ADDINGTON PLACE OF SHOAL CREEK.

PRINTED: 11/03/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERJCLIA [X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTIGN IDENTIFICATION NUMBER, A. BUILDING: COMPLETED Cc 28129 ————— 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8601 NORTH TULLIS DRIVE KANSAS CITY, MO 64757 (x4) 10 SUMMARY STATEMENT GF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 0X5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY GR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} ADDINGTON PLACE OF SHOAL CREEK A4797| 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceplable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirly (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the origina! pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to rernove from the container and self-administer, External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident 's physician se authorizes. All individuals who administer medication shail be trained in medication administration and, if not a physician or a licensed nurse, shall be a cerlified medication technician or level | medication aide. Wil This regulation is not met as evidenced by: Class Il Based on observation, interview, and record review, the facility staff failed to ensure they had a safe and effective medication system when they failed to store medication for four of five sampled residents (Resident #1, #3, #4 and #5} in a safe manner. The facility census was 50. The facility did not provide the requested policy Missouri Department cf Health and Senior Services LABORATORY DIBECTOR'S OR PROVIDER/SRIPPLIER REPRESENTATIVE'S SIGNATURE (XB) GATE Wcantinuatian sheet 1 of 19 082M11 PRINTED: 11/63/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ADDINGTON PLACE OF SHOAL CREEK A4797) 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ‘ medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians’ instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (20) residents to monitor each resident’ s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident’ s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Vt This regulation is not met as evidenced by: Class fl Based on observation, interview, and record review, the facility staff failed to ensure they had a safe and effective medication system when they failect to store medication for four of five sampled residents (Resident #1, #3, #4 and #5) in a safe manner. The facility census was 50. The facility did not provide the requested policy Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM S898 Q82M11 \f continuation sheet 1 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued Fram page 1 on safe and effective medication system. Areview of the undated package instructions for Lorazepam Oral Concentrate showed the medication must be discarded 90 days after opening the bottle. 1. Observation of the medication cart on 100 hail on 10/21/25 at 1:15 P_M., showed: -A botile of Lorazepam Oral Concenirate (used to treat anxiety) 2 milligrarns (mg) / milliliter (ml} labeled with Resident #1’s name with no open date; -A card of Hydrocedone 10/325 mg (used to treat pain) labeled with Resident #3's name with a piece of tape over the back of two doses of the medication. During an interview on 10/21/25 at 01:25 P.M. Level | Medication Aide (L1MA) A said: -The Lorazepam should have an open date; -No medications should be taped back into the card; -If the backing is compromised we are to take it to the Director of Nursing (DON). 2. Observation of the medication cart on the memory care unit on 10/21/25 at 1:40 P.M, showed: -A bottle of Lorazepam Oral Concentrate 2 mg/ ml labeled with Resident #4's name with no open date; -A card of Tramadol (used to treat pain) 50 mg labeled with Resident #5's name with tape over the back of two doses of the medication. During an interview on 10/21/25 at 01:50 P.M. Certified Medication Technician (CMT) A said: -Medications should be dated when the bottle is opened; Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 (X2) MULTIPLE CONSTRUCTION PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 2 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 -Medication should never be taped back into the card; -lf a pill falls out of a card staff are to take the card and the pill to the DON. During an interview on 10/21/25 at 3:50 P.M., the DON said: -She expected all bottles or boxes of medication to have an open daie; -She expected the staff to ensure there was no tape on the back of the cards of medication; -No staff should have taped pills into the cards. During an interview on 10/21/25 at 3:55 P.M_, the Administrator said: -He expected staff to follow the standard of practice when it carne to medications. -Medications should be labeled with an open date; -Cards with tape on the back should be taken the DON. 19 CSR 30-86.047(51)(A)(1) Schedule I Meds-Reconcile Each Shift, Record Records shall be maintained upon receipt and disposition of all controlled substances and shall be maintained separately from other records, for two (2) years. (A) Inventories of controlled substances shall be reconciled as follows: 1. Controlled Substance Schedule I! medications shall be reconciled each shift; I This regulation is not met as evidenced by: Class ll Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 3 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 Based on observation, interview and record review, the facility failed to ensure inventories of Schedule 1 controlled substances (medications which have a high potential for abuse) were reconciled each shift when staff failed to sign the Control Count Verification Log at every change of shift. This affected three of five sampled residents who where prescribed Schedule i] controlled substances (Resident #1, #3 and #4). The facility census was 50. The facilty dicl not provicle a policy on reconciliation of Schedule If controlled substances. 1. Review of the Controlled Substance Shift Change Sheet for the 100 hall on 10/21/25 at 12:52 P.M., showed there were no signatures for the following days: -10/11/25 on coming shift and off going shift; -10/12/25 on coming shift and off going shift; -10/15/25 on coming shift and off going shift; -10/18/25 on coming shift and off going shift; -10/18/25 on coming shift and off going shift. Review of the Individual Narcotic Count Book for the 100 hall on 10/21/25 at 1:10 P.M., showed the medication cart contained: -Morphine (used to treat severe pain) prescribed for Resident #1; -Hydrocedone (used to treat moderate pain) prescribed for Resident #3. Observation of the medication cart on 100 hall on 10/21/25 at 1:15 P.M., showed: -A bottle of Morphine labeled with Resident #1’s name; -A card of Hydrocedone labeled with Resident #3's name. Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 4 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 During an interview on 10/21/25 at 01:25 P.M. Level One Medication Aide (LIMA) A said Narcotics should be counted by the off going and on coming staff. 2. Review of the Controlled Substance Shift Change Sheet for the memory care unit on 10/21/25 at 01:12 P.M., showed there were no signatures for the following days: -10/15/25 on coming shift and off going shift; -10/16/25 off going shift; -10/18/25 off going shift; -10/20/25 on coming shift and off going shift. Review of the Individual Narcotic Count Book for the memory care unit on 10/21/25 at 1:38 P.M., showed the medication cart contained Morphine prescribed for Resident #4. Observation of fhe medication cart on the memory care unit on 10/21/25 at 1:40 P.M., showed one boftle of Morphine labeled with Resident #4's name. During an interview on 10/21/25 at 01:50 P.M. Certified Medication Technician (CMT) A said: -Narcotics should be counted at every shift change; -Staff should sign off that the count has been completed before handing off the keys. During an interview on 10/21/25 at 3:50 P.M., the Director of Nursing (DON) said: -She expected the narcotics to be counted every shift by two staff; -She expected the staff to ensure the count was completed at every shift change or when a new person takes over the cart. Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet § of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 During an interview on 10/21/25 at 3:55 P.M., the Administrator said: -He expected staff fo count the narcotics at every shift; -He expected the staff to sign that the count was complete. 19 CSR 30-86.047(51)(B)(1) Controlled Substances-Reconcile by Personnel (B) Inventories of controlled substances shall be reconciled by the following: 1. Two (2) medication personnel, one of whom is a licensed nurse; Il This regulation is not met as evidenced by: Class fl Based on observation, interview and record review, the facility failed to ensure inventories of controlled substances (medications which have a high potential for abuse} were reconciled each shift when the staff failed to sign the Control Count Verification Log at every change of shift. The facility census was 50. The facility did not provide a policy on reconciliation of controlled substances 1 Review of the Controlled Substance Shift Change Sheet for the 100 hall on 10/21/25 at 12:52 P.M., showed there were no signatures for the following days: -10/11/25 on coming shift and off going shift; -10/12/25 on coming shift and off going shift; -10/15/25 on coming shift and off going shift; -10/18/25 on coming shift and off going shift; Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 6 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 -10/18/25 on coming shift and off going shift. During an interview on 10/21/25 at 01:25 P.M. Level One Medication Aide (LIMA) A said Narcotics should be counted by the off going and on coming staff. 