AMERICAN HOUSE BURLINGTON CREEK.

PRINTED: 08/04/2025 FORM APPROVED Missouri Deoartrnent of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/ICUA {X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATIONNUMBER: A.BUILDING: COMPLETED c 8.WING 07/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIPCODE AMERICAN HOUSE BURLINGTON CREEK 6311 NCOSBY AVENUE KANSAS CITY,MO 64161 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS} (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS.REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AB018} 19 CSR 30-88.010(18) Emergency Discharges A8018 In emergency discharge situations the facility shall submit to the resident and his or her next of kin, legally authorized representative or designee awritten notice of discharge. The written notice of discharge shall be given as soon as practicable and advise the resident of the right to request an expedited hearing. In the event that there is no next of kin, legally authorized representative or designee known to the facility, the facility shall send acopy of the notice to the appropriate regional coordinator of the Missouri State Ombudsman's office. 11/111 This regulation is not met as evidenced by: Class Ill Based oninterview and record review the facility provided an emergency discharge notification to Resident #1 which failed to identify a safe discharge plan and advise the resident of the right to request an expedited appeal hearing. The facility census was 67 residents. Review of the facility's undated discharge policy showed: -lfthe facility initiated a discharge to the resident, the facility agreed to provide written notice of the reason for discharge, the effective date of the discharge, and the right to request a hearing. 1. Review of Resident #1's record showed: -The resident admitted to the facility on 08/31/22 and discharged on 07/18/25; -Diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic Missoun Department of Health and Senior Services we LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {XG)DATE Kec cetive. LMNhecta-~ STATE FORM my NKBF11 Ifconllnuation sheet 1 of 2 PRINTED: 08/04/2025 FORM APPROVED Missouri Denartment of Health and Senior Services STATEMENT OFDEFICIENCIES (4) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED A BUILDING: c 30198 BIMNG 07/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE AMERICAN HOUSE BURLINGTON CREEK KANSAS CITY, MO 64161 (41D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A&8018| Continued From page 1 A8018 disease of the brain). Review of the undated emergency discharge notification issued to Resident #1 and his/her next of kin showed: -Resident #1 was being discharged due to repeated unacceptable behaviors; -The resident was to vacate the facility by 07/18/25; -No safe discharge plan was identified inthe notification; -No information regarding the resident's right to appeal the discharge was provided. Durning an interview on 07/29/25 at 1:18 P.M. the Executive Director said: -He/She was in charge of writing and issuing the discharge notification to Resident #1 and his/her next of kin; -He/She usually sent these notifications to the Ombudsman’s office for feedback but did not this time; -He/She knew ail discharge notifications should include the resident's apeal rights; -The Director of Wellness discussed on the phone a safe discharge plan the facility had found for the resident, but this was not included in the written discharge notification; -He/She knew all discharge notifications should include identification of a safe discharge plan arranged by the facility. M0257410 M1ssoun Department of Health and Senior Services STATE FORM 6588 NKBF114 Hconllnualion sheet 2of 2 PLAN OF CORRECTION Provider/Supplier Name: American House Burlington Creek Street Address, City, Zip: 6311 North Cosby Ave Kansas City Missouri Date of Survey: July 29'1\ 2025 PROVIDER/SUPPLIER/CUA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROPRIATE DEFICIENCY) COMPLETION DATE Emernencv Discharne Regional Wellness Director conducted a complete audit of 8/30/2025 19 CSR 30-88.010(18} CO B/OT/2025 Cn 8/01/2025 will review all Emergency Discharge Letters prior to Submitting to Resident and/or their responsible party to ensure compliance of this rule. The Administrator signing and dating the first page of the CMS-2S67/State Form Isindicating their approval of the plan of correction being submitted on this form.

PRINTED: 11/15/2024 FORM APPROVED Missour} 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 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 (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) BURLINGTON GREEK SENIOR LIVING, THE A2214, 19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation Fire Drills and Emergency Preparedness. (A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility ‘ s entire plan shall be provided to the local jurisdiction 's emergency management director. WAN This regulation is not met as evidenced by: Class lil Based on record review and an interview on 9/19/24 this facility failed to provide documentation a request was made for consuitation and assistance annually from a local fire unit. The facility census was 63. This potentially affected 63 of 63 residents. Record review on 9/19/24 at 3:11 P.M. showed no documentation asking for and/or receiving consultation and assistance annually from a local fire unit. During an interview on 9/19/24 at 3:11 P.M. the Plant Operations Director said he/she did not know If anyone had tried to contact the local fire department. 19 CSR 30-86,022(6)(A)(1 - 3) Fire Safety Training Requirements-employees Fire Safety Training Requirements. (A) The facility shall ensure that fire safety Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {X6) DATE LU Dte-af #f continuation sheet 1 of 13 STATE FORM 9GT311 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 1 training is provided to all employees: 1. During employee orientation; 2. At least every six (6) months; and 3. When training needs are identified as a result of fire drill evaluations. II/III This regulation is not met as evidenced by: Class III Based on record review and an interview on 9/19/24 this facility failed to produce documentation or records of fire safety training as outlined in 19 CSR 30-86. 022 (6) (B). The facility census was 63. This potentially affected 63 of 63 residents. Record review on 9/19/24 at 3:11 P.M. showed no documentation of any fire safety and emergency preparedness training for the staff. During an interview on 9/19/24 at 3:11 P.M. the Plant Operations Director said he/she did not know if anyone was doing these trainings. 