BEEHIVE HOMES OF GRAIN VALLEY.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 24279 NAME OF PROVIDER OR SUPPLIER PRINTED: 12/02/2025 (X2) MULTIPLE CONSTRUCTION A BUILDING: B. WING 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 BEEHIVE HOMES OF GRAIN VALLEY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-88.010(23) Develop/Implement A/N Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. Ii/Il This regulation is not met as evidenced by: Class II" .Based on observation, interview and record review, the facility failed to follow their abuse and neglect policy for reporting allegations of potential abuse between employee, Nurse Aide (NA) A and Resident #1, to the resident's physician and Hospice (end of life) contacted care provider, and failed to complete a comprehensive investigation to include interviews with the resident's contracted care provider who had provided care at the facility on 11/10/25 out of three sampled residents. The facility census of 24 residents. Review of the facility Abuse Prevention and Reporting Policy dated 2023 showed: -The facility will investigate all reports of suspected abuse of any resident and will take appropriate action to protect the resident and prevent further incidents. -The attended physician will be notified of the incident and follow-up medical care provide as Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE A STATE FORM GYT411 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) TITLE FORM APPROVED Cc 11/18/2025 (46) DATE Hf continuation sheet 1 of 5 PRINTED: 12/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED [e 24279 BWING 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 (X4) ID | SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) BEEHIVE HOMES OF GRAIN VALLEY A8023 Continued From page 1 necessary. -Within 24 hours the facility will form an investigator team that will thoroughly investigate the allegation and document the investigation. -The facility administrator or designee will immediately notify the resident, resident representative of the alleged abuse, was investigation complete inform them the results of the investigation. -The Administrator or designee completed incident reports, interview will be conducted and statements obtained from all staff members, residents, family members volunteers and other that may have witness or have knowledge with respect to the alleged incident. -A written reports which among other things, provides an overview of the incident, pertinent medical data and summary of the statements taken, investigative findings, follow-up actions and a conclusion will be prepared. A copy of the written report shall be provided. 1. Review of Resident #1's Admission Face Sheet showed he/she admitted to the facility on | 7/28/25 with the following diagnoses: | -Picks disease (frontotemporal dementia (FTD | causes gradual deterioration of the frontal and temporal lobes of the brain). -Recent urinary tract infection (UTI, infection in bladder). Review of the resident's facility Incident Report dated 11/10/25 at 5:00 P.M. showed: -Allegation of abuse by a staff member the morning of 11/10/25 and allegedly occurred between 11:00 A.M. -12:00 P.M. -Employee allegedly involved was NAA. -The resident had no physical injuries observed Missouri Department of Health and Senior Services STATE FORM 6809 GYT411 If continuation sheet 2 of 5 PRINTED: 12/02/2025 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: Ac BLAU DING COMPLETED Cc 24279 B. WANG 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 101 CROSS CREEK DRIVE BEEHIVE HOMES OF IN VALLEY . saints GRAIN VALLEY, MO 64029 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5) | (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) | A8023 | Continued From page 2 or reported. -The resident had reported that NAA had stuck him/her in the stomach and shoulder while being assisted to the bathroom. -The resident's family member was notified on 11/11/25 at 1:00 P.M. -The box next to "did the facility notify the resident's physician about alleged abuse | incident" was marked "no". | -There was no documentation that indicated the _ resident's Hospice Nurse or Hospice Provider was notified of the alleged incident. Review of the resident's Hospice medical record binder showed: -Documentation that a Hospice Chaplin and a Hospice Registered Nurse (RN) visited on 11/10/25, there were no times indicated for the visits. -There was no detailed Hospice nurse visit note for 11/10/25 found in the hospice binder. -There was no documentation that showed the Hospice staff were notified of the alleged employee to resident abuse incident that happened on 11/10/25. Review of the resident's medical record dated 11/10/25 to 11/18/25 showed: -There was no documentation that the resident's | physician was notified of the alleged abuse incident on 11/10/25. -There was no documentation found related to | Hospice staff being notified of the alleged abuse. -There was no documentation that indicated Hospice staff were included in the facility investigation interviews related to the alleged abuse that indicated happen during the day-shift _ (6:00 A.M. to 2:00 P.M.) on 11/10/25. Missouri Department of Health and Senior Services. STATE FORM ba GYT411 if continuation sheet 3 of 5 PRINTED: 12/02/2025 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 Cc B. WING 14/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 (X4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) | CROSS-REFERENCED TO THE APPROPRIATE | DEFICIENCY) BEEHIVE HOMES OF GRAIN VALLEY A8023 Continued From page 3 During an interview on 11/18/25 at 1:30 P.M. the Administrator said: -He/she did not notify the resident's physician of alleged abuse on 11/10/25. -He/she did not report the incident due to the resident had no complaints of pain and no physical injury was noted related to alleged abuse incident. During an interview on 11/18/25 at 1:58 P.M., the Level 1 Medication Aide (L1MA) A said: -He/she would report any alleged abuse, or incident to the facility