2. Review of the Controlled Substance Shift Change Sheet for the memory care unit on 10/21/25 at 01:12 P.M., showed there were no signatures for the following days: -10/15/25 on coming shift and off going shift; -10/16/25 off going shift; -10/18/25 off going shift; -10/20/25 on coming shift and off going shift. During an interview on 10/21/25 at 01:50 P.M. Certified Medication Technician (CMT) A said: -Narcotics should be counted at every shift change; -Staff should sign off that the count has been completed before handing off the keys. During an interview on 10/21/25 at 3:50 P.M., the Director of Nursing (DON) said: -She expected the narcotics to be counted every shift by two staff; -She expected the staff to ensure the count was completed at every shift change or when a new person takes over the cart. During an interview on 10/21/25 at 3:55 P.M., the Administrator said: -He expected staff to count the narcotics at every shift; -He expected the staff to sign that the count was complete. Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 (X2) MULTIPLE CONSTRUCTION PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 7 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 19 CSR 30-87.020(12) Floor Surfaces All floors in the facility shall be clean and shail be maintained in good repair. Floors and floor coverings of all food-preparation, food-storage and utensil-washing areas, and the floors of all walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealed concrete, terrazzo, ceramic tile, durable grades of linoleum or piastic, or tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip floor covering in areas where necessary for safety reasons. Ill This regulation is not met as evidenced by: Class Ill Based on observations and interview, the facility failed to ensure the floor in the kitchen were kept clean and free from dirt and debris. The facility census was 50. 1. Observation on 10/21/25 beginning at 1:15 P.M. of the kitchen showed: -The floor under the pan storage rack was caked with dirt and debris; -The floor under the dishwashing sink was caked with a brown sticky substance; -The floor under the dishwasher was caked with dirt and debris. During an interview on 10/21/21 at 1:45 P.M. Cook A said: -The floor under shelves and appliances should be cleaned at least monthly; -He/She was unsure the last time the floor was cleaned under the storage rack; -He/She was unsure the last time the floor was cleaned under the dishwasher and dishwashing Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 8 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 sink. -The floors in the kitchen should be kept clean. During an interview on 10/21/25 at 3:55 P.M, the Administrator said: -He expected the floors in the kitchen to be kept clean; -He expected the dietarty staff to be responsible for cleaning of the kitchen. 19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable Light fixtures, vent covers, wall-mounted fans, decorative materials and similar equipment atiached fo walls and ceilings shall be easily cleanable and shall be maintained clean and in good repair. 1H This regulation is not met as evidenced by: Class tl Based on observation and interview the facility failed to ensure the vent covers in the kitchen were kept free from dirt and debris. The facility census was 50. 1. Observation of the kitchen on 10/21/25 at 10:19 A.M. showed: -The air vent and surrounding ceiling above the prep table and steam table was caked in dirt and debris; -An uncovered pan of chopped onions and cucumbers sat under the dirty vent; -The vent above the storage rack was caked in dirt and debris; During an interview on 10/21/25 at 10:28 A.M, Cook A said: Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 9 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 -All vents should be wiped down weekly; -He/She was not sure if this was being completed or by whorn. During an interview on 10/21/25 at 02:18 P.M., the Maintenance Supervisior said: -Maintenance is responsible for cleaning the vents on the ceiling in the kitchen; -He/She was noi sure the last time the vents had been cleaned; -The vents in the kitchen should be free of dirt and debris. During an interview on 10/21/25 at 03:54 P.M, the Administrator said: -He expected the dietary staff to report to maintenance when the vents needed cleaned: -He expected the vents in the kitchen to be free of dirt and debris. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. I/II This regulation is not met as evidenced by: Class Il Based on observation, interview and record review, the facility failed to ensure staff washed their hands before preparing food in the kitchen and in between tasks in the kitchen. This had the potential to affect all residents. The census was Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 10 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 50. The facility did not provide a policy on hand washing. 1. Observation on 10/21/25 at 11:30 A.M., showed: -Cook A returned to the kitchen from outside the back door of the kitchen; -Cook A took a cucumber from the refrigerator and took a knife from a drawer; -Cook A did not wash his/her hands after he/she returned to the kitchen; -Cook A did not wash his/her hands before he/she picked up the cucumber or when picking up the knife to cut the cucumber. 2. Observation on 10/21/25 at 11:55 A.M., showed: -Cook A opened the door to the freezer with his/her gloved hand; -Cook A took a pan of food with plastic wrap on it off the top shelf of the freezer; and dumped it in the trash can; -The piece of plastic wrap fell off the pan of food and landed on the floor; -Cook A dumped the contents of the pan into the trash can and with his/her gloved hand picked up the piece of plastic wrap off the floor and threw it in the trash can; -Cook A went back to the prep table and opened the oven door and took a pan of chicken out and sat it on the prep table; -Cook a took a clean platter from under the table and then took a pair of tongs from the drawer and removed the chicken from the pan onto the clean platter; -Cook A did not change gloves or wash his/her hands after he/she picked! up the plastic wrap off the floor or before removing the chicken from the Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Hf continuation sheet 11 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 pan to a platter. During an interview on 10/21/25 at 12:18 P.M., Cook A said: -He/She should have washed his/her hands before returning to work in the kitchen; -Staff should changed gloves and wash hands between tasks. During an interview on 10/21/25 at :54 P.M., the Administrator said: -The kitchen staff should be removing their gloves and washing their hands between any contaminants; -He expects dietary staff fo wash their hands before starting work in the kitchen. 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. Il] This regulation is not met as evidenced by: Class fll Based on observation, interview and record review, the facility failed to ensure staff used effective hair restraints to prevent the contamination of food or food contact surfaces. The census facility census was 50. The facility did not provide a policy on hair restraints. 1. Observation of the kitchen on 10/21/25 at 11:30 A.M., showed: Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 42 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 -Cook A returned to the kitchen from outside the back door of the kitchen; -Cook A took a cucumber from the refrigerator and took a knife from a drawer; -Cook A did not apply a hair restraint after he/she returned to the kitchen. 2. Observation of the kitchen on 10/21/25 at 11:55 A.M., showed: -Cook A opened the door to the freezer and took a pan of food with plastic wrap on it off the top shelf of the freezer; ancl dumped it in the trash can; -Cook A went back to the prep table and opened the oven door and took a pan of chicken out and sat it on the prep table; -Cook a took a clean platter from under the table and then took a pair of tongs from the drawer and removed the chicken from the pan onto the clean platter; -Cook A did not change gloves or wash his/her hands after he/she picked up the plastic wrap off the floor or before removing the chicken from the pan to a platter; -Cook did not have a hair restraint in place while he/she prepared foad in the kitchen. During an interview on 10/21/25 at 12:18 P.M, Cook A said: -The staff did not use hair nets in the kitchen; -The staff could use baseball caps if needed; -He/She thought it was up to the staff if they wanted to wear the baseball cap not a rule; -He/She should have used some type of hair restraint. During an interview on 10/21/25 at :54 P.M., the Administrator said: -He expected the dietary staff to used hair restraints while in the kitchen and while preparing Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 13 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 food; -He expected any staff that entered the kitchen to wear a hair restraint. 19 CSR 30-87.030(18) Refrigerator Temperatures, Thermometers Enough conveniently located refrigeration facilities or effectively insulated facilities shall be provided fo assure the maintenance of potentially hazardous food at required temperatures during storage. Each mechanically refrigerated facility storing potentially hazardous food shall be provided with a numerically scaled indicating thermometer, accurate to plus or minus three degrees Fahrenheit (+3°F), located to measure the air temperature in the warmest part of the refrigerated facility and located to be easily readable. Recording thermometers, accurate to plus or minus three degrees Fahrenheit (+3°F}, may be used in lieu of indicating thermometers. HI This regulation is not met as evidenced by: Class fl Based on observation, interview and record review the facility failed to document refrigerator and freezer temperatures to assure potentially hazardous foods were stored at the required temperature. This affected all residents. The facility census was 50. The facility did not provide a policy on documentation of freezer and refrigerator temperatures. Observation of the kitchen on 10/21/25 at 11:30 A.M., showed no documentation that refrigerator Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 44 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 or freezer temperatures had been taken was found. Observation of the kitchen on 10/21/25 at 11:55 A.M., showed no documentation that refrigerator or freezer temperatures had been taken was found. During an interview on 10/21/25 at 12:18 P.M, Cook A said: -A temperature log should be placed on the refrigerator and freezer that showed what the temperatures were; -Refrigerator temperatures should be taken and recorded at least once daily; -Freezer temperatures should be taken and recorded at least once daily. During an interview on 10/21/25 at :54 P.M., the Administrator said: -He expected the dietary staff to take freezer and refrigerator temperatures at least daily; -He expected the dietary staff to record freezer and refrigerator temperatures at least daily. 