present during the inspection.
Deficiencies (7)
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to document and date all fire extinguisher checks annually and monthly. A fire extinguisher on the 5th floor had not been inspected since 2020.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to perform monthly pressure gauge readings and valve position checks on the sprinkler system as required. No records were found for these checks.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The facility failed to maintain emergency lights in good repair; three emergency lights in the 4th floor dining area had weak batteries or no lighting.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility used non-approved wastebaskets in multiple rooms, failing to ensure all wastebaskets were metal or fire-resistant rated.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to show documentation of electrical wiring inspections within the last two years. The last inspection was in 2018.
19 CSR 30-86.032(19) Elevator Requirements. The facility failed to have current approved elevator inspection certifications as required by state statute.
State Statute A9998. The facility failed to have current approved boiler inspection certifications. No boiler certificates were posted for any of the five boilers.
Report Facts
Facility Census: 46
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 1
Date: Mar 29, 2022
Visit Reason
The inspection was conducted to assess compliance with protective oversight regulations, specifically regarding the use and monitoring of side rails and low air loss mattresses for residents.
Findings
The facility failed to ensure accurate and updated side rail assessments for one sampled resident and did not properly train staff on the risks and use of side rails and low air loss mattresses. Documentation and physician orders related to these devices were incomplete or missing.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility did not ensure side rail assessments were accurate and updated for one resident and failed to train staff on risks of entrapment with side rails and low air loss mattresses.
Report Facts
Facility census: 46
Resident weight: 114.4
Inspection Report
Life Safety
Census: 40
Deficiencies: 8
Date: Oct 5, 2021
Visit Reason
The inspection was a fire safety licensure inspection conducted to evaluate compliance with fire safety regulations including inspection rights, fire extinguishers, fire drills, sprinkler systems, wastebasket requirements, building maintenance, and lighting.
Findings
The facility failed to meet several fire safety regulations including improper storage of oxygen tanks, incomplete fire extinguisher documentation, lack of required fire drill documentation, incomplete sprinkler system maintenance, use of non-approved wastebaskets, failure to maintain fire doors, and outdated electrical inspections.
Deficiencies (8)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard. The facility failed to ensure no portion of the building presented a fire hazard by limiting oxygen tanks in resident rooms to one in use and one spare.
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to provide complete documentation that all fire extinguishers were checked monthly as required.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to produce documentation of at least 12 fire drills conducted within the last year as required.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to ensure monthly pressure gauge readings and valve position checks of the sprinkler system were done as required.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were of approved types, with multiple rooms having non-approved wastebaskets.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to maintain a fire door in good repair, with a panic bar pulled loose from a fire door.
19 CSR 30-86.032(14) Lighting-Electric Only. The facility failed to show documentation of electrical wiring inspection within the last two years by a qualified electrician.
19 CSR 30-86.032(14) Lighting-Electric Only. The deficiency remained uncorrected as of 05/18/2022 with no electrical inspection ever done.
Report Facts
Facility census: 40
Facility census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| new director of maintenance | Interviewed regarding corrective actions and maintenance issues | |
| Director of Maintenance | Interviewed on 05/18/22 about uncorrected electrical inspection |
Inspection Report
Life Safety
Census: 44
Deficiencies: 3
Date: Jul 12, 2019
Visit Reason
The inspection was conducted as part of the fire safety portion of the licensure inspection to assess compliance with area of refuge, locked exit doors, stairways/corridors free of obstructions, and related fire safety regulations.
Findings
The facility failed to ensure all entrance/exit doors for areas of refuge were properly protected from fire elements and that exit doors were properly locked and equipped with delayed egress locks. Stairways were obstructed by chair lifts, hindering evacuation. Corrective actions were planned with completion dates by August 31, 2019.
Deficiencies (3)
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements: The area of refuge door on the 4th floor by room 455 lacked a smoke seal and doors by rooms 470 and 568 did not properly close and latch.
19 CSR 30-86.022(7)(E) Locked Exit Doors: The exit door by room 472 on the fourth floor was not locked against egress and lacked a delayed egress sign, requiring a code to unlock.
19 CSR 30-86.022(7)(G) Stairways/Corridors Free of Obstructions: Two chair lifts in the northeast stairwell obstructed evacuation stairways, hindering prompt evacuation of wheelchair-bound residents.
Report Facts
Facility census: 44
Number of chair lifts obstructing stairways: 2
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 4
Date: Sep 13, 2018
Visit Reason
The inspection was a licensure inspection focusing on fire safety and compliance with state regulations for Brookdale Wornall Place.
Findings
The facility failed to ensure proper functioning of the area of refuge doors, monthly sprinkler system checks, oxygen storage compliance, and electrical wiring maintenance. Several deficiencies were observed and documented during the fire safety portion of the inspection.
Deficiencies (4)
A2228: The facility failed to ensure the area of refuge doors by room 568 were properly working and closing. Doors were observed hitting each other and not closing fully.
A2268: The facility failed to complete monthly pressure gauge readings and valve position checks for the sprinkler system as required by NFPA 13. Some checklists were outdated or missing.
A2298: The facility failed to properly store and support oxygen bottles in accordance with NFPA 99. Oxygen was found stored in resident rooms and no designated storage room was set up.
A3214: The facility failed to properly maintain electrical wiring. An exit sign outside room 470 was hanging by wires and not properly secured.
Report Facts
Facility census: 42
Deficiencies cited: 4
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