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. Atwo- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 2 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 2 landing of the exit stairway, attendants ' work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states " AREA OF REFUGE IN CASE OF FIRE" and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable; 6. Asign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge; 7. Emergency lighting for the area of refuge; and 8. The total area of the areas of refuge on a floor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II This regulation is not met as evidenced by: Class II Based on observations and an interview on 9/19/24 this facility is housing residents on floors that do not have accessible exits to grade and failed to have areas of refuge that meet all the requirements of 19 CSR 30-86.022 (7) (D) sections 1-8. The facility census was 63. This potentially affected 63 of 63 residents. Observations on 9/19/24 during the walk through of the fire safety portion of the licensure inspection showed in each area of refuge no Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 3 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 3 instructions on the usage of these areas were posted where they used to be. During an interview on 9/19/24 at 11:10 A.M. with the Plant Operations Assistant he/she said he/she thought they may have been taken down when painting was done. Every one of the citations in this SOD you use the date and time format, however the Observations in this citation you didn't include the time. In addition, in this citation you included the "during the walk through of the fire safety portion of the licensure inspection" verbiage, which is unnecessary. 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. 1/II This regulation is not met as evidenced by: Class II Based on observation and an interview on 9/19/24 this facility failed to retain or provide copies of the fire alarm system being inspected and tested at least annually in accordance with NFPA 72, 1999 edition by an approved qualified service person. The facility census was 63. This potentially affected 63 of 63 residents. Observation on 9/19/24 at 12:49 P.M. showed a Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 4 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 4 tag dated 9/18/24 on the main fire alarm panel. During an interview on 9/19/24 at 12:49 P.M. with the Plant Operations Director he/she said the alarm had just been inspected and he/she did not have the paperwork yet. But would email it over as soon as it was available. Note: As of 10/3/24 the new alarm report has not been received. 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. I/II This regulation is not met as evidenced by: Class II Based on record review and an interview on 9/19/24 this facility failed to show proof they had activated the fire alarm system at least once every month. The facility census was 63. This potentially affected 63 of 63 residents. Record review on 9/19/24 at 3:11 P.M. showed alarm activation in only six of the last twelve months with fire drills, but no further documentation was available to show a monthly activation for each month in the last year. During an interview on 9/19/24 at 3:11 P.M. with the Plant Operations Assistant he/she said he/she thought they did it with all drills except for overnight ones. 19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 5 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 5 Protection from Hazards. (C) Electric or gas clothes dryers shall be vented to the outside. Lint traps shall be cleaned regularly to protect against fire hazard. II/III This regulation is not met as evidenced by: Class III Based on observations and an interview on 9/19/24 this facility failed to keep the dryer vents in good repair so it could properly vent outside. The facility census was 63. This potentially affected 63 of 63 residents. Observation on 9/19/24 at 11:18 A.M. showed a malfunction code with the dryer vent booster fan in the 100-hall laundry room. Observation on 9/19/24 at 12:06 P.M. showed a malfunction code with the dryer vent booster fan in the 200-hall laundry room. Observation on 9/19/24 at 12:53 P.M. showed a malfunction code with the dryer vent booster fan in the main laundry room. During an interview on 9/19/24 at 11:18 A.M. with the Plant Operations Assistant he/she said he/she would let the Plant Operations Director know about the problem. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 6 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 6 facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on observation, record review, and an interview on 9/19/24 this facility failed to record monthly pressure gage readings and valve position checks of the sprinkler system. The facility census was 63. This potentially affected 63 of 63 residents. Observation on 9/19/24 at 1:45 P.M. showed no monthly sprinkler valve check sheets in the sprinkler room or on the annual tags on the sprinkle riser. Record review on 9/19/24 at 3:11 P.M. showed no records or documentation indicating monthly valve position and pressure gauge readings were being done. During an interview on 9/19/24 at 1:45 P.M. with the Plant Operations Assistant he/she said he/she did not know if they were being done. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. Il This regulation is not met as evidenced by: Class II Based on record review and interview on 9/19/24 this facility failed to show documentation of the Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 7 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 7 curtains being chemically treated with a fire-retardant chemical. The facility census was 63. This potentially affected 63 of 63 residents. Record review on 9/19/24 at 3:11 P.M. showed no records or documentation of the curtains and/or drapes being flame retardant material or treated with a flame-retardant chemical before being installed in the facility 's common areas. During an interview on 9/19/24 at 3:11 P.M. with the Plant Operations Director he/she said a new company had bought the building in December or January and they had not found a lot of the prior documentation. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observations and an interview on 9/19/24 this facility failed to insure all the wastebaskets were the approved types allowed. The facility census was 63. This potentially affected 63 of 63 residents. Observations on 9/19/24 during the fire safety portion of the licensure walkthrough showed the following rooms having wastebaskets that were not the approved types; Room 102 had one, Room 103 had one, Room 105 had one, Room 108 had one, Room 110 had one, Room 111 had three, Room 218 had one, Room 219 had one, Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 8 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 8 Room 217 had one, Room 209 had one, Room 223 had one, Room 302 had two and 325 had one. During an interview on 9/19/24 at 11:10 A.M. with the Plant Operations Assistant he/she said he/she would let the Plant Operations Director know about them. In your observation statement you omitted the time, which was included in all other Observation statements except one. This verbiage is unnecessary: "during the fire safety portion of the licensure walkthrough" 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 observation and an interview on 9/19/24 this facility failed to maintain oxygen storage and provide proper signage for the oxygen storage room in accordance with NFPA 99, 1999 Edition. The facility census was 63. This potentially affected 63 of 63 residents. Observation on 9/19/24 at 11:23 A.M. showed no signage on the door across from Room 221 indicating the room was the oxygen storage room. Further observation revealed the old sign had been removed. Inside this room were a Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 9 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 9 dozen oxygen bottles four of which were not properly racked. During an interview on 9/19/24 at 1:51 P.M. with the Plant Operations Director he/she said he/she had been told by his/her supervisor they did not need oxygen storage rooms. 