19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily The food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens shall be cleaned at least once a day, except that this shail not apply to hot oil-cooking equipment and hot ail-filtering systems. The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. [ll This regulation is not met as evidenced by: Class Ill Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 16 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 Based on observation, interview and record review the facility failed to ensure all cooking equipment was free of accumulated crusted food debris when staff failed to keep microwave ovens clean and free of food debris. The facility census was 50. The facility did not provide a policy on cleaning of microwaves. Observation of the kitchen on 10/21/25 at 11:30 A.M., showed: -No cleaning list for the kitchen was found; -A microwave oven with grease buildup and dried food particle and debris on the top, sides and turntable of the microwave. Observation of the kitchen on 10/21/25 at 12:13 P.M., showed a microwave oven in the dining room with grease buildup and dried food particle and debris on the top, sides and the turntable of the microwave. During an interview on 10/21/25 at 12:18 P.M., Cook A said: -The microwave ovens at the facility should be clean and free of debris; -The microwave ovens at the facility should be cleaned at least once daily; -He/She did not know where the cleaning list for the kitchen was located. During an interview on 10/21/25 at :54 P.M., the Administrator said: -He expected the microwaves in the facility to be free of dirt and debris; -He the kitchen staff should be responsible for the cleaning of the microwaves in the facility. Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 16 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 16 19 CSR 30-87.030(74) Chemical Sanitization, PPM Measured When chemicals are used for sanitization, they shall not have concentrations higher than the maximum permitted under 21 CFR 178.1010 of the (Revised 2005), Food and Drug Code of the United States Food and Drug Administration, Department of Health and Human Services, and a test kit or other device that accurately measures the parts per million concentration of the solution shall be provided and used. Ill This regulation is not met as evidenced by: Class fl Based on observation and interview, the facility failed fo ensure the chemical concentration of the dishwasher was being checked daily. The facility census was 50. 1. Observation and interview on 10/21/25 at 11:30 A.M., showed: -Cook A removed dishes from the dishwasher; -A five gallon container of commercial sanitizer connected to the dishwasher sat under the dish washer, -Cook A said the sanitizer was used to sanitize the dishes in the dishwasher; -The sanitizer should be checked at least daily; -Cook A could not locate documentation to show the sanitizer had been checked; -Cook A said there should be a log to record the sanitizer measurement. During an interview on 10/21/25 at 12:22 P.M, Dietary Aide A said: -The sanitizer in the dishwasher should be checked at least daily; Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 17 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 -There should be a log to record the concentration of the sanitizer; -There has never been a log to record the concentration of the sanitizer in the dishwasher. During an interview on 10/21/25 at :54 P.M., the Administrator said: -He expected the sanitizer in the dishwasher to be checked and recorded at every meal service; -He expected the kitchen staff to ensure this was getting done. 19 CSR 30-87.030(86) Store Equip/Utensils to Prevent Contamination Cleaned and sanitized ufensils and equipment shall be stored above the floor in a clean, dry location in a way that protects them from contamination by splash, dust and other means. The foad-contact surfaces of fixed equipment shall also be protected from contamination. Ill This regulation is not met as evidenced by: Class fll Based on observation and interview the facility failed to ensure cleaned and sanitized utensils and equipment shall be stored above in a clean, in a way that protects them from contamination by splash, dust and other means. The facility census was 50. The facility did not provide a policy on storing sanitized utensils and equipment. 1. Observation on 10/21/25 11:15 A.M. showed: - Eight bowls stored face on the top rack next to the drink area; - Seven saucers stored face up on the rack next Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 18 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 9607 NORTH TULLIS DRIVE ADDINGTON PLACE OF SHOAL CREEK KANSAS CITY, MO 64157 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 to the drink area; - Five eight ounce drinking glasses stored face up on the rack next to the drink area. During an interview on 10/21/25 at 1:32 P.M. Cook A said clean dishes, pans and utensils should be stored face down to keep them from contamination. During an interview on 10/21/25 at 3:50 P.M. the Administrator said: - Clean dishes should be stored in a clean way to prevent dirt or contaminants from making contact with the dishes; - He/she expects the kitchen staff to know how to properly store dishes and utensils. Missouri Department of Health and Senior Services STATE FORM 899 Q82M114 (X2) MULTIPLE CONSTRUCTION PRINTED: 11/03/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 49 of 19 PLAN OF CORRECTION Provider/Supplie Addington Place of Shaol Creek r Name: Street Address, City, Zip: 9601 N. Tullis Dr., Kansas City, MO 64157 Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER a ID PREFIX PROVIDER'S PLAN OF CORRECTION: (EACH COMPLETION TAG CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED DATE TO THE APPROPRIATE DEFICIENCY A4797 12/1/25 Plan of Correction for Deficiency: Medication Storage and Safe Medication System Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. The Lorazepam Oral Concentrate bottles for Residents #1 and #4 were discarded and replaced in accordance with manufacturer guidelines and pharmacy protocol. The Hydrocodone and Tramadol blister cards (for Residents #3 and #5) found with tape were removed and returned to the pharmacy for proper replacement. All medication carts and storage areas were audited for integrity, labeling, and dating by the Director of Health & Wellness (DHW) on (Date) The Medication Technicians involved received immediate retraining on proper labeling, dating, and handling of all medications—specitically regarding controlled substances and compromised packaging. How will you identify other residents having the potential to be affected by the same deficient practice: All residents receiving medication administration had the potential to be affected. 1. A facility-wide audit of all medication carts, medication room, and medication refrigerators will be completed by November 20, 2025, to verify: e Alloral liquid medications were dated upon opening. e No medication cards had tape or compromised seals; Controlled medications were properly secured and documented. No further issues were identified during this audit. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: To ensure long-term compliance and system reliability, the following systemic measures have been implemented: 1. All medication and nurses will be trained on Safe and Effective Medication System Policy, addressing: Proper dating of all oral liquid medications upon opening: Prohibition of taping or altering medication packaging; Immediate reporting of damaged or compromised packaging to the DHW; Requirements for safe storage and documentation of controlled substances. All licensed nurses, Certified Medication Techs, and Level I Medication Aides (LIMAs) will receive mandatory re-education covering the new policy and manufacturer labeling standards. The pharmacy consultant was notified of the deficiency and will verify compliance during monthly audits. How facility plans to monitor its performance to make sure that solutions are sustained: 1. The Director of Health & Wellness or designee will conduct weekly audits of all medication carts and storage areas for four consecutive weeks to ensure compliance with labeling, dating, and packaging integrity. . Beginning in the fifth week, audits will be conducted monthly and results reviewed in the QA monthly document. Any deviations identified during audits will result in immediate retraming and disciplinary follow-up if warranted. Plan of Correction for Deficiency: Schedule IT 12/1/25 Medications Reconciled Each Shift Corrective Action taken for those residents alleged to have been affected by the deficient practice are: Immediately following the surveyor’s observation on 10/21/25, the following actions were taken: 1. All Controlled Substances for all halls and all shifts change logs will be audited for missing signatures and reconciled to verify that all Schedule IT medications were accurately accounted for. Incoming and outgoing shift counts for all controlled substances will be completed and signed by both medication staff to ensure current compliance. Morphine and Hydrocodone inventories for Residents #1, #3, and #4 were verified as accurate against the individual narcotic count sheets and pharmacy supply. All staff responsible for medication administration (L1Mas and CMTs) will received immediate education on controlled substance documentation and reconciliation expectations. How will you identify other residents having the potential to be affected by the same deficient practice: All residents recetving Schedule II controlled medications had the potential to be affected. 