CARE NETWORK OF GLADSTONE.

PRINTED: 07/01/2025 FORM APPROVED Missour Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET CARE NETWORK OF GLADSTONE GLADSTONE, MO 64119 PROVIDER'S PLAN OF CORRECTION 5) (x4) 10 SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE a TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | wo | CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A4513. 19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of _Tesidents and upkeep of the facility. Ata minimum, the staffing pattern for fire safety and _ care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every fifteen (15) residents or major fraction of fifteen (15) during the evening shift, and one (1) _ person for every twenty (20) residents or major | fraction of twenty (20) during the night shift. I/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 1 3-15 3 p.m. to 9 p.m. (Evening)* 1 3-15 9 p.m. to 7 a.m. (Night)* 1 3-20 *If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than | six (6) hours. Ill This regulation is not met as evidenced by: Class II _ Based on observation, interview and record review, the facility failed to ensure they had an adequate number and type of personnel for the _ proper care and protective oversight of residents. | This had the potential to affect all residents in the a 3l2020 if continuation sheet 1 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 07/01/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 06/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 CARE NETWORK OF GLADSTONE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A4513) 19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of residents and upkeep of the facility. Ata minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every fifteen (15) residents or major fraction of fifteen (15) during the evening shift, and one (1) person for every twenty (20) residents or major fraction of twenty (20) during the night shift. I/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 1 3 p.m. to 9 p.m. (Evening)* 1 9 p.m. to 7 a.m. (Night)* 1 3-15 3-15 3-20 *If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than six (6) hours. Ill This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to ensure they had an adequate number and type of personnel for the proper care and protective oversight of residents. This had the potential to affect all residents in the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 S95M11 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (X6) DATE If continuation sheet 1 of 11 PRINTED: 07/01/2025 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 Cc 12510C —ESESE———————s 06/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) CARE NETWORK OF GLADSTONE Continued From page 1 facility. The census was 53. Review of the facility's undated staffing policy showed: -There should be an adequate number of staff for proper resident care, social well-being, and facility upkeep; -Exact staffing ratios could vary depending on the residents needs and the facility's level of care; -Facility's that provide services to residents with evacuation impairments would need 1:15 ratio during the day and evening, and 1:20 at night. 1. During an interview on 6/12/25 at 11:15 A.M., Resident #2 said: -It was often hard to find a staff member in the evening time; -His/Her medication was sometimes late because there was not enough staff working. 2. During an interview on 6/12/25 at 11:40 A.M., Resident #5 said: -The facility was short staffed; -He/She asked a staff member for assistance on 6/3/25 and was told they were too busy. 3. During an interview on 6/12/25 at 11:40 A.M., Resident #6 said: -Sometimes it is difficult to get his/her pain medication because the facility was short staffed and the staff they do have are always busy. Review of the facility staffing scheduled showed: - The facility only had two staff members scheduled from 2:15 P.M. - 10:45 P.M. and 10:15 P.M. - 6:45 A.M. during the week of April 27, 2025 to May 3, 2025, May 4 2025 to May 10, 2025, May 11, 2025 to May 17, 2025, May 18, 2025 to May 24 2025, May 25, 2025 to May 31, 2025, June 1, 2025 to June 7, 2025, and June 8, 2025 Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 If continuation sheet 2 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 07/01/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 06/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 CARE NETWORK OF GLADSTONE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 to June 14, 2025 During an interview on 06/12/25 at 1:10 P.M. the Administrator said: -The facility census was 44 when she started working at the facility on 4/17/25; -Since that date, there had been a few new residents admitted to the facility; -As of 6/12/25, the facility census was 53; -She thought that the facility only needed one staff member for every forty residents; -She was not aware that the facility needed more than two staff for the evening and overnight shifts . MO255242 MO255910 MO255893 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; II This regulation is not met as evidenced by: Class II Based on interview and record review the facility failed to complete community based Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 11 PRINTED: 07/01/2025 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 Cc 12510C —ESESE———————s 06/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) CARE NETWORK OF GLADSTONE Continued From page 3 assessments (CBA) at least semi-annually for five of six sampled residents (Resident #1, #2, #3, #4, and #5). The facility census was 53. Review of the facility's undated Community Based Assessments policy showed: -CBA's should be completed within 5 days of a resident's admission, semi-annually, and whenever a resident experiences a significant change in condition. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 07/08/21; -Diagnoses included: Cerebral Infarction (also known as an ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced) and Contracture of Right Hand; - The last CBA completed was on 08/05/24. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 11/01/21; -Diagnoses included: Depression and Anxiety; - The last CBA was completed on 08/13/24. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 08/28/24: -Diagnoses included: Depression and Anxiety; - The last CBA was completed on 09/03/24. 4. Review of Resident #4's record showed: -He/She was admitted to the facility on 10/28/22: -Diagnoses included: Vascular Dementia, and Cerebral Infarction; -The last CBA completed was on 08/06/24. 5. Review of Resident #5's record showed: -He/She was admitted to the facility on 05/16/18; -Diagnoses included: Depression, Anxiety, and Congestive Heart Failure (CHF); -The last CBA completed was on 08/13/24. Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 If continuation sheet 4 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 07/01/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 06/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 CARE NETWORK OF GLADSTONE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 During an interview on 06/12/25 at 1:10 P.M. the Administrator said: -She knew that CBA's should be completed at admission and semi-annually; -The facility's new Director of Nursing had been working at the facility for three weeks and had begun updating CBA's but had not been able to complete all of them. 19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (I) Includes the signatures of an authorized representative of the facility and the resident or the resident's legal representative in the individualized service plan to acknowledge that the service plan has been reviewed and understood by the resident or legal representative; II This regulation is not met as evidenced by: Class II Based on interview and record review the facility failed to ensure individualize service plans (ISP) included signatures from the resident or his/her legal representative to acknowledge the ISP had been reviewed and understood by the resident or his/her legal representative, for five of six sampled residents (Resident #1, #2, #3, #4, and #5). The facility census was 53. The facility did not provide a policy regarding Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 11 PRINTED: 07/01/2025 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 Cc 12510C —ESESE———————s 06/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) CARE NETWORK OF GLADSTONE Continued From page 5 signatures on ISP's. 1. Review of Resident #1's record showed: -Diagnoses included: Cerebral Infarction (also known as an ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced) and Contracture of Right Hand; -The last completed ISP dated 08/16/24 was not signed by the resident or his/her legal representative. 2. Review of Resident #2's record showed: -Diagnoses included: Depression and Anxiety; -The last completed ISP dated 08/19/24 was not signed by the resident or his/her legal representative. 3. Review of Resident #3's record showed: -Diagnoses included: Depression and Anxiety; -The last completed ISP dated 09/09/24 was not signed by the resident or his/her legal representative. 4. Review of Resident #4's record showed: -Diagnoses included: Vascular Dementia, and Cerebral Infarction; -The last completed ISP dated 08/16/24 was not signed by the resident or his/her legal representative. 5. Review of Resident #5's record showed: -He/She was admitted to the facility on 05/16/18; -Diagnoses included: Depression, Anxiety, and Congestive Heart Failure (CHF); -The last completed ISP dated 08/18 /24 was not signed by the resident or his/her legal representative. During an interview on 06/12/25 at 1:10 P.M. the Administrator said: Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 If continuation sheet 6 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 07/01/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 06/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 CARE NETWORK OF GLADSTONE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 -She did not realize ISP's had to be signed by the resident or their legal representative; -She would expect ISP's to be signed by the resident or their legal representative in accordance with the regulation. 19 CSR 30-86.047(58)(B) Resident Condition/Medication Review The facility shall maintain a record in the facility for each resident, which shall include the following: (B) Areview monthly or more frequently, if indicated, of the resident 's general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III This regulation is not met as evidenced by: Class III Based on record review and interview, the facility failed to ensure monthly summaries were completed for, for five of five sampled residents (Resident #1, #2, #3, #4, and #5). The facility census was 53. Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 11 PRINTED: 07/01/2025 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 Cc 12510C —ESESE———————s 06/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) CARE NETWORK OF GLADSTONE Continued From page 7 The facility did not provide a policy regarding the completion of monthly summaries. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 07/08/21; -Diagnoses included: Cerebral Infarction (also known as an ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced) and contracture of right hand; -The only monthly summaries found in the resident's record included June 2024, July 2024, August 2024, September 2024, October 2024, and April 2025; -There were no monthly summaries for November 2024, December 2024, January 2025, February 2025, March 2025, or May 2025. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 11/01/21; -Diagnoses included: Depression and anxiety; -The only monthly summaries found in the resident's record included June 2024, July 2024, August 2024, September 2024, October 2024, and April 2025; -There were no monthly summaries for November 2024, December 2024, January 2025, February 2025, March 2025, or May 2025. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 08/28/24: -Diagnoses included: Depression and anxiety; -The only monthly summaries found in the resident's record included September 2024, October 2024, and April 2025; -There were no monthly summaries for November 2024, December 2024, January 2025, February 2025, March 2025, or May 2025. 4. Review of Resident #4's record showed: Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 If continuation sheet 8 of 11 PRINTED: 07/01/2025 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 Cc 12510C —ESESE———————s 06/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) CARE NETWORK OF GLADSTONE Continued From page 8 -He/She was admitted to the facility on 10/28/22: -Diagnoses included: Vascular Dementia, and cerebral infarction; -The only monthly summaries found in the resident's record included June 2024, July 2024, August 2024, September 2024, October 2024, and April 2025; -There were no monthly summaries for November 2024, December 2024, January 2025, February 2025, March 2025, or May 2025. 5. Review of Resident #5's record showed: -He/She was admitted to the facility on 05/16/18; -Diagnoses included: Depression, anxiety, and congestive heart failure (CHF); -The only monthly summaries found in the resident's record included June 2024, July 2024, August 2024, September 2024, October 2024, and April 2025; -There were no monthly summaries for November 2024, December 2024, January 2025, February 2025, March 2025, or May 2025. During an interview on 06/12/25 at 1:10 P.M. the Administrator said: -The Director of Nursing was responsible for completing monthly summaries; -She expected all residents to have a monthly summary completed each month; -She was not aware that monthly summaries were not being done consistently. 