19 CSR 30-86.032(2) Substantially Constructed & Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class II Based on observation and an interview on 9/19/24 this facility failed to maintain the building in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. The facility census was 63. This potentially affected 63 of 63 residents. Observation on 9/19/24 at 11:15 A.M. showed the fire door by Room 101 not properly latching on one side when closed. During an interview on 9/19/24 at 11:15 A.M. with the Plant Operations Director he/she said he/she would get the door adjusted to where it will properly latch. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 10 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 10 approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on record review and an interview on 9/19/24 this facility failed to show documentation the electrical wiring had been inspected within the last two years by a qualified electrician. The facility census was 63. This potentially affected 63 of 63 residents. Record review on 9/19/24 at 3:11 P.M. showed the last electrical inspection was done on 9/28/21 making it expired on 9/28/23. During an interview on 9/19/24 at 3:11 P.M. with the Plant Operations Director he/she said he/she was aware it was expired and thought it had been scheduled to a company called Clayco Electric Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 11 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 11 and he/she would email a copy over after it was completed. Note: As of 10/3/24 the new electrical inspection report has not been received. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/III This regulation is not met as evidenced by: Class III Based on observations and an interview on 9/19/24 this facility failed to prevent extension cords from being used with more than one electrical item plugged into it and to limit using only two appliances in some of the duplex receptacles in resident's rooms. The facility census was 63. This potentially affected 63 of 63 residents. Observation on 9/19/24 at 11:47 A.M. showed in Room 219 an extension cord with three items plugged into it. Observation on 9/19/24 at 1:19 P.M. showed in Room 317 an extension cord with three items plugged into it. Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 12 of 13 PRINTED: 06/18/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 30198 B. WING 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AMERICAN HOUSE BURLINGTON CREEK Continued From page 12 During an interview on 9/19/24 at 11:47 A.M. with the Plant Operations Assistant he/she said he/she would let the Plant Operations Director know about them and see about getting power strips in place of them. State Statute This regulation is not met as evidenced by: CLASS II Based on record review and an interview on 9/19/24 this facility failed to have a current approved boiler inspection certification under Section 11 CSR 40-2.022 - Certificates, Inspections, and Fees for the pressure vessels available. The facility census was 63. This potentially affected 63 of 63 residents. Record review on 9/19/24 at 3:11 P.M. showed no current or expired state boiler certificates available. During an interview on 9/19/24 at 3:11 P.M. with the Plant Operations Director he/she said he/she was not sure if there were current certificates. He/she said a new company had bought the building in December or January and they had not found a lot of the prior documentation. Missouri Department of Health and Senior Services STATE FORM 6899 9GT311 If continuation sheet 13 of 13 PLAN OF CORRECTION Provider/Suppli er Name: Street Address, City, Zip: Date of Survey: Burlington Creek Senior Living 6311 N Cosby Ave Kansas City, MO 64151 9/19/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION DATE ID PREFIX PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE TAG ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. Correction of Cited Deficiency: Emailed Community has called and left messages to schedule plan | 11/20/24, A2214 review with Local Fire Marshall. calied 11/22/24 and 11/25/24 Assessment to Identify other areas that may be Emailed affected: This impacts all areas. Community has called 11/20/24, and left messages to schedule plan review with Local Fire called Marshall. 11/22/24 and 11/25/24 Procedure to ensure on-going compliance: Emailed Plant Ops Director will schedule Annual Review of 11/20/24, Emergency Plan with the Local Fire Marshall in October called each year. TELS work order system will be updated to 41/22/24 reflect the annual appointment to meet with the Local Fire and Marshall yearly. 11/25/24 Monitoring for on-going compliance: TELS work order system will be updated to reflect the annual appointment to meet with the Local Fire Marshall yearly. Executive Director will confirm upcoming 12/3/24 appointments due for the month with Piant Operations Director during their 1:1 on the first week each month Fire Safety Training is completed during orientation and in The Community Town Hall Meetings with Staff in addition to the routine monthly fire drills. This was already in place, See Plan of but the Plant Ops Assistant did not provide documents to C ti the surveyor. Documents are available for review during all orrection . Binder surveys and are available by request. The Plant Operations Director or their designee is responsible to maintain all inspection records. Correction of Cited Deficiency: Temporary Area of Refuge signs were hung in designated 44/25/2024 areas. New signs were ordered to replace temporary signs. Assessment to Identify Other Area that may be affected: Sweep of community made to identify areas missing Area of Refuge signs. Area of Refuge will be discussed with residents during Town Hall Meetings and Fire Drills to ensure residents understand where they are located and what to do in the event of a fire. Procedure to ensure ongoing compliance: Plant Ops Director or designee wili ensure that signs are in place 11/25/2024 monthly during the check of the Fire Extinguishers. Monitoring for ongoing compliance: Documentation of the visual check will be documented in TELS system monthly to