1. A facility-wide audit of all controlled substance logs will be completed to ensure all reconciliation sheets and count logs contained the required signatures at every shift change, with no missing doses or discrepancies being identified during audits. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: To ensure sustained compliance and accountability: 1. All LIMAs and Certified Medication Techs will be trained on the Controlled Substance Reconciliation Policy, specifying that: o Schedule II controlled substances must be counted and documented at every shift change by both oncoming and outgoing staff; Any discrepancy or missing signature must be immediately reported to the Director of Health & Wellness (DHW) and Executive Director; The Shift-to-Shift Controlled Substance Verification Form will be implemented. All medication staff will receive re-education on Control Substance. The Consultant Pharmacist will be notified of the deficiency and will verify reconciliation documentation during monthly audits. How facility plans to monitor its performance to make sure that solutions are sustained: 1. The Director of Health & Wellness or designee will review all controlled substance reconciliation logs weekly for four weeks to verify complete and accurate documentation. . Begmning week five, monthly audits will be performed on all medication carts. . Thereafter, the DHW & ED will verify compliance through monthly spot audits, and results will be reviewed in our QA assessment forms. Any deviation or missing signature will result m immediate retraining and progressive disciplinary action as warranted. Plan of Correction for Deficiency: Controlled 12/1/25 Substances Reconciled by Two Medication Personnel Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. Alli Controlled Substance Shift Change Logs for MC and AL Halls were reviewed and reconciled for missing signatures. All Schedule II and other controlled substances were verified for count accuracy by the Director of Health & Wellness (DHW). Effective immediately, all controlled substance counts are conducted by two qualified staff. All medication personnel were re-educated on this policy and required to demonstrate the correct process before assuming cart responsibility. How will you identify other residents having the potential to be affected by the same deficient practice: All residents receiving controlled medications had the potential to be affected. 1. A facility-wide audit of controlled substance logs and reconciliation sheets will be completed. 2. No missing doses or discrepancies will be identified during the audit. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: To prevent recurrence and ensure full compliance: A Controlled Substance Reconciliation Policy will be implemented, outlining that: Controlled substances must be counted and verified at every shift change. The count must be performed by two medication personnel. Both staff must sign the Controlled Substance Shift Verification Log immediately after completion; Any discrepancy or missing signature must be reported to the DHW and Executive Director immediately. All medication staff (LIMAs and CMTs) will complete refresher training regarding documentation, reconciliation, and accountability of controlled substances. How facility plans to monitor its performance to make sure that solutions are sustained: 1. The DHW or designee will review all controlled substance logs for four weeks to confirm dual signatures are present. Beginning week five, random audits of both medication carts will occur. Thereafter, compliance will be verified monthly by the DHW and Executive Director, with results reviewed during monthly QA reviews. . Any instance of missing signatures or improper reconciliation will result in immediate correction, staff retraining, and progressive disciplinary action if warranted. Plan of Correction for Deficiency: Kitchen Floor 12/1/25 Cleanliness Corrective Action taken for those residents alleged to have been affected by the deficient practice are: Immediately following the observation on 10/21/25, the kitchen floors—including areas under the pan rack, dishwashing sink, and dishwasher—were thoroughly cleaned and sanitized by the dietary team. A follow-up inspection by the Executive Director and Maintenance Director verified all areas were free of dirt and debris. How will you identify other residents having the potential to be affected by the same deficient practice: All residents could have been potentially affected as the kitchen serves the entire facility. The entire kitchen area was inspected, and no additional issues were identified. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: 1. The Culinary Director will revise the daily and deep cleaning schedule to include all under-equipment and hard-to-reach areas. The Culinary Director will ensure that the “Clean Under/Behind Equipment” checklist be used as part of the weekly cleaning log. Staff will receive re-education on environmental sanitation standards, with emphasis on floor and under- equipment cleaning. How facility plans to monitor its performance to make sure that solutions are sustained: The Culinary Director or designee will conduct and document weekly inspections of all floor areas, including under and behind kitchen equipment, for four weeks. After four weeks, inspections will continue monthly and be reviewed during the Safety Committee meetings. 3. Any findings will be corrected immediately and reviewed with the Executive Director. Plan of Correction for Deficiency: Kitchen Vent Covers and Ceiling Cleanliness: Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 12/1/25 1. Immediately followme the observation on 10/21/25, the air vents and surrounding ceiling areas above the prep table, steam table, and storage rack were thoroughly cleaned and sanitized. The pan of uncovered onions and cucumbers was immediately discarded, and the prep area was sanitized. A full inspection of all kitchen ceiling vents and surrounding surfaces was completed, with all areas cleaned and confirmed to be free from dirt and debris. How will you identify other residents having the potential to be affected by the same deficient practice: 1. All residents could have been potentially affected since the kitchen serves the entire facility. All other kitchen and dining area vents were inspected and cleaned as necessary to ensure cleanliness and prevent contamination risk. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur 1. The Culinary Director and Maintenance Director implemented a monthly vent and ceiling cleaning schedule. . The Culinary team was re-educated on food safety and environmental sanitation, emphasizing that food must never be prepared or stored under dirty or uncovered vents. . A “Ceiling and Vent Inspection” section will be checked during the weekly sanitation checklist used by culinary staff. 4. The Maintenance Director will ensure vent filters and covers are removable and easily cleanable during routine maintenance. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: 1. The Dietary Manager or designee will conduct and document weekly inspections of kitchen vents and surrounding ceiling areas for four weeks. . After four weeks, inspections will continue monthly and be reviewed during QA meetings. The Executive Director will review inspection logs monthly to verify completion and follow-up on any issues noted. Plan of Correction for Deficiency: Handwashing 12/1/28 Policy and Practice Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. Immediately following the surveyor’s observation, all cooks, including cook A will be re-educated on proper handwashing and glove use procedures, including the requirement to wash hands: Upon re-entering the kitchen from outside, Before handling food or utensils, After handling trash or contaminated items, And between glove changes. Handwashing Policy and Procedure was presented to culinary staff, implemented, and posted in the kitchen. All dietary staff were re-trained on the policy and completed a return demonstration of proper handwashing and glove use to ensure understanding. How will you identify other residents having the potential to be affected by the same deficient practice: 1. Allresidents could have been potentially affected since the dietary department provides meals to all residents. All kitchen staff were observed and evaluated to ensure compliance with hand hygiene standards. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: 1. The Culinary staff will be re-educated on the written Handwashing and Glove Use Policy. 