BLUFF CREEK TERRACE ASSISTED LIVING.

PRINTED: 10/28/2025 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: COMPLETED A. BUILDING: 20625C Sh 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3104 BLUFF CREEK DRIVE COLUMBIA, MO 65201 (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) BLUFF CREEK TERRACE ASSISTED LIVING A4704 19 CSR 30-86.047(6) Operator/Administrator | Responsibilities The operator shall be responsible to assure compliance with all applicable laws and regulations. The administrator shall be fully authorized and empowered to make decisions | regarding the operation of the facility and shall be held responsible for the actions of all employees. The administrator 's responsibilities shall include oversight of residents to assure that they receive care as defined in the individualized service plan. UI _ This regulation is not met as evidenced by: Class III Based on observation, interview, and record review, facility staff failed to assure compliance with all applicable laws and regulations when the | facility staff failed to maintain active exception approval from the Department of Health and Senior Services (DHSS) in regards to the separation of hazardous areas by smoke partitions and doors and the doors shall be self or auto closing for the kitchen's pass-thru window, and in regards to the separation of food service operations by complete partitioning and solid, self-closing doors for the kitchen's pass-thru window. The facility census was 27. 1. Review of an exception certificate granted to the facility showed the following: -An approved exception regarding the separation of hazardous areas by smoke resistant partitions and doors and the doors shall be self closing for the kitchen's pass-thru window; -An approved exception regarding the separation of food service operations by complete partitioning and solid, self-closing doors for the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE reread STATE FORM 6899 LLM711 If continuation sheet 1 of 6 WN Via, WA S\U\avalo STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER BLUFF CREEK TERRACE ASSISTED LIVING (x4) 1D PREFIX TAG A4704 Missouri Department of Health and Senior Services STATE FORM (X1} PROVIDER/SUPPLIER/CLIA {IDENTIFICATION NUMBER: 20625C (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 10/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED COLUMBIA, MO 65201 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} Continued From page 1 kitchen's pass-thru window; ~The operator will maintain compliance with all stipulations listed in the Section for Long-Term Care Regulation exceptions approval, dated 02/19/20, for continued approval of the above listed exceptions; -An expiration date of 02/28/22 for the approved exception and instructions to post the approved certificate alongside the facility license. Review of a letter addressed to the facility from DHSS, dated 02/19/20, showed the exception will be for a period of two years and the letter provided instruction for the facility to make a written request to DHSS 45 days prior to the approval's expiration date of 02/28/22 in order to renew the approved exception. Review of the facility's licensure and certification records, showed the DHSS approval for the exception expired on 02/28/22 and the facility did not have an active approval for the use of the kitchen's pass-thru window. Observation on 10/22/25 at 12:30 P.M., showed the exception certificate was not pasted on the wall by the facility's license. Observation on 10/22/25 at 12:35 P.M., showed the kitchen pass-thru window in the facility's memory care building. Observation showed the kitchen pass-thru window without the ability to self or automatically close and only able to close with a manual latch. Observation showed the facility staff utilizing the kitchen pass-thru window and showed plates of cookies placed on the counter at the opening of the pass-thru window. During an interview on 10/22/25 at 3:50 P.M., the 6899 CROSS-REFERENCED TO THE APPROPRIATE LLM7114 10/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3104 BLUFF CREEK DRIVE PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY) If continuation sheet 2 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER BLUFF CREEK TERRACE ASSISTED LIVING {X4) 1D PREFIX TAG A4704 Missoun Depariment of Health and Senior Services STATE FORM IDENTIFICATION NUMBER: 20625C (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING COLUMBIA, MO 65201 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Administrator said he/she was not aware the facility had an approved exception for the kitchen's pass-thru window. The administrator said the exception certificate is not posted by the facility license and was not aware the approved exception expired on 02/28/22. 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shal! immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. ti/Ill This regutation is not met as evidenced by: Class III Based on observation and interview, facility staff failed to protect food from potential contamination when facility staff failed to discard expired food 68es LLM711 STREET ADDRESS, CITY, STATE, ZIP CODE 3104 BLUFF CREEK DRIVE PRINTED: 10/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/22/2025 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 6 PRINTED: 10/28/2025 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 20625C B. WING 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3104 BLUFF CREEK ORIVE COLUMBIA, MO 65201 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL : (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BLUFF CREEK TERRACE ASSISTED LIVING A7015 Continued From page 3 items and failed to labet and date prepackaged food to protect the food from potential contamination. The facility census was 27. 