ensure ongoing compliance. Plant Operations 41/25/2024 Director will add to monthly tasks in TELs. Executive Director will review task sheet monthly with Plant Operations Director during their 1:1. Correction of Cited Deficiency: Annual fire alarm system check was completed with Marmic on 9/30/2024. _ Assessment to Identify Other Areas that may be affected: Plant Ops Director audited TELS to ensure that all inspections that need to be completed by vendor need to be prescheduled for preventative maintenance, Procedure to Ensure ongoing compliance: Annual Fire Alarm System Check by vendor is scheduled for every 11/25/2024 September. Monitoring for ongoing compliance: TELS work order system will continue to have this scheduled every 11/25/2024 September. Executive Director will confirm upcoming 11/22/2024 9/30/2024 11/25/24 inspections due for the month with Plant Operations Director during their 1:1 on the first week each month Fire Alarm System was activated monthly. Inspection reports were not provided to the surveyor during time of survey. The Plant Operations Assistant has confirmed inspections were completed timely as required by regulation. Inspection reports will be made available during all surveys & available upon request. The Plant Operations Director or their designee is responsible to maintain all inspection records.” See Plan of Correction Binder Correction of Cited Deficiency: Vendor is scheduled to be onsite on 11/26/2024 to fix the malfunction codes that are being signaled on the dryer vent booster fan. Assessment to Identify Other areas that may be affected: All dryers will be audited by vendor on 11/25/2024 and will be corrected if needed to ensure proper operation. 11/26/2024 11/25/2024 Procedure to Ensure ongoing compliance: Housekeeping, Wellness and Memory Care staff will be trained to submit a work order in TELS if they notice error codes. Plant Operations Director will add this to his weekly task list in TELS 11/26/2024 Monitoring for ongoing compliance: Plant Ops Director will monitor work order system and address with vendor timely. Plant Operations Director will add this to his weekly task list in TELS to confirm proper operation. 11/26/2024 Correction of Cited Deficiency: Documentation was being kept in TELS system. Piant Ops Assistant did not pull any documentation during visit for surveyor. A Clip board has been added to document the monthly sprinkler valve check being completed in the sprinkler room. 11/22/2024 Assessment to Identify Other Areas that may be affected: Plant Ops Director will ensure all inspections are scheduled in TELS as part of our preventative maintenance program. 11/26/24 Procedure to Ensure ongoing compliance: Documentation will be kept on a clip board in the Sprinkler Room as well as in TELS to ensure this is being completed monthly. Monitoring of ongoing compliance: Plant Ops Director will monitor monthly preventative maintenance tasks in TELS along with doing a visual check of the clip board at the end of each month to ensure compliance. Executive Director will confirm preventative maintenance due for the month with Plant Operations Director during their 1:1 on the first week each month Documentation showing the Curtains in the community are made from flame resistant material or have been treated with flame-retard chemicals before installation was available, but the Plant Ops Assistant did not share this 11/22/2024 11/22/2024 See Plan of Correction Binder with the surveyor. Inspection reports were not provided to the surveyor during time of survey. Inspection reports will be made available during all surveys & available upon request. The Plant Operations Director or their designee is responsible to maintain all inspection records.” Correction of Cited Deficiency: Identified waste baskets were removed and replaced with UL or FM fire resistant 11/22/2024 waste baskets in the resident apartments. Assessment to Identify Other Areas that may be affected: Community walk- through of resident apartments 44/29/2024 was conducted to remove trash cans that did not meet the fire safety code. Procedure to Ensure ongoing compliance: Housekeeping will monitor the trash cans in resident apartments while cleaning apartments weekly. Plant Ops Director will be notified of any trash cans that need to be 11/26/2024 replaced. Sales Team will educate families and residents prior to move in that they do not need to bring a trash can as the community will supply them in the apartments. Monitoring for ongoing compliance: Safety Committee Members will spot check an apartment on each floor as part of the monthly Safety Committee Meeting to ensure compliance. Correction of Cited Deficiency: Oxygen company educated that all oxygen must be stored properly in resident apartments. Oxygen in Use signs were placed on the outside of the apartment for safety. Assessment to Identify Other areas that may be affected: Executive Director and Director of Wellness reviewed resident records to ensure that ail residents who 44/25/2024 have Oxygen in their apartments have a posted sign outside the apartment and that Oxygen cylinders are stored properly in the apartment. Procedure to Ensure ongoing compliance: Training of wellness staff on requirements for oxygen storage and sign requirements. Director of Wellness or designee will 11/29/24 confirm proper storage and signage upon move in or order changes. Monitoring for ongoing compliance: Director of Weliness will review residents on Oxygen with Executive 44/25/2024 Director monthly during 1:1 meeting. Walking rounds will be conducted to ensure interventions are in place. Correction of Cited Deficiency: Plant Ops Director 44/18/2024 adjusted door to ensure it was latching properly. Assessment to Identify Other Areas that may be affected: Plant Ops Director will check all other fire doors | 11/26/2024 to ensure that they latched properly when closed. Procedure to Ensure ongoing compliance: Plant Ops Director will check all fire doors weekly X 4 weeks to 11/25/2024 ensure they are latching properly when closed. 