2. The Culinary Director will provide in-service tramimg to all dietary employees, covering: e Handwashing requirements (when and how) e Proper glove use and changing techniques e Prevention of cross-contamination . Handwashing signage was posted at all kitchen sinks. The Culinary Director or designee will now observe and document staff hand hygiene compliance daily during meal preparation times. How the facility plans to monitor its performance to make sure that solutions are sustained: The Culinary Director or designee will conduct daily spot checks for hand hygiene and glove use compliance for 4 weeks. After 4 weeks, observations will occur weekly and results will be reviewed during the QA. Any staff found non-compliant will receive immediate corrective coaching and re-training. The Executive Director will review compliance reports monthly. Plan of Correction for Deficiency: Clean Clothing | 12/1/29 and Hair Restraints Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. Immediately following the observation on 10/21/25, Cook A was re-educated on the requirement to wear effective hair restraints while in food preparation areas. A new hair restraint policy was created, implemented, and posted in the kitchen on [insert date]. All dietary staff were provided with new hair nets, and clean outer clothing guidelines. The Culinary Director verified that all staff are wearing appropriate hair restraints during food preparation and service. How will you identify other residents having the potential to be affected by the same deficient practice: 1. All residents could have been potentially affected, as the dietary department serves the entire facility. All dietary employees were observed for compliance with hair restraint and clothing cleanliness requirements, and no additional issues were identified. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: 1. The Executive Director presented and implemented the Hair Restraint and Clean Clothing Policy to all Culinary staff. All new culinary hires during orientation will also receive this training. All current Culinary employees will receive in-service training covering: e Hair restraint use (when and where required) e Clean clothing expectations e Food contamination prevention practices e Hair restraint compliance was added to the daily opening and closing kitchen checklist. How the facility plans to monitor its performance to make sure that solutions are sustained: The Culinary Director or designee will conduct daily visual inspections during each meal period for four weeks to ensure all dietary employees are properly wearing hair restraints and clean outer clothing. After four weeks, compliance checks will occur weekly, with results reviewed during QA reviews Any noncompliance will result in immediate re- education and documentation of corrective action. Plan of Correction for Deficiency Refrigerator and 12/1/25 Freezer Temperature Documentation Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. Immediately following the surveyor’s observation, all refrigerators and freezers in the kitchen were checked to ensure they were maintaining proper temperatures. A temperature log was implemented to document daily temperature readings for all cold storage equipment. All dietary staff were re-educated on proper temperature monitoring and documentation procedures. How will you identify other residents having the potential to be affected by the same deficient practice: 1. Allresidents could have been potentially affected, as the dietary department stores and prepares food for the entire facility. All refrigeration and freezer units in the dietary department were inspected and confirmed to be maintaining proper temperature ranges. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: All staff will be trained on the written Refrigerator and Freezer Temperature Policy. Temperatures to be recorded (morning and evening). Immediate corrective action if any unit is found out of range. Documentation of all corrective actions on the temperature log. The Culinary Director will review temperature logs daily and initial each entry. How the facility plans to monitor its performance to make sure that solutions are sustained: The Culinary Director or designee will review and sign all temperature logs daily to ensure completeness and accuracy. The Culinary Director will review logs weekly for four weeks, then monthly thereafter. Findings and trends will be reported to the Executive Director and during QA meetings. Any missed entries or temperature variances will result in immediate corrective action and staff re-education. Plan of Correction for Deficiency: 12/1/25 Grills/Griddles/Microwaves/ Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. Immediately following the observation on 10/21/25, ail microwave ovens and cooking equipment in both the kitchen and dining area were thoroughly cleaned and sanitized. A daily cleaning checklist was created and implemented on [insert date] for all dietary equipment, including microwaves, griddles, ovens, and other food- contact surfaces. The Culinary Director verified that all equipment was free of grease, debris, and food residue. How will you identify other residents having the potential to be affected by the same deficient practice: 1. Allresidents could have been potentially affected as the dietary department prepares and serves meals for the entire facility. All other cooking and food-preparation equipment were inspected and cleaned as necessary to ensure compliance. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: 1. The Culinary staff will receive the written Cooking Equipment Cleaning Policy. The Daily Cleaning Checklist includes microwaves, stove tops, ovens, griddles, and other feod-contact surfaces. The Culinary Director & Executive Director will provide in-service training to all culinary staff. Proper cleaning and sanitizing of all cooking equipment, including microwave interiors and door seals--frequency requirements (daily or as needed). The Culinary Director or designee will initial all completed cleaning logs at the end of each day to confirm compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: The Culinary Director or designee will conduct daily visual inspections of all cooking and microwave equipment for four weeks. After four weeks, inspections will continue weekly, and findings will be reviewed in QA meetings. Any noncompliance will result in immediate corrective cleaning and staff re-education. The Executive Director will review cleaning checklists and inspection records monthly for continued compliance. Plan of Correction for Deficiency: Chemical 12/1/28 Sanitization Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. Immediately followmeg the observation on 10/21/25, the Culinary Director verified that the dishwasher sanitizer was functioning properly and measured within the required range using a test kit. A sanitizer concentration log was created on [msert date] and implemented to document daily sanitizer readings in parts per million (PPM). All dietary staff were re-educated on how to correctly test and record sanitizer concentrations before and after each meal period. How will vou identify other residents having the potential to be affected by the same deficient practice: 1. Allresidents could have been potentially affected since the dietary department provides meals and utilizes sanitized dishware for the entire facility. All other sanitation equipment, including three- compartment sinks Gf applicable), were checked to ensure proper sanitizer concentrations. No additional issues were identified. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: 1. All culinary staff will receive a written Dishwasher and Sanitizer Testing Policy 2. The Culinary Director and Director of Facilities will provided in-service traming on proper sanitizer testing and documentation to all dietary employees. Replacement test kits are now stored in the dietary office to ensure ongoing availability. How the facility plans to monitor its performance to make sure that solutions are sustained: The Culinary Director or designee will review the sanitizer log weekly to verify that readings are documented and within acceptable range. Logs will be reviewed monthly by the Director of Facilities for four weeks, then monthly thereafter. Any out-of-range readings will be addressed immediately, with documentation of corrective actions. Compliance will be reviewed in QA meetings each month. Plan of Correction for Deficiency Storage of 12/4/25 Cleaned and Sanitized Utensils and Equipment Corrective Action taken for those residents alleged to have been affected by the deficient practice are: 1. Immediately following the observation on 10/21/25, all clean dishes, utensils, and glassware stored next to the drink area were rewashed, sanitized, and properly stored to prevent contamination. 2. Allitems were stored face down on clean, dry shelving above the floor to protect from splash or dust. The Culinary Director verified that all storage racks were clean and properly arranged. How will you identify other residents having the potential to be affected by the same deficient practice: 1. All residents could have been potentially affected, as the kitchen serves the entire facility. All dish storage areas, utensil racks, and shelving units throughout the dietary department were inspected for proper storage practices, and any items found improperly stored were corrected immediately. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur: All culinary staff will receive a written Clean Equipment and Utensil Storage Policy All culinary staff will be recetve in-serviced regarding proper storage procedures, including: Dishes and glassware must be stored face down. Utensils must be stored in clean containers with handles upright to avoid hand contact with food-contact surfaces. All shelves and racks must be kept clean, dry, and free from debris or splash risk. The Daily Cleaning and Closing Checklist was revised to include verification of proper utensil and dish storage. How the facility plans to monitor its performance to make sure that solutions are sustained: The Culinary Director or designee will conduct daily visual inspections of utensil and dish storage areas for four weeks. After four weeks, inspections will occur weekly, with results reviewed during QA meetings. Any staff observed storing items incorrectly will receive immediate re-education. The Executive Director will review compliance documentation monthly to ensure sustained adherence. 