19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below At time of service to the resident, food shall be at least one hundred twenty degrees Fahrenheit (120°F) or forty-five degrees Fahrenheit (45°F) or below. II/III Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 If continuation sheet 9 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 07/01/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 06/17/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 CARE NETWORK OF GLADSTONE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility failed to maintain food at a sufficient temperature during meal service when the facility staff served hot food to residents that was not held at or above 120° Fahrenheit (F) and cold food that was not held at or below 45°F. This had the potential to affect all residents of the facility. The facility census was 53. Review of the facility's undated Transfer of Food Policy showed: -Food should be covered; -Hot food should be kept hot and cold food kept cold during transport. 1. Observation on 6/12/25 at 10:35 A.M. of the daily menu showed lunch was: -Sliced turkey; -Mashed potatoes with gravy; -Green beans; -Banana pudding. Observation on 6/12/25 at 12:15 P.M. showed Dietary Aide A: -Had 12 plates of food on a metal rolling cart; -The plates were not covered; -He/She transported the plates of food from the kitchen on the first floor to the elevator, and then down to the basement level dining room; -He/She then served each resident in the basement dining room a plate of food; -The temperature of the food on the last plate served showed the turkey was 101°F, the mashed potatoes with gravy was 112°F, the green beans were 93°F, and the banana pudding was 78°F. Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 11 PRINTED: 07/01/2025 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 Cc 12510C —ESESE———————s 06/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) CARE NETWORK OF GLADSTONE Continued From page 10 During an interview on 6/12/25 at 12:30 P.M., Dietary Aide A said: -He/She knew the food he/she served was not at the temperature it should be; -He/She did not put plate covers on the plates because the facility only had eight of them and it wouldn't be enough to cover all the plates. During an interview on 6/12/25 at 11:40 A.M., Resident #3 said: -He/She ate meals in the dining room in the basement; -The food was always served cold. During an interview on 6/12/25 at 11:50 A.M., Resident #5 said: -He/She ate meals in the dining room in the basement; -The food was served cold most of the time. During an interview on 6/12/25 at 12:40 P.M., the Dietary Manger said: -He/She was aware the food was cold by the time it was served in the basement dining room; -He/She talked with management about it but they had not done anything about it. During an interview on 06/12/25 at 1:10 P.M. the Administrator said: -Residents had voiced concerns regarding the temperature of food at the time of service; -She was going to try and get a warming box for the cart but had not been able to yet. *The higher classification merited due to the extent of the violation. MO255910 Missouri Department of Health and Senior Services STATE FORM 6899 S95M11 If continuation sheet 11 of 11 PLAN OF CORRECTION Provider/Supplier | ii 7abeth Ballard Name: Street Address, : . 3000 NE 64" st Kansas City MO 64119 City, Zip: Date of Survey: 06/17/2025 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 M4513 B oe 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire 07/07/25 The correct staff has been in place since 7/7/25. The Administrator or designee will verify appropriate staffing ratios every two weeks for the next 10 weeks. AA750 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment 08/17/2025 - Semi-Annuall The Administrator or designee will verify that the DON a completes the CBA within the required time frame weekly for the next ten weeks. a The Administrator or designee will review all move-ins, changes in condition, and semi-annual assessments weekly for the next ten weeks. |A4756 A4756 19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures 08/17/2025 The facility will ensure that all individualized service plans are signed by an authorized facility representative and the resident or the resident’s legal representative. This will be verified weekly for the next ten weeks. A4837 19 CSR 30-86.047(58)(B) Resident Condition/Medication 08/17/2025 Review The Administrator or designee, along with the DON, will educate staff on the requirement to complete monthly summaries on a monthly basis. i that monthly summaries are completed on time. The Administrator or designee will verify that monthly summaries are being completed as required for the next ten weeks. A7036 19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 07/01/2025 Degrees/Below The Administrator or designee will check food temperatures once a week for the next ten weeks. Mealtimes have been adjusted, and all residents have been divided into two groups. Group A mealtimes are 8:00 AM, 12:00 PM, and 5:00 PM. Group B mealtimes are 8:30 AM, 12:30 PM, and 5:30 PM. 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.

PRINTED: 05/21/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 12510C 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (X4) ID 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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HERITAGE VILLAGE OF GLADSTONE A2238 19 CSR 30-86.022(8)(C) Exit Sign-Illumination Exit Signs. (C) All required exit signs and directional indicators shall be positioned so that both normal and emergency lighting illuminates them. II/III This regulation is not met as evidenced by: Class [il. Based on observation and interview on 5/07/24, facility fails to ensure exit lights shall be lighted. The facility census is forty-three (43). This deficiency affects forty-three (43) of forty-three (43) residents. Observation at 10:15 a.m. showed the exit light between the elevator and room 208 is not lighting when tested. Observation at 10:55 a.m. showed the exit light marked 1B by room 207 is nat lighting when tested. During an interview with the Administrator at 5:05 p.m., she/he made a list of repairs needed and said the facility will make the repairs. 19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps Protection from Hazards. (C) Electric or gas clothes dryers shall be vented to the outside. Lint traps shall be cleaned regularly to protect against fire hazard. {i/lil This regulation is not met as evidenced by: Class Ill. Based on observation and interview on 5/07/24, facility fails to ensure clothes dryers are properly Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S ORPROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE mis STATE FORM ee PZ3C11 If continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C PRINTED: 05/21/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A, BUILDING: B. WING COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 HERITAGE VILLAGE OF GLADSTONE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A2258 Continued From page 1 vented to the outside, and lint shall be cleaned regurally to protect against fire hazard. The facility census is forty-three (43). This deficiency affects forty-three (43) of forty-three (43) residents. Observation at 12:13 p.m. found the center dryer vent does not have any air coming from it outside the building when the dryer is operating. Observation at 12:14 p.m. found the dryer vent flue has lint built-up in it. Observation at 12:18 p.m. found a large amount of lint built-up on the walls and floor behind the dryer. During an interview with the Administrator at 5:05 p.m., she/he said they will make this a high priority to get the dryer vents fixed. 