medical supervisor and administrator. | -He/she would have notified the resident's physician, family member/durable power of attorney, and Hospice Provider if the resident was on Hospice services of any alleged incident. -He/she had not had any Abuse and Neglect training since he/she was hired over a year ago. During an interview on 11/18/25 at 2:00 P.M., the Administrator said: -He/she was notified by the owner of the allegation of abuse on 11/10/25 around 5:00 P.M. -He/she had started the facility investigation for alleged employee to resident incident. -He/she did not complete the investigation as thoroughly as he/she should have. --The investigation should have included notification of the resident's physician and Hospice agency of the alleged abuse incident. -He/she did not think about notifying and contacting the resident's Hospice provider about the incident. -He/she should have interviewed the resident's Missouri Department of Health and Senior Services STATE FORM 6899 GYT411 if continuation sheet 4 of 5 PRINTED: 12/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (43) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 2 [i 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 (4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) BEEHIVE HOMES OF GRAIN VALLEY A8023 Continued From page 4 Hospice staff that were in building during the day shift on 11/10/25. | During an interview on 11/18/25 at 2:16 P.M., the Hospice Clinical Director said: -The Hospice RN and Chaplin both had visited the resident at the facility on 11/10/25 from 12:45 P.M. to 2:00 P.M. -There was no documentation in the Hospice RN's visit note that indicated alleged abuse or any change in the resident's behavior or skin changes. -There was no documentation that the facility had notified the Hospice nurse of the alleged abuse that occurred on 11/10/25 during the day-shift. *Higher classification merited due to the extent of the violation and the violation effect on the residents. MOQ00259293 Missouri Department of Health and Senior Services STATE FORM eons GYT411 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier BeeHive Homes of Grain Valley Name: Street Address, City, Zip: 101 sw cross creek dr. Grain Valley MO. Nov. 18th 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE 7 - _ Date of Survey; Plan of Correction for Deficiency Tag A8023: Beehive Homes of Grain Valley Deficiency: Failure to follow abuse and neglect policy for reporting allegations of potential abuse, including failure to notify the resident's physician and Hospice provider, and failure to conduct a comprehensive investigation. 1. Immediate Actions Taken ¢ Resident Safety: Resident #1 was assessed for injuries or changes in condition Immediately upon learning of the allegalion; no injuries or changes in condition were reported. e Staff Member: NA A was removed from direct care responsibilities pending investigation. and is no longer employed at Bashive Homes. e Notification to Family: The resident's family/durable power of attorney was notified of the incident on 11/11/25 2. Corrective Actions to Address Deficiency a. Policy Review and Education ° All facility staff will receive retraining on the Abuse Prevention and Reporting Policy, with emphasis on: °o Immediate reporting requiraments to the resident’s physician and contracted care providers (including Hospice) following any allegation of abuse or neglect. Comprehensive investigation procedures, including mandatory interviews with all involved parties (staff, contracted providers, hospice, family). ¢ = Training will occur within 7 days of this plan and will be documented in personnel files. bh. Notification Protocols e Anew checklist will be implemented for all alleged abuse/neglect incidents, requiring: oc Immediate physician nolification, o =Jmmediate notification of all contracted care providers {such as Hospice). co Documentation of all notifications, including date, time, and person contacted, e¢ The administrator/designee will monitor compliance and sign off on each checklist. c, Investigation Process Improvement e The investigator team will include at least one staff member not directly involved in the incident, and will: o = Interview all relevant individuals, including outside providers (e.g., Hospice slaff present at the time of the alleged incident). Obtain written statements from all parties, Complete and file a written report summarizing findings, actions taken, and follow-up recommendations within 72 hours of the allegation. d. Documentation e All notifications, investigation steps, and outcomes will be dacumented in both the resident's medical record and in the facility's incident file. Documentation will be monitored by the Administrator for completeness and timeliness, e. Ongoing Monitoring The Administrator or designee will conduct random audits of abuse/neglect incident reports for six months to ensure: All notifications and investigations have been properly completed and documented. Any deficiencies identified will trigger immediate retraining and corrective action. 3. Systemic Prevention Annual] refresher training on reporting abuse/neglect and investigation protocols for all staff. Feedback from contracted care providers (e.g., Hospice) will be solicited quarterly to ensure communication protocols are effective 4. Completion Date All corrective actions will be completed by December 18, 2025. Ongoing monitoring and training will continue as outlined above. Prepared by: Cal Hutson, Administrator Beehive Homes of Grain Valley Date:12-4-2025 The Administrator signing and dating the first page of the CMS-2567/State Form is Indicating thelr approval of the plan of correction being submitted on this form. A, Yor