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. An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 03/11/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R-C 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ADDINGTON PLACE OF SHOAL CREEK A4798) 19 CSR 30-86.047(47)(A) Physicians Orclers Followed Medication Orders. (A) No medication, treatment or diet shail be administered without an order from an individual lawfully authorized to prescribe such and the order shail be followed. IV/HI This regulation is not met as evidenced by: Class Il* Based on interview and record review, the facility failed to ensure all physician's orders were followed when one sampled resident (Resident #1) had an order dated 11/11/25 to be moved to the facilities all women's unit due to behaviors, and was not moved until 11/19/25. The facility census was 47. The facility did not provide a policy regarding following physician's orders. 1. Review of Resident #1's record showed diagnoses inclucled: Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Review Resident #1's progress notes showed on 11/19/25 at 11:00 A.M. the ADHW documented Resident #1 was moved to the all women's memory care unit af 6:45 A.M. that morning. Review of a Physician's Order dated 11/11/25 for Resident #1 showed he/she needed to be placed on an ail female unit due to behaviors. Review of the facility's daily census log for 11/11/25 - 11/19/25 showed one room was open and available on the all women’s unit from Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 Q82MiI2 lf continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued Fram page 1 41/11/25 to 11/19/25. During an interview on 12/03/25 at 3:27 A.M. Resident #1's doctor said: -He/She wrote the order for Resident #1 to be moved to the facility's all women's memory care unit due to his/her behaviors triggered by men; -He/She expected his/her order to be followed as it was an order, not a suggestion; -He/She would have expecied Resident #1 be moved to the all women's unit as soon as a room was available. During an interview on 12/02/25 at 3:15 P.M. the ADHW and Director of Health and Wellness said: -They were aware of the physician's order from Resident #1's doctor, dated 11/11/25; -They mentioned the order and asked management when the resident would be moved, at daily stand up meetings; -lt was not up to them on when to move residents; -They were unsure why it fook so long to move the resident to the all women's unit; -They expected all physician's orders to be followed as they were wrote. During an interview on 12/02/25 at 3:27 P.M. the ED said: -The doctor's order to place Resident #1 on the all women's unit was a suggestion; -He/She had the final say on residents being moved to different rooms; During a follow up interview on 12/04/25 at 10:34 A.M. the ED said he/she expected all physician's orders to be followed. *Higher class merited due to extent of violation. Missouri Department of Health and Senior Services STATE FORM 899 Q82M12 PRINTED: 03/11/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED R-C 12/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 2 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 MO259262, MO259418 19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed If the administrator or other employee of a long-term care facility has reasonable cause to believe that a resident of the facility has been abused or neglected, the administrator or employee shail immediately report or cause a report to be made to the department. Any administrator or other employee of a long-term care facility having reasonable cause to suspect that a vulnerable person has been subjected to abuse or neglect or observes such a person being subjected to conditions or circumstances that would reasonably result in abuse or neglect shall immediately report or cause a report to be made to the department and to the Department of Mental Health. Wil This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to immediately report or cause a report to the Department of Health and Senior Services (DHSS) upon notification when Resident #1 hit Resident #2 on 11/07/25 and 11/18/25. The facility census was 47. Review of the facility's Abuse, Neglect and Exploitation policy dated 06/13/24 showed: -Staff were required to immediately notify the Director of Health and Wellness and Executive Director upon observing or suspecting any form of abuse; -Reporting of any suspected, alleged, or witnessed abuse would be completed according Missouri Department of Health and Senior Services STATE FORM 899 Q82M12 PRINTED: 03/11/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED R-C 12/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 3 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 to state reporting requirements; -The facility used Section 198.070.1, RSMo as a guideline for facility self reporting incidents to DHSS, which required Administrators or employees who have reasonable cause to believe that a resident of a facility had been abused or neglected, to immediately report or cause a report to DHSS. 1. Review of Resident #1’s record showed diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Review of Resident #2's record showed diagnoses included dementia. Review of the facility's investigation dated 11/07/25 showed: -Upon arriving to the facility for his/her shift on 11/07/25 the Assistant Director of Health and Wellness (ADHW) was notified by Care Manager (CM) A that he/she witnessed Resident #1 hit Resident #2 in the head multiple times; -The residents were separated immediately and taken to their rooms, and later evaluated by the ADHW where no injuries were found: -The ADHW notified the Executive Director (ED), the Director of Health and Wellness (DHW), families, and physicians; -The ED made a report to DHSS on 11/08/25 at 11:00 A.M.. Review of a progress note for Resident #2 dated 11/07/25 at 8:00 P.M. the ADHW noted the resident had been struck on the head multiple times by Resident #1, and that the family, doctors, and ED had been notified. Missouri Department of Health and Senior Services STATE FORM 899 Q82M12 (X2) MULTIPLE CONSTRUCTION PRINTED: 03/11/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED R-C 12/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 4 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 During an interview on 12/03/25 at 1:13 P.M. CM A said: -He/She witnessed Resident #1 strike Resident #2 on the head with a closed fist the evening of 11/07/25; -This altercation happened about 30 minutes prior to him/her notifying the ADHW who came in to relieve him/her; -He/She did not report immediately because of everyihing going on and being the only staff on the unit; -No management was onsite when the incident occurred, but he/she should have called to report the incident immediately. During an interview on 12/02/25 at 3:15 P.M. the ADHW said: -He/She came in to work at 6:00 P.M. on 11/07/25 to relieve CM A, at which time CMA reported that Resident #1 had struck Resident #2 on the head during his/her shift, he/she was unclear when the incident occurred but it had not just happen; -Upon being notified of the incident, he/she notified the ED immediately; -Resident to resident altercations were supposed to be reported to DHSS within two hours, that was why he/she reported it to the ED that evening. 2. Review of the facility's investigation dated 11/18/25 showed: -At 5:30 P.M. on 11/18/25 Level One Medication Aide (LIMA) A called the ADHW and notified that Resident #1 just struck Resident #2 on the left arm with his/her hand; -The residents were separated, and observed to have no injuries; -The ADHW notified the ED, the DHW, families, and physicians of the incident; -The ADHW was directed to send Resident #1 to Missouri Department of Health and Senior Services STATE FORM 899 Q82M12 (X2) MULTIPLE CONSTRUCTION PRINTED: 03/11/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED R-C 12/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 5 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9607 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 ER for a psych evaluation, but Resident #1 had fallen asleep within 10 minutes of that directive, so he/she contact the ED back to inform him/her of resident being asleep and was instructed not to move the resident if he/she was asleep. Review of a progress note for Resident #2 dated 11/18/25 at 6:00 P.M. the ADHW noted the resident had been struck on the arm by Resident #1, no injuries noted, and that doctor and family were notified. During an interview on 12/02/25 at 3:15 P.M. the ADHW said: -He/She received a call about the incident on 11/18/25, and immediately notified the ED that evening, and received direction not to send out by the ED since the resident had fallen asleep. During an interview on 12/02/25 at 3:27 P.M. the ED said: -Any resident to resident altercation should be reported to DHSS within two hours or twenty four hours depending on the severity of harm or injuries; -He/She was not immediately notified of the incidents between Resident #1 and Resident #2 on 11/07/25 and 11/18/25: -He/She should have been notified immediately for both incidents, so that both incidents could have been reported to DHSS within two hours. MO259262, MO259418 Missouri Department of Health and Senior Services STATE FORM 899 Q82M12 PRINTED: 03/11/2026 FORM APPROVED {X3} BATE SURVEY COMPLETED R-C 12/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 6 of 6