19 CSR 30-86.022(12)(A) Emergency Lighting - locations | Emergency Lighting. (A) Emergency lighting of sufficient intensity shall be provided for exits, stairs, resident corridors, and required attendants’ station. II This regulation is not met as evidenced by: | Class Il. Based on observation and interview on 5/07/24, facility fails to ensure emergency lighting of sufficient intensity shall be provided. The facility census is forty-three (43). This deficiency affects forty-three (43) of forty-three (43) residents. Observation at 11:10 a.m. showed the emergency light in the nurses office was unplugged, and not Missouri Department of Health and Senior Services STATE FORM 6899 PZ3C11 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 6 PRINTED: 05/21/2024 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 12510C SEWING 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) HERITAGE VILLAGE OF GLADSTONE A2276 Continued From page 2 operable when tested. Observation at 11:35 a.m. showed the emergency light by room 111 was not operable when tested. Observation at 12:31 p.m. showed the emergency light in the hall by the laundry room was very dim. During an interview with the Administrator at 5:05 p.m., she/he made a list of repairs needed and said the facility will make the repairs. 19 CSR 30-86.032(2) Substantially Constructed & 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/II| This regulation is not met as evidenced by: Class Ill. Based on observation and interview on 5/07/24, facility fails to ensure building shall be substantially constructed and shall be maintained in good repair. The facility census is forty-three (43). This deficiency affects forty-three (43) of forty-three (43) residents. Observation at 9:44 a.m. showed a gap between the sprinkler head and the ceiling of Room 214, and between the sprinkler head and the ceiling in the bathroom of Room 214. Observation at 10:37 a.m. showed gaps from missing drywall tape at the ceiling, near the attic hatch, in the office closet of the Director of Missouri Department of Health and Senior Services STATE FORM 6899 PZ3C11 If continuation sheet 3 of 6 PRINTED: 05/21/2024 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 12510C B. WING 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) HERITAGE VILLAGE OF GLADSTONE A3201 Continued From page 3 Nursing, and the attic hatch is cracked in two places. Observation at 11:08 a.m. showed the bathroom exhaust fan in Room 100 is not working. Observation at 11:12 a.m. showed two missing ceiling tiles in the small conference room by the front door. | Observation at 11:15 a.m. showed the bathroom _ exhaust fan in the restroom between the front door and elevator is not working. Observation at 11:19 a.m. showed several gaps in the drywall of the right furnace closet in the dining room. | Observation at 11:20 a.m. showed several gaps in the drywall of the left furnace closet in the dining room. Observation at 11:50 a.m. showed a missing drywall cover in the ceiling of the unlabeled storage room across from Room 114. Observation at 12:25 p.m. showed three (3) holes or gaps in the drywall near or on the ceiling in the basement furnace room that's near the laundry room. Observation at 12:34 p.m. showed missing drywall panels in the elevator room. During an interview with the Administrator at 5:05 p.m., she/he made a list of repairs needed and said the facility will make the repairs. Missouri Department of Health and Senior Services STATE FORM 6899 PZ3C11 If continuation sheet 4 of 6 PRINTED: 05/21/2024 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 12510C B. WING 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) HERITAGE VILLAGE OF GLADSTONE A3214 Continued From page 4 A3214 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 Ill. Based on observation and interview on 5/07/24, facility fails to ensure electrical wiring shall be maintained in good repair and shall not present a safety hazard. The facility census is forty-three (43). This deficiency affects forty-three (43) of forty-three (43) residents. Observation at 10:18 a.m. shows the bathroom GFCI in Room 201 won't trip when tested. Observation at 10:20 a.m. shows the bathroom Missouri Department of Health and Senior Services STATE FORM ee PZ3C11 If continuation sheet 5 of 6 PRINTED: 05/21/2024 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 12510C B WING 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) | HERITAGE VILLAGE OF GLADSTONE A3214 Continued From page 5 GFCI in Room 202 has been painted over so the _ button is stuck. Observation at 10:28 a.m. shows the bathroom GFCI in Room 205 won't trip when tested. Observation at 10:37 a.m. shows an extension cord running improperly from the closet, into the attic, through a broken attic hatch in the closet office of the Director of Nursing. Observation at 11:18 a.m. shows an improperly installed, pinched wire at the grommet, coming from the furnace's switch box, in the right furnace closet near the dining room. Observation at 11:28 a.m. shows an improperly spliced fire alarm wire, outside of a junction box, in the right furnace closet, above the door, near the dining room. Observation at 12:26 p.m. showed a cracked cover plate on the furnace's electrical switch in the basement furnace room. | Observation at 12:28 p.m. showed a missing | junction box cover plate with exposed wires on the ceiling above the basement furnace that's near the laundry room. During an interview with the Administrator at 5:05 p.m., she/he made a list of repairs needed and said the facility will make the repairs. Missouri Department of Health and Senior Services STATE FORM 6899 PZ3C11 If continuation sheet 6 of 6 Page 1 PLAN OF CORRECTION ining gue Heritage Village of Gladstone Name: Street Address, . . 3000 NE 64" Street Gladstone, MO 64119 City, Zip: Date of Survey: May 7, 2024. ____mowoensuiruveuatemneconnommer ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A2238 19 CSR 30-86.022(8)C Exit Sign-Illumination Rs |__| Exit light between elevator and room 208 will be replaced 8/1/24 |__| Exit light marked 1B by room 207 will be replaced 5/9/24 | Ps A2258 19 CSR 30-86.022(10)C Clothes Dryer Vented Lint Traps PF es |__| Middle dryer flue was cleaned out from beginning to end of pipe 5/9/24 | Cd a Dryer vent flues will be cleaned thoroughly every 6-months b 8/1/24 |__| Maintenance dept. Administrator will keep record of cleaning PF | | A2276 19 CSR 30-86.022(12)(A) Emergency Lighting Locations | ee ne |__| Emergency light in nurses station cord was secured to wall to 5/9/24 |__| Prevent it from getting unplugged. Po Re | sd Emergency light by room 111 will be replaced 8/1/24 | sd ——e Emergency light in the hall by the laundry room will be replaced 8/1/24 Re | fs | sd | 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. Page 2 PLAN OF CORRECTION Provider/Supplier Name: Heritage Village of Gladstone Street Address, City, Zip: 3000 NE 64'* Street Gladstone, MO 64119 Date of Survey: May 7, 2024. 