11/26/2024 11/22/2024 Monitor for ongoing compliance: Executive Director or designee will check doors during monthly check of 41/25/2024 activating the fire alarm system. Electrical wiring inspection was last completed by a qualified electrician on 9/13/2024. Plant Ops Assistant did not share this paperwork with the surveyor. Inspection reports were not provided to the surveyor during time of survey. The Plant Operations Assistant has confirmed inspections were completed timely as required by regulation. Inspection reports will be made available during all surveys & available upon request. The Plant Operations Director or their designee is responsible to maintain all inspection records.” Correction of Cited Deficiency: Identified extension cords were removed from the resident apartments. Assessment to Identify Other Areas that may be affected: Community walk- through of resident apartments was conducted to remove extension cords being used. 41/29/2024 Housekeeping received additional education on surge protectors in resident apartments. Procedure to Ensure ongoing compliance: Housekeeping will look for extension cords being used in the resident apartments weekly. If found, they will notify the Plant Ops Director who will reach out to the family for removal. Sales Team will educate families and residents prior to move on extension cords vs surge protectors in resident apartments. Resident & Staff will receive additional training during Town Hall meetings. Monitoring for ongoing compliance: Safety Committee Members will spot check an apartment on each floor as part of the monthly Safety Committee Meeting to ensure compliance. Correction of Cited Deficiency: Boilers are scheduled for inspection on 11/27/2024. Assessment to Identify Other Areas that may be affected: Plant Ops Director will ensure all inspections are scheduled in TELS as part of our preventative maintenance program. Procedure to Ensure ongoing compliance: Annual Boiler inspection will be scheduled for October each year 11/27/2024 in the TELS system. Monitoring for ongoing compliance: Plant Ops Director will ensure that the Boiler Inspection is scheduled every October on his annual Preventative Maintenance Calendar in TELS. Documentation from vendor will be uploaded into TELS annually to prevent lost documentation. Executive Director will confirm upcoming inspections due for the month with Plant Operations Director during their 1:1 on the first week each month See Plan of Correction Binder 11/26/2024 41/26/2024 11/26/2024 11/27/2024 11/29/24 11/25/2024 PRINTED: 06/16/2025 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 R 05/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 (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) AMERICAN HOUSE BURLINGTON CREEK A3214 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/IIl This regulation is not met as evidenced by: Class III Based on record review and an interview on 9/19/24 and on 5/14/25 this facility failed to show documentation the electrical wiring had been inspected within the last two years by a qualified electrician. The facility census was 69. This potentially affected 69 of 69 residents. Record review on 5/14/25 at 10:35 A.M. showed the last electrical inspection was done on 9/28/21 making it expired on 9/28/23. During an interview at 10:35 A.M. . with the Plant Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9GT312 If continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE AMERICAN HOUSE BURLINGTON CREEK KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PRINTED: 06/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED R 05/14/2025 (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 A3214 | Continued From page 1 Operations Director stated the facility had changed ownership in February and alot of records were not avaiable. Missouri Department of Health and Senior Services STATE FORM oeee 9GT312 If continuation sheet 2 of 2

PRINTED: 09/23/2024 FORM APPROVED Missourl Department of Heaith and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIERJCLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION A, BUILDING; (X3} DATE SURVEY COMPLETED C 09/41/2024 30198 B. WING NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64164 BURLINGTON CREEK SENIOR LIVING, THE SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE _ CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (Xt) COMPLETE DATE 19 CSR 30-86,047(35) Protective Oversight Protective oversight shall be provided iwenty-four (24) hours a day, For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident's guardian of the resident’ s departure, of the resident ‘s estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. Ill This ragulation Is not met as evidenced by: Class |i Based on observation, Interview and record review, the facllily falled to provide adequate protective oversight for one rasident (Resident #1} out of four sampled residents when the resident fell after exiting the facility unattended and had no way to reenter the faclilly from outside. The facility staff addltlonally were unaware that the resident had left the bullding, and the resident was found by an outside pedestrian who assisted the resident back into the bullding. The facility census was 61, 4, Review of Resident #t's face sheel showed: -Admit date was 1/16/18; -Diagnoses Included: Age related cognitive decline, mild cognitive Impalrment, osteoarthritis, chronic obstructive pulmonary disease, macular degeneration, and chronic paln syndrome. Review of the resident's medical record showed: -His/her most recent elopement evaluation dated 8/28/24 indicated he/she was occasionally disoriented and had a history of wandering; -His/her most recent Mental Status Questionnalre dated 8/28/24 showed he/she had moderately advanced Impalrment (medium); -His/her Fall Assessment dated 6/19/24 showed Missouri Department of Health and Sentor Services LABORATORY DIRECT! OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6} DATE STATE FORM 6bICF14 If coniloustlon shest 7 of & 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 BURLINGTON CREEK SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 09/23/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED Cc 09/11/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4776 19 CSR 30-86.047(35) Protective Oversight Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident 's guardian of the resident's departure, of the resident's estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to provide adequate protective oversight for one resident (Resident #1) out of four sampled residents when the resident fell after exiting the facility unattended and had no way to reenter the facility from outside. The facility staff additionally were unaware that the resident had left the building, and the resident was found by an outside pedestrian who assisted the resident back into the building. The facility census was 61. 