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER BEEHIVE HOMES OF GRAIN VALLEY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 11/06/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 09/18/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/IIl This regulation is not met as evidenced by: Class III Based on record review and an interview on 9/18/24 this facility failed to produce documentation of at least one fire drills being conducted on each shift every other month in the last year. The facility census was 22. This potentially affected 22 of 22 residents. Record review on 9/18/24 at 3:20 P.M. showed 8 of the last 12 fire drills on the first shift During an interview on 9/18/24 at 3:20 P.M. with the new manager he/she said he/she was aware they were not bouncing back and forth from month to month, but he/she said he/she would correct it. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 LuWw111 If continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 BEEHIVE HOMES OF GRAIN VALLEY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Based on observation, record review, and an interview on 9/18/24 this facility failed to insure all the wastebaskets were the approved types allowed. The facility census was 22. This potentially affected 22 of 22 residents. Observations on 9/18/24 during the fire safety portion of the licensure walkthrough showed the following rooms having wastebaskets that were not the approved types: Room 24 had two Room 20 had one, Room 12 had one, Room 10 had two, Room 7 had one, Room 2 had two, and Room 5 had one. Record review on 9/18/24 at 3:20 P.M. showed most of the same rooms documented as having the wrong type of wastebaskets. During an interview on 9/18/24 at 2:09 P.M. with the new manager he/she said he/she was aware many rooms had non-approved types of wastebaskets and he/she indicated he/she had made a list of them and was getting ready to get them all replaced with the proper types. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III Based on observations and an interview on Missouri Department of Health and Senior Services STATE FORM 6899 LJW111 PRINTED: 11/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/18/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 BEEHIVE HOMES OF GRAIN VALLEY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 9/18/24 this facility failed to provide a proper oxygen storage room in accordance with NFPA 99, 1999 Edition. The facility census was 22. This potentially affected 22 of 22 residents. Observation on 9/18/24 at 2:12 P.M. showed in resident room 23, two full bottles of oxygen free standing in their room, with one other bottle in use and in a rack cart. Observation on 9/18/24 at 2:54 P.M. showed some oxygen stored in the sprinkler riser room, but this room contained combustible products. During an interview on 9/18/24 at 2:54 P.M. with the new manager he/she said he/she would get the residents spare bottles reduced to one spare, get the oxygen company to come out and bring an oxygen storage rack. He/she further stated he/she would be sure the oxygen was stored away from combustible products. 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 Missouri Department of Health and Senior Services STATE FORM 6899 LJW111 PRINTED: 11/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/18/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 BEEHIVE HOMES OF GRAIN VALLEY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on record review and an interview 9/18/23 the facility failed to show documentation the electrical wiring had been inspected within the last two years by a qualified electrician. The facility census was 22. This potentially affected 22 of 22 residents. Record review on 9/18/24 at 3:20 P.M. produced no previous electrical inspection records. During an interview on 9/18/24 at 3:20 P.M. with the building owner he/she said he/she would call and email the electrical company to get them out to do an electrical inspection. Missouri Department of Health and Senior Services STATE FORM 6899 LJW111 PRINTED: 11/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/18/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 4 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 07/18/2025 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 24279 B. WING 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BEEHIVE HOMES OF GRAIN VALLEY 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 II Based on observation and interview on 9/18/23 the facility failed to maintain all the emergency lights in good repair. The facility census was twenty (20). This potentially affected twenty (20) of twenty (20) residents. Observation on 9/18/23 at 11:45 A.M. showed the emergency light outside Room 110 not working when tested. During an interview on 9/18/23 at 11:45 A.M. the administrator stated it had just been replaced maybe two years ago. He/she would get the electrician out to look at it. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 FNON11 If continuation sheet 1 of 2 PRINTED: 07/18/2025 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 24279 B. WING 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 101 CROSS CREEK DRIVE GRAIN VALLEY, MO 64029 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BEEHIVE HOMES OF GRAIN VALLEY Continued From page 1 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/IIl This regulation is not met as evidenced by: Class III Based on record review and an interview 9/18/23 the facility failed to show documentation the electrical wiring had been inspected within the last two years by a qualified electrician. The facility census was twenty (20). This potentially affected twenty (20) of twenty (20) residents. Record review on 9/18/23 at 1:24 P.M. produced no previous electrical inspection records. During an interview on 9/18/23 at 1:24 P.M. the Administrator stated he/she thought it had been done within the last two years. He/she contacted the electrical company personnel via phone and he confirmed it was two years ago he thought and would send over the information via email. Record review on 9/25/23 at 4:25 P.M. via an email from the Administrator showed an attached electrical inspection, but it was from 2017. Missouri Department of Health and Senior Services STATE FORM 6899 FNON11 If continuation sheet 2 of 2