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 A3201 19 CSR 30-86.022(2) Substantially Constructed & Maintained [| —s_s_i | fF Gap between sprinkler head and ceiling of room 214 & 5/10/24 bathroom in 214 has been fixed a |__| Gaps from missing drywall tape at ceiling, near attic hatch, 8/1/24 | | in DON office will be fixed | a ——— Bathroom exhaust fan in room 100 is fixed 5/10/24 | |__| Missing ceiling tiles in small conference room by front door fixed 5/10/24 | Bathroom exhaust fan in restroom between front door and : 8/1/24 elevator fixed | Gaps in drywall of the right furnace closet in the dining room will 8/1/24 be fixed Gaps in drywall of the left furnace closet in the dining room will ‘ 8/1/24 be fixed Missing drywall cover in the ceiling of the unlabeled storage 5/10/24 room next to room 114 was fixed a Holes/gaps in the drywall near or on the ceiling in the basement : 8/1/24 furnace room near the laundry room will be fixed a a |_| Missing drywall panels in the elevator room will be fixed | Page 3 PLAN OF CORRECTION Provider/Supplier Name: Heritage Village of Gladstone Street Address, City, Zip: 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 A3214 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected GFCI outlet in Room 201 has been fixed 5/28/24 CO GFCI outlet in Room 202 has been fixed 5/28/24 3000 NE 64* Street Gladstone, MO 64119 GFCI outlet in Room 205 has been fixed 5/28/24 Extension cord running improperly from the closet in the attic, through a broken attic hatch in the closet of the DON’s office 8/1/24 was removed Improperly installed, pinched wire at the grommet, coming from the furnace’s switch box, in the right furnace closet near the 8/1/24 dining room will be fixed Improperly spliced fire alarm wire, outside junction box, in the right furnace closet, above the door, near the dining room will be 8/1/24 Cracked cover plate on the furnace’s electrical switch in the ; 8/1/24 basement furnace room will be replaced Missing junction box cover plate with exposed wires on the ceiling above the basement furnace that’s near the laundry room 8/1/24 will be fixed

PRINTED: 01/17/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: C 01/10/2024 12510C B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 HERITAGE VILLAGE OF GLADSTONE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES 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) A8008 19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure Prior to or at the time of admission and during his or her stay in the facility, each resident and/or his or her next of kin, legally authorized representative or designee shall be fully informed, in writing, of services available in the facility and of related charges, including any charges for services not covered by the facility's basic per diem rate or federal or state programs. Information shall include procedures to be followed by the facility in cases of medical emergency, including transfer agreements and | costs. All residents who receive treatment in an Alzheimer's special care program or unit and their next of kin, legally authorized representatives or designees shall be given a copy of the Alzheimer's Special Care Services Disclosure Form at the time of admission. Residents also shall be informed of services outside the facility which may reasonably be made available to the resident and of any reasonable estimate of any foreseeable costs connected with those services. IWAN This regulation is not met as evidenced by: Class II* Based on record review and interview, the facility failed to specify in the Rental (Admission) Agreement the amount owed to the facility after an emergency discharge is issued for one resident (Resident #1). The facility charged the resident for a full month of room and board even though the facility issued an emergency discharge, and the Rental Agreement did not address how much was owed to the facility after an emergency discharge. Additionally, the facility failed to charge the correct amount for room and board for the resident. The facility census was Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S’ PROVIDI WPPLIER REPRESENTATIVE'S SIGNATURE y = = 7SGP11 TITLE (X6) DATE STATE FORM “Ly If continuation sheet 1 of 4 PRINTED: 01/17/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION A. BUILDING: C 01/10/2024 B. WING 12510C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (x4) ID 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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HERITAGE VILLAGE OF GLADSTONE A8008 Continued From page 1 45. 1. Record review of the facility Rental Agreement, signed and dated 01/19/2021 by Resident #1's Power of Attorney and facility Administrator #2, showed the Discharge Criteria as the facility may terminate the Agreement, upon providing thirty (30) days written notice for any of the following events, as determined by the facility: - The transfer or discharge is necessary for the resident's welfare when the resident's needs | cannot be met at the residence; | - The resident requires continual medical or nursing care which the residence is not permitted by law or regulation to provide; - Resident's physician determines that the | resident requires physical or chemical restraints in situations other than emergencies; - The safety of the resident or other individuals in the residence is endangered; - The health of the resident or other individuals in | the residence is endangered; - Resident has failed, after reasonable and appropriate notice, to pay the rates and charges imposed by the facility; or - The residence ceases to operate. Record review of the facility Rental Agreement showed the process for charging for room and board after a 30 day discharge, but not for an emergency discharge. Record review of the facility Notice of Discharge dated 10/02/23, showed the facility was no longer able to achieve the goal of meeting Resident #1's needs and/or the safety of the resident and/or other residents and informed Resident #1 of an emergency discharge of no later than 10/04/2023. Record review of the facility Discharge Resident Missouri Department of Health and Senior Services STATE FORM 6899 7SGP11 If continuation sheet 2 of 4 PRINTED: 01/17/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/10/2024 B. WING 12510C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 HERITAGE VILLAGE OF GLADSTONE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x6) 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} A8008 Continued From page 2 Report for the period 10/01/23 through 01/02/24, showed Resident #1 discharged on 10/12/23. Record review of the facility provided room and board statement for the period 01/01/23 through 12/31/23, showed the facility charged the resident for the full month of 10/2023, even though the | facility gave the resident an emergency discharge notice. During an interview on 01/10/24 at 3:15 P.M., the Administrator #1 said he/she was not the Administrator when Resident #1 was discharged and did not know why Resident #1 was charged for the full month of 10/2023. 