1. Review of Resident #1's face sheet showed: -Admit date was 1/15/18; -Diagnoses included: Age related cognitive decline, mild cognitive impairment, osteoarthritis, chronic obstructive pulmonary disease, macular degeneration, and chronic pain syndrome. Review of the resident's medical record showed: -His/her most recent elopement evaluation dated 8/28/24 indicated he/she was occasionally disoriented and had a history of wandering; -His/her most recent Mental Status Questionnaire dated 8/28/24 showed he/she had moderately advanced impairment (medium); -His/her Fall Assessment dated 6/19/24 showed Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 5JCF11 If continuation sheet 1 of 5 PRINTED: 09/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 (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) BURLINGTON CREEK SENIOR LIVING, THE Continued From page 1 he/she was a high risk for falling and his/her 9/4/24 assessment showed he/she was at moderate risk for falling; -His/her July and August 2024 monthly summaries showed he/she was at high risk for falling; -His/her individual Service Plan (ISP) dated 7/28/24 showed: He/she had a current or history of occasional disorientation to person, place, time or situation even in familiar surroundings and required supervision and oversight for safety; -His/her Community Based Assessment dated 9/5/24 showed impaired vision, history of wandering or pacing, medium risk for falls, a history of occasional disorientation to person, place, time, or situation and required supervision and oversight for safety, and that he/she enjoyed going outside and that staff would take him/her out on the patio as desired. Review of an un-witnessed fall report dated 9/9/24 showed: -The resident fell while outside on 9/9/24: -A passerby noticed the resident on the ground sitting by his/her wheelchair and assisted the resident back into his/her wheelchair and then knocked on the door to notify staff of the situation; -He/she had an abrasion to the front of the right knee. Observation of Resident #1 on 9/11/24 between 10:00 A.M.-5:40 P.M. showed: -He/she had a patch over his/her right eye; -He/she appeared confused and asked Medication Partner A "What am | supposed to do?", "Where am | supposed to be?" During an interview on 9/11/24 at 5:40 P.M., Resident #1 said: -He/she enjoyed going outside; Missouri Department of Health and Senior Services STATE FORM 6899 5JCF11 If continuation sheet 2 of 5 PRINTED: 09/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 (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) BURLINGTON CREEK SENIOR LIVING, THE Continued From page 2 -He/she did not know what she did when she went outside; -He/she did not know how he/she got back inside but did not think he/she had to push any buttons to operate the door. During an interview on 9/11/24 at 11:34 A.M. the Interim Executive Director (ED) said: - Video showed that on 9/9/24 Resident #1 went out the side patio door at 2:05 P.M. and the passerby knocked on the door with the resident at 2:18 P.M.; -The door was operated by a four-digit code; -Resident #1 was not able to remember the code; -If there wasn't anyone at the door to let the resident in, he/she would knock on the door for someone to let him/her in. Observation on 9/11/24 at 12:06 P.M. of the side patio door showed: -The door did not open from the inside when the handicap button was pushed; -The door did not open from the outside when the handicap button was pushed; -The door did open when the four-digit code provided by a staff member was put in. During an interview on 9/11/24 at 5:50 P.M., Medication Partner A said: -He/she had worked at the facility for about one month; -A key fob or a four-digit pin code was required to operate the side patio door from the outside; -He/she did not know the door should open from the outside by pushing the handicap button without first inputting the four-digit code or using a key fob. During an interview on 9/11/24 at 5:53 P.M., Care Partner A said: Missouri Department of Health and Senior Services STATE FORM 6899 5JCF11 If continuation sheet 3 of 5 PRINTED: 09/23/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 09/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 (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) BURLINGTON CREEK SENIOR LIVING, THE Continued From page 3 -He/she had worked at the facility for about one year; -He/she had always known the side patio door to require either a four-digit code or a key fob to operate it from the outside. During an interview on 9/17/24 at 10:05 A.M., the Activity Director said: -On the afternoon of 9/9/24 she asked Resident #1 if she wanted to participate in an activity; -The resident said she did not and that she wanted to go outside; -She did not go outside with the resident; -She did not ask or make any other staff aware that the resident wanted to go outside. During an interview on 9/17/24 at 10:38 A.M., the resident's Hospice Nurse Case Manager said: -Resident #1 was admitted to Hospice on 9/21/23; -He/she had been the resident's Nurse Case Manager for approximately ten months; -The resident's baseline was "confused"; -His/her cognition varied from day to day but had declined over the past year; -The resident wore an eye patch over her left eye due to issues with the eyelid and the inability to blink and would be needed long-term. -He/she was at the facility on 9/9/24 when Resident #1 fell outside but did not see the fall: -He/she spoke with the resident approximately 15 minutes after the fall, but the resident did not remember falling; -He/she felt the resident needed assistance and oversight while outside and should not be left unattended. During an interview on 9/11/24 at 6:02 P.M., the Interim Executive Director said: -The side patio door should open and close from Missouri Department of Health and Senior Services STATE FORM 6899 5JCF11 If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE BURLINGTON CREEK SENIOR LIVING, THE KANSAS CITY, MO 64151 PRINTED: 09/23/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 09/11/2024 (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 Continued From page 4 both the inside and the outside by pushing the handicap button between the hours of 7:00 A.M.-7:00 P.M.; -Resident #1 frequently went outside unattended but would let staff know where she was going; -She did not know the side patio door was not operating as it should; -Resident #1 and all residents should be kept safe. MO241847 Missouri Department of Health and Senior Services STATE FORM oeee 5JCF11 DEFICIENCY) If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Suppller The Burlington Creek Senior Living Name: Street Address, City, Zip: 6311 N Cosby Ave, Kansas City, MO 64151 Date of Survey: 9-11-24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ae ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE This pian of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the communily as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state ‘ules of civil procedure and should be inadmissible in any proceeding on that basis. The communily submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. _ Correction of Cited Deficiency: Resident #1 will have a 1:1 companion from 8am — 8 pm to escort sutdoors, Once the wander guard system is installed at the community (completion A4776 date: 11/1/2024), resident will be issued a wander guard to alert staff that resident wants to go outside and: _— will be escorted by staff at that time. Resident will be reassessed prior to wander guard placement or with change in condition. 10/10/24 Assessment to Identify other Residents that may be affected: DOW and ED completed an audit of the elopement A4776 evaluations and assessed that no other residents were identified 10/10/24 at this time Procedure to ensure on-going compliance: DOW or designee will audit new move in’s as well as current residents’ elopement evaluation form to ensure those resident's going outside to the patios/sidewalks independently, are able to A4776 navigate and safely enter/exit the doors. These residents will 10/10/24 also be assessed to ensure they are able to utilize the call system/pendants to request assistance if needed. Audit will be completed and shared with the Executive Director weekly during 1:1 meeting or as needed. Monitoring for on-going compliance: Audit will continue weekly for the next 3 months with the results being shared AA776 weekly at the Department Directors Meeting to ensure compliance and ongoing communication regarding protective oversight of all residents. 10/10/24