1. Review of the facility's Kitchen Services policy, undated, showed the facility will maintain proper storage of dry and refrigerated food. Observation on 10/22/25 at 10:15 A.M., showed the large refrigerator in the main kitchen contained: -A plastic bag with a zip closure which contained sliced ham dated 08/08/25; -A plastic bag with a zip closure which contained parmesan cheese and undated. Observation on 10/22/25 at 10:28 A.M., showed the dry storage room contained: -Two 18.6 ounce package of tortilla shells with a best buy date of 06/02/25; -A 18.6 ounce package of tortilla shells with a best buy date of 09/02/25; -Two 82.5 ounce package of white corn tortilla shells with a best buy date of 06/03/25; -A 82.5 ounce package of white corn tortilla shells with a brownish substance and a best buy date of 06/03/25. Observation on 10/22/25 at 11:05 A.M., showed dry storage in the memory care buildings kitchen contained: -A 10 ounce bag of mini marshmallows with a best buy date of 05/10/25; -A 10 ounce bag of mini marshmallows with a best buy date of 05/18/25; -Three 10 ounce bags of mini marshmallows with Missouri Department of Health and Senior Services STATE FORM 6899 LLM711 if continuation sheet 4 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER BLUFF CREEK TERRACE ASSISTED LIVING A7015 STATE FORM Missouri Department of Health and Senior Services IDENTIFICATION NUMBER: 20625C (X2} MULTIPLE CONSTRUCTION A. BUILDING: B. WING COLUMBIA, MO 65201 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} Continued From page 4 a best buy date of 07/19/25; -Five 24.5 ounce packages of tortilla shells with a best buy date of 09/01/25. Observation on 10/22/25 at 11:10 A.M., showed the freezer in the memory care buildings kitchen contained: -A plastic bag of garlic bread opened and undated: -A plastic bag of bread sticks opened and undated; -A plastic bag of waffles opened and undated. During an interview on 10/21/25 at 3:30 P.M., Cook A said the cooks and Dietary Manager are all responsible to ensure expired food items are thrown out and food is dated after being opened. Cook A said staff usually check for expired and undated food items monthly and said the tortilla shells and marshmallows were overlooked. During an interview on 10/21/25 at 3:35 P.M., the Dietary Manager said all cooks and him/herself are responsible to ensure expired food items are thrown out and food is dated after being opened. He/She said staff should be checking for expired and undated foad items daily and the expired and undated food items must have been missed. The Dietary Manager said he/she was not aware of the expired and undated food items. During an interview on 10/21/25 at 3:50 P.M., the Administrator said all kitchen staff, the Dietary Manager and him/herself are ultimately responsible to ensure expired food items are thrown out and food is dated after being opened. The Administrator said he/she would expect for expired food items to be thrown away and for 6aa9 ID PREFIX TAG LLM711 STREET ADDRESS, CITY, STATE, ZIP CODE 3104 BLUFF CREEK DRIVE PRINTED: 10/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/22/2025 PROVIDER'S PLAN OF CORRECTION {X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 6 PRINTED: 10/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20625C B. WING 40/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3104 BLUFF CREEK DRIVE COLUMBIA, MO 65201 (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 OATE ' DEFICIENCY) BLUFF CREEK TERRACE ASSISTED LIVING A7015 Continued From page 5 opened food items to be dated. Missouri Department of Health and Senior Services STATE FORM 68a9 LLM714 If continuation sheet 6 of 6 PLAN OF CORRECTION L _ | i, as Provider/Supplier | 51 Creek Terrace Name: | Sane | Street Address, | 3104 Bluff Creek DR Columbia MO, 65201 City, Zip: Date of Survey: 10-22-2025 i SS PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE } A4704 Exception letter sent to MO-DHSS 10/28/2025 10/28/2025 | | | Gas Stove turned to “Off” and will continue to stay “Off” until 10/22/2025 _| Bluff Creek Terrace is granted an exception or finds an | acceptable solution to meet MODHSS regulation standard | Exception will be hung by State of MO Licensure in foyer, kitchen, and a copy will be kept in the State Ready binder Alert added to Administration Calendar to renew exception T 41/03/2025 Within correct time frame of 2 years | | es A7015 All kitchen staff and Administrator sign and review label, dating, im 11/03/2025 And proper storage protocol per State Regulation | Daily Duty Sheet updated to reflect proper food storage, 40/24/2025 . { labeling, checking dates, and discarding expired food items | Kitchen staff enrolled into corporate food storage education | 44/03/2025 ; class. Class is 11/17/2025 at 1:30 oe ls c — — - —_— }———~ -| —t + = pis == rf — —_—_—+ iin idan — a) al a oa 4 L cose ei 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.