2. Record review of the facility Financial/Admission Agreement Resident or Responsible Party signed and dated 01/19/2021 by Resident #1's Power of Attorney, showed the room and board rate will be Medicaid plus Social Security. Record review of the facility room and board statement showed Resident #1 was billed $1,505.50 for Social Security for months 02/2023 through 10/2023. During a telephone conversation on 01/04/24 at 10:16 A.M., the Administrator #2 said he/she did not know the correct amount of Social Security for Resident #1. During Email correspondence dated 01/10/24 at 3:04 P.M., showed Social Security Regional Representative Payee Coordinator said Resident #1's Social Security payable amount was $1,505.00 for 2023. M0Q00229298 Missouri Department of Health and Senior Services STATE FORM 6899 7SGPI1 {f continuation sheet 3 of 4 PRINTED: 01/17/2024 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 12510C — 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) HERITAGE VILLAGE OF GLADSTONE A8008 Continued From page 3 *The higher classification merited due to the violation's effect on the resident(s). Missouri Department of Health and Senior Services STATE FORM cone 7SGP11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider Name: Heritage Village of Gladstone Street Address, 3000 NE 64" Street Gladstone, MO 64119 City, Zip: Date of Survey: 1/10/2024 PROVIDER/SUPPLI ER/CLIA IDENTIFICATION W510G NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is only in submission to meet regulations. It is in no way an admission of any deficiency or scope and COMPLETION severity of any deficiency by Heritage Village of Gladstone, or DATE anyone in association. A8008 affected by the alleged deficient practice, the | following corrective action was implemented A. A refund was issued to resident 1’s representative for the incorrect amount and the remainder of 10-23 1-14-24 room and board. B. Resident 1 discharged on 10/13/23 1-10-24 C. The facility administrator or designee will make sure any discharge notice given to a resident is in 1-14-24 accordance with regulation D. Any time a discharge noticed is issued that administrator or designee will follow up with corporate to ensure there are no refunds due and if there is a refund due that it will be refunded. 2. All residents have the potential to be affected by the alleged deficient practice. However, due to the implementation of the above A-D corrective action: alleged deficient practice will not recur. For the Resident (1) found to have been potentially 1-14-24 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.

PRINTED: 12/11/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 11/30/2023 12510C BL WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (X4) ID 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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE { DEFICIENCY) HERITAGE VILLAGE OF GLADSTONE AS206 19 CSR 30-86.052(6) Menus, Substitutes Menus shall be planned in advance and shall be readily available for personnel involved in food | purchase and preparation. Food shall be served | as planned although substitutes of equal nutritional value and complementary to the remainder of the meal can be made if recorded. lll This regulation is not met as evidenced by: Class Ill Based on observation, record review and interview, the facility failed to serve planned | meals or record and serve substitutes that were of equal nutritional value and complementary to the remainder of the meal. This potentially | affected all residents. The facility census was 45. 1. During an interview on 11/30/23 at 11:12 A.M., Resident #1 said: | - The facility food was good on some days and | other days it was "terrible". 2. During an interview on 11/30/23 at 11:06 A. M Resident #6 said: -The facility food was "not good"; -The facility food often tasted too salty. Review of the weekly menu showed lunch on 11/30/23 was: -Open faced turkey sandwich and gravy, mashed potatoes, green beans, and cranberry fluff. Observation on 11/30/23 at 12:15 P.M. showed the lunch meal being served was: -Chili, cornbread, broccoli, and fruit salad. During an interview on 11/30/23 at 12:32 P.M., Cook A said: Missouri Department of Health and Senist t Sei ices ——_—" aaa LABORATORY DIRECTOR'S OR PROVIDER/SUP. TATIVE'S SIGNARE = (X6) DATE f= 3 2y If continuation sheet 1 of 8 STATE FORM / e598 cso111 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 12/11/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/30/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 HERITAGE VILLAGE OF GLADSTONE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 -The chili served came from a can; -He/She did not make the planned meal because the person who worked the evening before did not take the turkey out of the freezer; -He/She reported to work at 6:00 A.M.; -He/She had worked at the facility for approximately one month; -He/She had substituted the planned meal for chili a couple of times. Review on 11/30/23 of the substitution log showed: -Chili was substituted for chicken on 10/26/23; -Toast was substituted for cinnamon rolls on 10/20/23; -No other substitutions recorded. During an interview on 12/1/23 at 1:05 P.M. the dietary manager said: -She expected the cook to follow menus, and record any substitutions; -The Cook A could have taken the turkey out of the freezer that morning and had time for it to thaw before lunch was prepared. During an interview on 11/30/23 at 2:10 P.M. the Administrator said she expected the cook to follow menus, and record any substitutions. 19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources Food shall be in sound condition, free from spoilage, filth or other contamination and shall be safe for human consumption. Food shall be obtained from sources that comply with all laws relating to food and food labeling. The use of food in hermetically sealed containers that was not prepared in a food-processing establishment is Missouri Department of Health and Senior Services STATE FORM 6899 cso111 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 8 PRINTED: 12/11/2023 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 12510C — 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) HERITAGE VILLAGE OF GLADSTONE Continued From page 2 prohibited. Nothing in this section shall prohibit facilities from using fresh vegetables or fruits purchased from farmers ' markets or obtained from the facility garden or residents ' family gardens. I/II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to ensure food was in sound condition, free from spoilage, or other contamination and safe for human consumption, when facility staff did not date food when it was opened. The facility census was 45. 