PRINTED: 01/24/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (Xa) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED Cc B, WING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 (X4) 1D | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ADDINGTON PLACE OF SHOAL CREEK A4749 19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day 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: A. Within five (5) calendar days of admission; |! This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure two residents (Residents #3 and #4) out of five sampled residents! Community Based Assessments (CBA's) were completed within five days of admission. The facility's census was 51. | 1. Review of Resident #3's medical record | showed the following: - An admission date of 11/25/24; - No documentation of a CBA completed within five days of admission or since the resident's | admission to the facility. 2. Review of Resident #4's medical record showed the following: ~ An admission date of 11/25/24- - Na documentation of a CBA completed within five days of admission or since the resident's admission to the facility. During an interview on 01/18/24 at 1:28 P.M., the Missouri Department of Health and Senior Services LABORATORY DIRECTOR (X6) DATE STATE FORM $080) 43Z111 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: 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Executive Director said: -She expected all residents to have a CBA completed within five days of admission; -She did not know why all residents did not have a CBA completed within 5 days of admission; -She recently hired a new Director of Nursing but and did not know why the previous director of nursing did not complete the CBA's. 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 record review and interview the facility failed to ensure a community based assessment (CBA) was completed at least semiannually (twice per year) for two of five sampled residents (Resident #1 and #2). The facility census was 51. The facility did not provide a policy regarding CBA's. 1. Review of Resident #1's record showed: -Admit date 8/11/23; Missouri Department of Health and Senior Services STATE FORM 6899 432111 PRINTED: 01/24/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/16/2025 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 5 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: 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 -The most recent CBA found was completed on 8/11/23; -No CBA was found for 2024 or 2025. 2. Review of Resident #2's record showed: -Admit date 8/16/22: -There was no CBA on file. During an interview on 01/18/24 at 1:28 P.M. the Executive Director said: -She expected all residents to have a CBA completed at least semiannually; -She did not know why all residents did not have a CBA completed at least semiannually; -She recently hired a new Director of Nursing but and did not know why the previous director of nursing did not complete the CBA's. 19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements 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: (H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident "s condition which may require a change in services; II This regulation is not met as evidenced by: Class II Based on interview and record review the facility failed to ensure Individual Service Plans (ISP) were reviewed and updated when there was a significant change in the resident's condition Missouri Department of Health and Senior Services STATE FORM 6899 432111 PRINTED: 01/24/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/16/2025 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 5 PRINTED: 01/24/2025 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 (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) ADDINGTON PLACE OF SHOAL CREEK Continued From page 3 which may have required a change in services for four of five sampled residents (Resident #1, #2, and #5). The facility census was 51. Review of the facility's Falls policy, dated 6/13/24, showed: -Each resident's identified fall risks would be addressed with recommended interventions included in the resident's ISP; -Each resident's ISP would be reviewed and updated when a resident had a first fall (no prior documented/reported fall), two or more falls within thirty (30) days, or a fall with an injury requiring medical treatment. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 8/11/23; -Diagnoses included dementia (a disease that causes memory loss and reasoning) and anxiety; -His/Her ISP was last updated on 2/9/24: -In the past three months the resident had falls on 11/9/24 and 11/13/24; -His/Her ISP indicated she had no falls and no interventions were recommended or implemented. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 8/16/22: -Diagnoses included dementia and tremors; -The resident's ISP was updated on 12/18/24 and showed he/she had one fall in the prior three months; -In the past three months the resident had falls on 11/18/24, 11/22/24, 11/25/24, and 11/26/24; -No fall interventions recommended or implemented. 3. Review of Resident #5's record showed: -He/She was admitted to the facility on 8/30/21; -Diagnoses included dementia and anxiety; Missouri Department of Health and Senior Services STATE FORM 6899 432111 If continuation sheet 4 of 5 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: 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 -In the past three months the resident had one fall on 1/11/25; -His/Her ISP was last updated 11/24/24 and indicated she had one fall in the prior three months; -No fall interventions were recommended or implemented. Observation on 1/16/25 at 11:15 A.M. of Resident #5 showed: -He/she had a large bruise on the right side of his/her face. During an interview on 1/16/25 at 11:15 A.M., LIMA A said: -He/she believed the bruise on Resident #5's face was caused from a recent fall. During an interview on 01/18/24 at 1:28 P.M. the Executive Director said: -She expected ISP's to be updated every six months and with each significant change; - ISP's should be updated when a resident had a first fall, or two or more falls within a 30 day time period. -She expected interventions to be implemented after each fall. MO246863 Missouri Department of Health and Senior Services STATE FORM 6899 432111 PRINTED: 01/24/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/16/2025 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 5 of 5 PLAN OF CORRECTION Provider/Supplier Addington Place of Shoal Creek Name: Street Address, City, Zip: 9601 Tullis Dr Kansas City MO 64157 Date of Survey: 01/16/2025 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 A4749 All residents have a current CBA on File. 02/15/2025 The designated manager will audit the CBA weekly x6 weeks to ensure all new residents have a CBA on file within 5 days of 02/15/2025 admission. The DHW was educated on CBA requirements 02/15/2025 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/Supplier Addington Place of Shoal Creek Name: Street Address, City, Zip: 9601 North Tullis Dr Kansas City MO 64157 Date of Survey: 01/16/2025 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 A4750 All residents have a current CBA on file. 02/15/2025 A designated manager will audit the CBA’s to ensure they are updated semiannually 02/19/2025 The DHW was educated that the CBA’s must be updated 02/45/2025 semiannually 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/Supplier Addington Place of Shoal Creek Name: Street Address, City, Zip: 9601 N Tullis Dr Kansas City MO 64157 Date of Survey: 01/16/2025 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 A4755 All ISP’s have been updated with current falls and interventions. 02/15/2025 DHSW has been educated on ISP 02/15/2025 The designated manager will audit the ISP’s weekly x 6 weeks to ensure they are updated timely and after each fall with 02/15/2025 interventions. 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: 05/17/2024 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 B. WING 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE ADDINGTON PLACE OF SHOAL CREEK KANSAS CITY, MO 64157 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 DATF DEFICIENCY) A221?7/ 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/II| This regulation is not met as evidenced by: Class III Based on record review and an interview on 5/6/24 the facility failed to produce documentation of at least 12 fire drills being conducted within the last year, the facility further failed to produce documentation of at least one fire drills being conducted on each shift every three months within the last year. The facility census was 49. This potentially affected 49 of 49 residents. Record review on 5/6/24 at 2:52 P.M. showed the following fire drills being conducted and recorded within the last 12 months: 1. 5/8/23. 3rd shift 2. 6/2/23 2nd shift 3. 7/12/23 1st shift 4. 8/3/23 1st shift 5. 9/8/23 2nd shift 6. 9/9/23 3rd shift Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (%6) DATE f cA STATE FO saa TS0911 IFconfinuation sheet 1 of 7 PRINTED: 12/22/2025 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 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 (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) ADDINGTON PLACE OF SHOAL CREEK 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 5/6/24 the facility failed to produce documentation of at least 12 fire drills being conducted within the last year, the facility further failed to produce documentation of at least one fire drills being conducted on each shift every three months within the last year. The facility census was 49. This potentially affected 49 of 49 residents. Record review on 5/6/24 at 2:52 P.M. showed the following fire drills being conducted and recorded within the last 12 months: 1. 5/8/23. 3rd shift 2. 6/2/23 2nd shift 3. 7/12/23 1st shift 4. 8/3/23 1st shift 5. 9/8/23 2nd shift 6. 9/9/23 3rd shift Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TS0911 If continuation sheet 1 of 7 PRINTED: 12/22/2025 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 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 (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) ADDINGTON PLACE OF SHOAL CREEK Continued From page 1 7.10/17/23. 1st shift 8. 11/23 no fire drill records available 9. 12/23 no fire drill records available 10. 1/24 no fire drill records available 11. 2/24 no fire drill records available 12. 