NAME OF PROVIDER OR SUPPLIER ANTHOLOGY OF BURLINGTON CREEK (Xd) ID PREFIX TAG Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 30198 (X2) MULTIPLE CONSTRUCTION A, BUILDING: B, WING KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. 1 This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB) screening test was completed for five of five sampled staff members (Caregiver A, Caregiver B, Caregiver C, Certified Nursing Assistant (CNA) A, and Engagement Associate A). The facility census was 64. General requirements for TB testing for staff in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long Term Care Employees and Volunteers. All new long-term care facility employees and volunteers who work ten (10) or more hours per week are required to obtain a Mantoux Purified Protein Derivative (PPD) (Mantoux, TB skin test, tuberculin skin test, and PPDs are often used interchangeably. Mantoux refers to the technique for administering the test. Tuberculin (also called PPD) is the solution used to administer the test) two (2)-step tuberculin test within one (1) month prior to starting employment in the facllity. If the initial test is zero to nine millimeters (0-9 mm), the second test should be given as soon as possible within three (3) weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two (2) years. Itis the responsibility of each facility to maintain a documentation of each Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ; ; oo QLAKG | 6899 —ahe HT24 1 STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE PRINTED: 04/19/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/22/2023 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (X6) DATE if continuation sheet 1 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 BURLINGTON CREEK SENIOR LIVING, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 and volunteer's tuberculin status. (E) Employees and volunteers with an initial Zero to nine millimeters (0-9 mm) Mantoux PPD two (2)-Step test shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. Review of the facility's TB Screening policy revised in October 2022 showed: -All staff would be screened for TB per regulations; -All staff would receive a 2-step TB screening after an employment offer, but prior to the first day of duty. 1. Record review of Caregiver A's personnel file showed: -Hire date of 07/28/23; -The initial step was administered on 08/17/23 and read on 08/19/23, results were negative; -The second step was administered on 08/28/23 and read on 08/31/23, results were negative. 2. Record review of Caregiver B's personnel file showed: -Hire date of 11/30/23; -The initial step was administered on 12/05/23 and read on 12/07/23, results were negative; -The second step was administered on 12/14/23 and read on 12/16/23, results were negative. 3. Record review of the Caregiver C's personnel file showed: -Hire date of 11/06/23; -The initial step was administered on 11/01/23 and read on 11/03/23, results were negative; -The second step was administered on 11/17/23 and read on 11/19/23, results were negative. 4. Record review of the CNAA's personnel file Missouri Department of Health and Senior Services STATE FORM 6899 WHT211 PRINTED: 04/03/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/22/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 7 PRINTED: 04/03/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 (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) BURLINGTON CREEK SENIOR LIVING, THE Continued From page 2 showed: -Hire date of 05/24/23; -The initial step was administered on 06/27/23 and read on 06/30/23, results were negative; -The second step was administered on 07/18/23 and read on 07/20/23, results were negative. 5. Record review of the Engagement Associate A's personnel file showed: -Hire date of 09/08/23; -The initial step was administered on 10/31/23 and read on 11/02/23, results were negative; -The second step was administered on 11/11/23 and read on 11/13/23, results were negative. Record review of a 06/15/23 all staff meeting agenda showed: -TB clinic started on 06/27/23; -Any new hires would need their two step completed if it was not already completed since hire. During an interview on 12/22/23 at 2:50 P.M., the Administrator said: -She was not aware staff member TB screenings were not completed prior to their first day on duty; -All employees should have had a two-step TB test completed prior to their first day on duty. 19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (I) Written statement signed by a licensed physician or physician ' s designee indicating the person can work in a long-term care facility and indicating any limitations; III Missouri Department of Health and Senior Services STATE FORM 6899 WHT211 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 BURLINGTON CREEK SENIOR LIVING, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to ensure five of five sampled staff members (Caregiver A, Caregiver B, Caregiver C, Certified Nursing Assistant (CNA) A, and Engagement Associate A) had a written and signed statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. The facility census was 64. The facility did not provide a policy. 1. Record review of Caregiver A's personnel file showed: -Hire date of 07/28/23; -The personnel file did not contain a written and signed statement by a licensed physician or physician's designee indicating the person can work in a long-term care facility and indicating any limitations. 2. Record review of Caregiver B's personnel file showed: -Hire date of 11/30/23; -The personnel file did not contain a written and signed statement by a licensed physician or physician's designee indicating the person can work in a long-term care facility and indicating any limitations. 3. Record review of the Caregiver C's personnel file showed: -Hire date of 11/06/23; -The personnel file did not contain a written and Missouri Department of Health and Senior Services STATE FORM 6899 WHT211 PRINTED: 04/03/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/22/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE 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 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 BURLINGTON CREEK SENIOR LIVING, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 signed statement by a licensed physician or physician's designee indicating the person can work in a long-term care facility and indicating any limitations. 