1. Observation of the refrigerator on 11/30/23 at 12:35 P.M., showed: -Cooked bacon wrapped in plastic with no label or date; -Ham wrapped in plastic with no label or date; -Unknown meat wrapped in aluminum foil with no label or date; -Two opened bags of whipped topping with no date; -Sliced turkey wrapped in plastic with no label or date. During an interview on 12/1/23 2:30 P.M., the dietary manager said that all foods should be labeled and dated. During an interview on 1/5/23 at 2:40 P.M. the administrator said: -All foods in the refrigerator should be labeled and dated; -It was the dietary manager's responsibility to ensure the refrigerator was cleaned out regularly. Missouri Department of Health and Senior Services STATE FORM 6899 cS0111 If continuation sheet 3 of 8 PRINTED: 12/11/2023 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 12510C — 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) HERITAGE VILLAGE OF GLADSTONE Continued From page 3 19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below At time of service to the resident, food shall be at least one hundred twenty degrees Fahrenheit (120°F) or forty-five degrees Fahrenheit (45°F) or below. II/III This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to maintain food at a sufficient temperature during meal service when the facility staff did not refrigerate fruit salad resulting in the fruit salad temperature rising to 65 degrees Fahrenheit and not able to serve. This had the potential to affect all residents of the facility. The facility census was 45. Observation of the lunch meal service on 11/30/23 at 12:15 P.M. showed: -A tray of 4 ounce cups with fruit salad in them sitting on the counter; -The whipped topping in the salad was liquefied; -The temperature of the fruit salad was 65 degrees Fahrenheit. During an interview on 11/30/23 at 12:15 P.M., Cook A said: -The fruit salad should have been kept in the refrigerator until it was served; -He/She did not know why it was not kept in the refrigerator; -He/She knew the fruit salad should not be served at 65 degrees but did not know what temperature it should be served at. During an interview on 12/1/23 at 1:30 P.M. the Dietary Manager said: Missouri Department of Health and Senior Services STATE FORM 6899 cS0111 If continuation sheet 4 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 12/11/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/30/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET HERITAGE VILLAGE OF GLADSTONE GLADSTONE, MO 64119 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 -The fruit salad should have been kept in the refrigerator until it was served; -Cold food should be below 40 degrees when served. 19 CSR 30-88.010(29) Dignity/Privacy Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III This regulation is not met as evidenced by: Class II * The higher classification merited due to the violation's effect on the resident(s), and due to the extent of the violation. Based on observation, interview, and record review, the facility staff failed to treat four residents (Resident #1, #2, #3, and #6) of six sampled residents with dignity and respect. The facility census was 45. 1. Review of Resident #2's face sheet showed: -Admission date of 7/6/23; -Diagnoses included anxiety disorder, colon cancer, calculus of kidneys (kidney stones), and unsteady on feet. Review of the resident October 2023 monthly Missouri Department of Health and Senior Services STATE FORM 6899 cso111 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 12/11/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/30/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 HERITAGE VILLAGE OF GLADSTONE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 summary showed: -His/Her cognitive status was confused; -He/She used a wheelchair with assistance for ambulation ; -He/She needed full assistance with grooming; -He/She needed assistance with shampooing hair and bathing. During an interview on 11/30/23 at 10:34 A.M., the resident said: -There was a staff member that worked on the night shift that was rude and mean; -The staff member would not come in his/her room because of the camera; -He/She did not know the staff member's name, and he/she did not wear a name tag; -The staff member was so mean that he/she tried not to push his/her call light at night. 2. During an interview on 11/30/23 at 10:11 A.M., Resident #6 said: -Most of the staff were really nice and accommodating; -There was one staff member who worked at night who was not very nice or helpful; -He/She did not know the staff member's name; 3. During an interview on 11/30/23 at 10:05 A.M., Resident #1 said: -All of the staff were really nice, except for one; 4. During an interview on 11/30/23 at 11:40 A.M., Resident #3 said: -There was a staff member that worked at night who was loud and yelled a lot; -He/She said the staff member was Certified Medication Technician (CMT) A; -He/She heard the staff member yell at someone and say "Come on, | aint got time for this". Missouri Department of Health and Senior Services STATE FORM 6899 cso111 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 8 PRINTED: 12/11/2023 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 12510C — 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET GLADSTONE, MO 64119 (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) HERITAGE VILLAGE OF GLADSTONE Continued From page 6 During an interview on 11/30/23 at 11:10 A.M., the Personal Care Supervisor said: -Several resident had told him/her that CMT A was not very nice; -He/She became loud and lashed out when he/she was frustrated. -He/She reported it to the Director of Nursing (DON) and the Administrator. Review of Resident #2's nurse's notes showed: -On 11/29/23 the resident asked CMT A to cover her up and CMT A told the resident he/she could do it him/herself; -On 11/19/23 the resident pushed his/her call light to go to the restroom and CMT A told him/her the he/she had just helped him/her and he/she was not going help her again; -On 11/16/23, CMT A responded to the resident's call light, resident was on the toilet and asked for help but did not say what he/she needed help with. CMT A attempted to get resident to stand up but he/she would not stand up. CMT A then left the room and told the morning shift staff "they would have to deal with the resident"; -On 11/14/23, while CMT A assisted resident in getting ready for the day resident stated he/she felt his/her pants were too tight. CMT A refused to change the resident's pants; -On 11/3/23, CMT A responded to the resident's call light. The resident requested help to the restroom. CMT A told the resident he/she "would have to wait or take him/herself because the caregiver was busy”. During an interview on 11/30/23 at 3:10 