3/24 no fire drill records available 13. 4/24/24 1st shift During an interview on 5/6/24 at 2:52 P.M. the maintenance coordinator stated he/she knew they had been done but maybe did not get properly filed. 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 III Based on observation and an interview on 5/6/24 the facility failed to provide sufficient exit sign illumination. The facility census was 49. This potentially affected 49 of 49 residents. Observations on 5/6/24 during the fire safety inspection walkthrough found the following exit/emergency light signs were not working on the battery side when tested; in the hall by Room 214, in the hall by Room 101, in the hall by Room Missouri Department of Health and Senior Services STATE FORM 6899 TSs0911 If continuation sheet 2 of 7 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: 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 112, and down the hall from the staff break room. During an interview on 5/6/24 the maintenance coordinator stated he/she would get them fixed. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. 1/Il This regulation is not met as evidenced by: Class II Based on record review and an interview on 5/6/24 the facility failed to produce documentation of the fire alarm being activated at least once a month during the last year. The facility census was 49. This potentially affected 49 of 49 residents. Record review on 5/6/24 at 2:52 P.M. showed no documented records of the fire alarm system being activated for the months of; Aug, Sept, Nov, and Dec of 2023, then Jan, Feb, and Mar of 2024. During an interview on 5/6/24 at 2:52 P.M. the maintenance coordinator stated he/she knew they had been done but maybe did not get written down. 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems. Missouri Department of Health and Senior Services STATE FORM 6899 TS0911 PRINTED: 12/22/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/06/2024 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 7 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: 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 ADDINGTON PLACE OF SHOAL CREEK (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on observation, an interview, and record review on 5/6/24 the facility failed to ensure the monthly pressure gage readings and valve position checks of the sprinkler system was done every month as required in accordance with NFPA 13, 1999 edition. The facility census was 49. This potentially affected 49 of 49 residents. Observation on 5/6/24 at 10:51 A.M. showed no monthly sprinkler valve and pressure gage checks being done after Dec of 2023 on the clip board hanging in the riser room. Record review on 5/6/24 at 2:52 P.M. showed no monthly sprinkler valve and pressure gage checks available. During an interview on 5/6/24 at 2:52 P.M. the maintenance coordinator stated he/she had gotten behind on doing them. 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: Missouri Department of Health and Senior Services STATE FORM 6899 TS0911 PRINTED: 12/22/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/06/2024 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 7 PRINTED: 12/22/2025 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 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 (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) ADDINGTON PLACE OF SHOAL CREEK Continued From page 4 Class II Based on observation and an interview on 5/6/24 the facility failed to ensure all the wastebaskets were the approved types allowed. The facility census was 49. This potentially affected 49 of 49 residents. Observations on 5/6/24 during the fire safety inspection walkthrough found the following rooms with improper wastebaskets; Room 203 had one, Room 207 had three, Room 208 had two, Room 212 had two, Room 113 had one, Room 116 had one, Room 118 had one, Room 128 had one, Room 411 had two and Room 412 had one. During an interview on 5/6/24 at 2:52 P.M. the maintenance coordinator stated he/she would get the proper ones. 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 5/6/24 the facility failed to provide proper storage for the oxygen bottles in accordance with NFPA 99, 1999 Edition. The facility census was 49. This potentially affected 49 of 49 residents. Observation on 5/6/24 at 11:25 A.M. showed in Missouri Department of Health and Senior Services STATE FORM 6899 TSs0911 If continuation sheet 5 of 7 PRINTED: 12/22/2025 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 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 (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) ADDINGTON PLACE OF SHOAL CREEK Continued From page 5 Room 205 five spare oxygen bottles and one in use in the room. Observation on 5/6/24 at 11:37 A.M. showed in Room 215 six spare oxygen bottles and one in use in the room. During an interview on 5/6/24 at 2:52 P.M. the maintenance coordinator stated he/she would get the extra bottles moved to the oxygen storage room and will let the staff know the residents can only have one bottle in use and one spare in their rooms. 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 Missouri Department of Health and Senior Services STATE FORM 6899 TSs0911 If continuation sheet 6 of 7 PRINTED: 12/22/2025 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 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9601 NORTH TULLIS DRIVE KANSAS CITY, MO 64157 (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) ADDINGTON PLACE OF SHOAL CREEK Continued From page 6 This regulation is not met as evidenced by: Class Ill Based on record review and an interview on 5/6/24 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 49. This potentially affected 49 of 49 residents. Record review on 5/6/24 at 2:52 P.M. showed the last electrical inspection had just expired on 3/22/24. During an interview on 5/6/24 at 2:52 P.M. the Administrator said he/she would get the inspection scheduled and done immediately Missouri Department of Health and Senior Services STATE FORM 6899 TSs0911 If continuation sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier Addington Place of Shoal Creek Name: Street Address, City, Zip: Date of Survey: 05/06/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 9601 N Tullis Dr, Kansas City, MO 64157 28129 COMPLETION DATE ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) It is the facility's responsibility to make sure that at least 12 fire drills are being conducted within a year. The fire drills will include a resident evacuation at least once a year. The ED and maintenance director will ensure that all fire drills are conducted and recorded on different shifts with at least on resident evacuation annually. 6/17/2024 The ED will educated/ disciplined the maintenance director on the importance of fire drills by June 17, 2024. To make sure this doesn't occur again, the ED will implement a weekly QAP! meeting with maintenance for 4 weeks and then monthly thereafter until substantial compliance is achieved. It is the facility's responsibility to make sure that all the exit signs are illuminated and in proper working condition. The following exit signs have been fixed and batteries have been replaced. Exit light by room 214. In the hall by room 101, 112. The ED will educate/ disciplined the maintenance director on the salaimnaal monthly check of all exit signs by June 17", 2024. To make sure this doesn’t occur again, the ED will implement a weekly QAP! meeting with maintenance for 4 weeks and then monthly thereafter until substantial compliance is achieved. it is the facility's responsibility to make sure that the fire alarm system is being activated once a month. The ED will educate/ disciplined the maintenance director on the importance of activating the fire alarm system by June 17%, A2251 2024, 06/17/2024 To make sure this doesn't occur again, the ED will implement a weekly QAPI meeting with maintenance for 4 weeks and then monthly thereafter until substantial compliance is achieved. A2268 it is the facility’s responsibility to make sure that monthly checks are done on sprinkler pressure gage readings and valve positions are done and documented. The ED will educate/ disciplined the maintenance director on the monthly checks on the sprinkler system by June 17", 2024. To make sure this doesn’t occur again, the ED will implement a weekly QAPI meeting with maintenance for 4 weeks and then monthly thereafter until substantial compliance is achieved. It is the facility's responsibility to ensure all the wastebaskets that are in use are fire rated. The facility ED/ maintenance will do a daily round to check make sure all used wastebaskets are fire rated. The ED will educate/ disciplined the maintenance director on the proper use of all wastebaskets and daily checking by June 17%, 2024. To make sure this doesn't occur again, the ED will implement a weekly QAPi meeting with maintenance for 4 weeks and then monthly thereafter until substantial compliance is achieved. It is the facility's responsibility to ensure that oxygen is stored in accordance with NFPA99, 1999 edition. A2298 All extra O2 bottles from room 205 and 206 have been removed. The facility ED/Maintenace will do a daily round to ensure that there aren't extra bottles of O2 in the resident rooms. To make sure this doesn't occur again, the ED will implement a weekly QAPI meeting with maintenance for 4 weeks and then monthly thereafter until substantial compliance is achieved. A3214 It is the facility's responsibility to ensure that wiring is inspected every two years by a qualified electrician. The facility will get the wiring inspected by a qualified electrician by 06/1 7/2024. To make sure this doesn't occur again, the ED will implement a weekly QAPI meeting with maintenance for 4 weeks and then monthly thereafter until substantial compliance is achieved. 06/17/2024 06/17/2024 06/1 7/2024 06/17/2024 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.