4. Record review of the CNAA's personnel file showed: -Hire date of 05/24/23; -The personnel file did not contain a written and signed statement by a licensed physician or physician's designee indicating the person can work in a long-term care facility and indicating any limitations. 5. Record review of the Engagement Associate A's personnel file showed: -Hire date of 09/08/23; -The personnel file did not contain a written and signed statement by a licensed physician or physician's designee indicating the person can work in a long-term care facility and indicating any limitations. During an interview on 12/22/23, at 2:50 P.M., the Administrator said: -She was not aware that all employees should have a written and statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations; -She had not acquired these written and signed statements for new staff because her management company advised her this was not a policy required for them, she assumed this was in line with the state regulations. 19 CSR 30-86.047(47)(F)(2) Influenza/Pneumococcal Documented Assessment Missouri Department of Health and Senior Services STATE FORM 6899 WHT211 PRINTED: 04/03/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/22/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 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 BURLINGTON CREEK SENIOR LIVING, THE (X2) MULTIPLE CONSTRUCTION A. BUILDING: KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 Medication Orders. (F) Influenza and pneumococcal polysaccharide immunizations may be administered per physician-approved facility policy after assessment for contraindications- 2. The assessment for contraindications and documentation of the education and opportunity to refuse the immunization shall be dated and signed by the nurse performing the assessment and placed in the medical record; II/IIl This regulation is not met as evidenced by: Class III Based on record review and interview, the facility failed to ensure documentation of the opportunity to refuse the Influenza (a common viral infection which effects the lungs, nose, and throat) vaccination was kept in residents’ records for two of six (Resident #1 and #2) sampled residents. The facility census was 64. Review of the facility's policy regarding Infection Control and Influenza revised in February 2022, showed: -Each resident should have been offered the flu vaccinations annually by October. 1. Record review of Resident #1's files showed: -Admit date 09/30/22: -No documentation of administration or declination of Influenza vaccination for 2023 was found for the resident. 2. Record review of Resident #2's files showed: -Admit date 07/30/21; -No documentation of administration or declination of Influenza vaccination for 2023 was Missouri Department of Health and Senior Services STATE FORM 6899 WHT211 PRINTED: 04/03/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/22/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 7 PRINTED: 04/03/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 12/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6311 N COSBY AVENUE KANSAS CITY, MO 64151 (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) BURLINGTON CREEK SENIOR LIVING, THE Continued From page 6 found for the resident. During an interview on 12/22/23 at 2:50 P.M., the Administrator said: -She expected flu shots to be offered to every resident; -She emailed all residents with dates and times to receive Influenza vaccinations at the facility for 2023; -She did not know documentation of refusal of the vaccination was required; -She was unable to provide the missing documentation. Missouri Department of Health and Senior Services STATE FORM 6899 WHT211 If continuation sheet 7 of 7 PLAN OF CORRECTION Provider/Supplier Name: The Burlington Creek Senior Living Street Address, City, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2166237 6311 N Cosby Ave Kansas City Missouri 64151 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS- COMPLET REFERENCED TO THE APPROPRIATE ION DATE DEFICIENCY) This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. ID PREFIX TAG Correction of Cited Deficiency: All staff required to start two step TB process Assessment to identify other Staff members that may be affected: All staff required to start two step TB process Procedure to ensure ongoing compliance: Employee file check list and resident move in coordination list will be used for each employee and resident and annual audit to 12/22/23 ensure compliance. Residents TB obtained and tracked in point click care. Monitoring for on-going compliance: Business Office Director will follow up with Director of Weliness or designee to ensure completion of two step TB for all new 1/23/24 employees and residents. Business Office Director and Executive Director to audit a sample of 10 employees and reat buff, A) 01, 1B.cvay AAT724 12/22/23 12/22/23 Director of Wellness to audit 10 residents each month for four months to ensure TB screening completed, And thereafter, ongoing monitoring will be completed through employee and resident TB tracker or reports. Correction of Cited Deficiency: All staff signed a Health Status Verification assessment and physical exam was performed by a Physician at the Designated Occupation 12/22/23 Medicine Office. Documentation of physical exam placed in employee file. Assessment to identify other staff members that may be affected: All staff signed a Health Status Verification assessment and physical exam was performed by a 12/22/23 Physician at the Designated Occupation Medicine Office. Documentation of physical exam placed in employee file. Procedure to ensure on-going compliance: New Employee Checklist identifies the Health Status Verification and physical exam as a requirement for all new hires. Community staff will ensure that new employee checklist is followed for all new hires and documentation placed in employee file. Monitoring for Ongoing Compliance: Business Officer Director and Executive Director to perform a monthly audit for four months of all newly hired staff to ensure the ersomnel file contains the Health Status Verification 12/22/23 1/23/24 Correction of Cited Deficiency: Documentation for noted residents will be obtained. Assessment to identify other residents that may be affected: All resident files reviewed to confirm documentation completed. Procedure to ensure on going compliance: Director of Wellness in-serviced nurse managers of the need for a signed acknowledgment of refusal from resident or health care power of attorney. Process established for annual 12/22/23 influenza clinic where residents will be assessed and offered the opportunity to accept or refuse influenza vaccination. Monitoring for Ongoing Compliance: Director of Wellness will implement monthly audits for the next four months of new resident files to ensure proper 1/23/24 documentation is obtained. After that period, the Director of Wellness will complete annual audits. 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. Koay Wyle 6.19. 2004 A