P.M., CMT B said: -Several residents told him/her CMT A was mean and yelled at them; -He/She did not know if the DON or the Administrator was aware of it. Missouri Department of Health and Senior Services STATE FORM 6899 cS0111 If continuation sheet 7 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 12510C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 12/11/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/30/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 3000 NORTH EAST 64TH STREET HERITAGE VILLAGE OF GLADSTONE GLADSTONE, MO 64119 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 During an interview on 11/30/23 3:15 P.M., CMT A said: -"102 is becoming a problem"; -"Everyone has a problem with 102"; -He/She did not feel that he/she should have to write a nurse's note every night; -He/She no longer touched the resident, and made him/her do everything for him/herself; -The last person was fired because they moved the resident's camera; -He/She should not have to take the resident's disrespect. During an interview on 11/30/23 at 3:22 P.M., the DON said: -CMT Awas "a little rough around the edges; -Staff should always remain professional; -All residents should be treated with dignity and respect. During an interview on 11/30/23, at 3:40 P.M., the Administrator said: -She expected all resident's to be treated with dignity and respect. M0O227334 Missouri Department of Health and Senior Services STATE FORM 6899 cso111 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 8 PLAN OF CORRECTION Provider Name: Heritage Village of Gladstone Street Address, | 3000 NE 64" Street Gladstone, MO 64119 City, Zip: Date of Survey: 11/30/23 PROVIDER/SUPPLI ER/CLIA IDENTIFICATION 125100 NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is only in submission to meet regulations. It is in no way an admission of any deficiency or scope and COMPLETION severity of any deficiency by Heritage Village of Gladstone, or DATE anyone in association. 1. For the Resident (1,6) found to have been AS206 potentially affected by the alleged deficient practice, the following corrective action was implemented A. Cook A was terminated based on inability to follow ; ; . 12-1-23 company policy / obtain food handlers license B. All staff will be in-serviced on following menu provided or substituting of equal nutritional value 42-18-23 and filling out substitution log by the executive director and or designee. C. Dietary Manager will monitor weekly that all products needed for menus are available and when necessary, a substitution of equal nutritional value is 12-18-23 made and recorded in the substitution log by dietary staff. D. Administrator and or designee will audit Dietary 12-18-23 manager for audit completion. 2. All residents have the potential to be affected by the alleged deficient practice. However, due to the implementation of the above A-D corrective action; alleged deficient practice will not recur. 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. PLAN OF CORRECTION Provider Name: Heritage Village of Gladstone Street Address, | 3000 NE 64" Street Gladstone, MO 64119 City, Zip: Date of Survey: 11/30/23 PROVIDER/SUPPLI ER/CLIA IDENTIFICATION 125100 NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is only in submission to meet regulations. It is in no way an admission of any deficiency or scope and COMPLETION severity of any deficiency by Heritage Village of Gladstone, or DATE anyone in association. 1. For the Resident found to have been potentially A?013 affected by the alleged deficient practice, the following corrective action was implemented A. Fridge cleaned out of undated & expired food. Food properly stored in airtight containers. Food and 12-1-23 drinks in fridge labeled and dated B. Kitchen staff in-serviced on proper food storage & labeling procedures by executive director and or 12-18-23 designee. C. Dietary Manager or Cook will check fridge at time food is stored to make sure food is stored properly 12-1-23 and labeled and dated. D. Log will be kept and used for putting away left over food. Log will be audited by dietary manager and or designee 2. All residents have the potential to be affected by the alleged deficient practice. However, due to the implementation of the above A-D corrective action; alleged deficient practice will not recur. 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. PLAN OF CORRECTION Provider Name: Heritage Village of Gladstone Street Address, —_/ 3000 NE 64" Street Gladstone, MO 64119 City, Zip: Date of Survey: 41/30/23 PROVIDER/SUPPLI ER/CLIA IDENTIFICATION 12510 NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is only in submission to meet regulations. It is m no way an admission of any deficiency or scope and COMPLETION severity of any deficiency by Heritage Village of Gladstone, or DATE anyone in association. 1. For the Resident found to have been potentially A7036 affected by the alleged deficient practice, the following corrective action was implemented A. Cook A was terminated based on inability to follow : ; ; 12-1-23 company policy/ obtain food handlers license B. All staff will be in-serviced on maintaining sufficient temps on hot and cold meal items during meal 12-18-23 service by executive director and or designee. C. Food Temperatures are to be monitored and recorded at time of preparation by dietary manager 12-18-23 and or cook. 2. All residents have the potential to be affected by the alleged deficient practice. However, due to the implementation of the above A-C corrective action; alleged deficient practice will not recur. 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. PLAN OF CORRECTION Provider Name: Heritage Village of Gladstone Street Address, | 3000 NE 64" Street Gladstone, MO 64119 City, Zip: Date of Survey: 41/30/23 PROVIDER/SUPPLI ER/CLIA IDENTIFICATION 12510 NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is only in submission to meet regulations. It is m no way an admission of any deficiency or scope and COMPLETION severity of any deficiency by Heritage Village of Gladstone, or DATE anyone in association. 1. For the Resident (1,2,3, and 6) found to have been A8030 potentially affected by the alleged deficient practice, the following corrective action was implemented A. CMT A mentioned by residents was fired 42-41-23 immediately for her rude behavior. B. All staff will be in-serviced on treating all residents with dignity and respect, including privacy in treatment of care of his or her personal needs . . - ng - : 12-18-23 includes reporting any violations of this policy to the Director of Nursing and/or Administrator by the executive director or designee. C. Executive director and or designee will ask 3 random residents of any concerns including with staff 3 days a week for 4 weeks 2. All residents have the potential to be affected by the alleged deficient practice. However, due to the implementation of the above A-C corrective action; alleged deficient practice will not recur. 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.