PRIMROSE RETIREMENT COMMUNITY OF KANSAS CITY.

PRINTED: 11/07/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES ‘| (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION A, BUILDING: B. WING 40/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 NAME OF PROVIDER OR SUPPLIER PRIMROSE RETIREMENT COMMUNITY OF KANSAS ¢ PROVIDER'S PLAN OF CORRECTION | (x5) {EACH CORRECTIVE ACTION SHOULD BE | COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL. REGULATORY OR LSC IDENTIFYING INFORMATION} (X4) 1D PREFIX TAG 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. II This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility staff failed to ensure the required two step tuberculosis (TB - a communicable disease that ; affects the lungs characterized by fever, cough, and difficuity in breathing) screening test was administered upon hire for four of five sampled employees. The facility census was 40. General requirements for Tuberculosis testing for employees in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) two {2)-step tuberculin test within one month prior to starting employment; | -It is the responsibility of the facility to maintain ' documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documeniation is provided indicating a Mantoux PPD test in the past and at least one (1) | subsequent annual test within the past two years. 1. Record review on 10/21/25 of Aide A's personnel file showed: -Date of hire 10/13/25; -No TB's were found. Missouri Department of Health and Senior Services r LABORATORY DIRECT@R'S OR PROVIDER/SUPPLIER REPRESENTAFIVE'S SIGNATURE (X68) DATE : i STATE FORM § ~ YUN PRINTED: 11/07/2025 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 BWING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES i 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) PRIMROSE RETIREMENT COMMUNITY OF KANSAS € | Continued From page 1 2. Record review on 10/21/25 of Aide B's personnel file showed: -Date of hire 10/20/25; -No TB's were found. 3. Record review on 10/21/25 of Medication Aide A's personnel file showed: -Date of hire 10/17/25; . «No TB's were found. 4. Record review on 10/21/25 of Medication Aide B's personnel file showed: -Date of hire 10/20/25; «No TB's were found. During an interview on 10/21/25 at 4:00 P.M., the Director of Clinical Operations said: -A two-step must be done upon hire; -Employees must have a TB test completed : annually; | -The previous Director of Nursing was responsible for Tb testing: -The new Director of Nursing started September 9th and has not been fully trained on responsibilities; -He/She was not always in the facility but was available via phone; «He/She would expect the facility to send new staff to a physician office or health department for Tb testing if a nurse was not available to complete it; | -Allemployees should have current TB tests. 19 CSR 30-86.047(58)(B) Resident Condition/Medication Review The facility shall maintain a record in the facility for each resident, which shall include the Missouri Department of Health and Senior Services STATE FORM 6032 7JYUt If continuatian sheet 2 of 4 PRINTED: 11/07/2025 . FORM APPROVED - Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 10/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 NAME OF PROVIDER OR SUPPLIER PRIMROSE RETIREMENT COMMUNITY OF KANSAS (€ {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 CROSS-REFERENCED TO THE APPROPRIATE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) } DEFICIENCY) Continued From page 2 following: {B) Areview monthly or more frequently, if indicated, of the resident's general condition and needs; a monthly review of medication ; consumption of any resident controlling his or her | own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen i review process; a monthly weight; a record of ( each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentiaily could result in injury or did result in injuries involving the resident; Iil i This regulation is not met as evidenced by: Class I Based on record review and interview, the facility failed to ensure that monthly summaries were completed for three (Resident #1, #2, and #3) of four sampled residents. The facility census was 40. 1, Record review on 10/21/25 of Resident #1's medical file showed: -Admit date 1/27/25; -A monthly summary for May, June, July, August and September, 2025 were not found. Record review on 10/21/25 of Resident #2's : medical file showed: | Admit date 1/23/22: -Monthly summaries for 3/25 and 4/21 were found; Missouri Department of Health and Senior Services STATE FORM base TJYUNM If continuation sheet 3 of 4 PRINTED: 11/07/2025 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 B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 (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} PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ 44837 | Continued From page 3 i -No other monthly surnmaries were found. Record review on 10/21/25 of Resident #3's medical file showed: -Admit date 11/1/19; -Monthly summaries for 3/21 and 4/21 were found; -No other monthly summaries were found. | Record review on 5/5/21 of Resident #5’s medical ' file showed: -Admit date 6/26/23; -Monthly summaries for 3/21 and 4/21 were found; -No other monihly summaries were found. During an interview on 10/21/25 at 4:30 P.M. the Director of Clinical Operations said: -Monthly summaries should be completed ; monthly; -The Director of Nursing (DON) is responsible for completing monthly summaries; -The previous DON left in May and a new DON was hired September Sth; -The new DON has completed all resident October Monthly Summaries; -He/She was available to staff via phone every day; -He/She was nat in the facility daily; : “There was no one to complete the monthly summaries. Missouri Dapartment of Health and Senior Services - STATE FORM e638 7aYvu1 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Primrose Retirement Community Name: Street Address, 8559 N Line Creek Parkway City, Zip: Kansas City, MO 64154 Date of Survey: October 21, 2025 A4724 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER P| SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) e What corrective action(s) will be accomplished for the deficient practice? The 4 staff that were deficient with TB testing have received their 2-step TST per policy. 11/10/2025 All Current employee records have been audited for TB testing, and all current staff have documentation of initiation of the 2- 11/15/2025 step TST per policy. Internal policies for TB testing were reviewed without change. This policy was reviewed with all staff, including community ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION DATE those residents who found to have been affected by « How will you identify other residents having the potential to be affected by the same deficient practice? » What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not occur? leadership at our team meeting on 11/04/2025. Our onboarding process includes meeting with the DON, or 11/15/2025 another licensed nurse to initiate TB testing at least 1 month prior to hire, but no later than 48 hours of the employee beginning work in the community. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. DON or designee to audit employee records 1x/week for 4 weeks, then 1x bi-weekly for 4 weeks, then monthly for 2 months to ensure 2-step TST is administered, Results of audits will be provided to QA committee for review to ensure compliance, Lduntlle &. Kendrick, Bie. eek, /tabs ¢ What corrective action(s) will be accomplished for . those residents found to have been affected by the deficient practice? The 4 resident records that were deficient with monthly summaries were completed. Monthiy summaries were 41/01/2025 completed for all residents in assisted living for the month of October 2025. How will you identify other residents having the potential to be affected by the same deficient A compliance report was run, ensuring that all current residents have monthly summaries completed and documented for the 11/13/2025 month of October. * What measures will be put into place or what systemic changes will you make to ensure that the aa deficient practice does not occur? DON or designee will run compliance reports monthly to ensure all residents have current monthly summaries completed for each month moving forward. The DON has reviewed the Nursing Audit Schedule for compliance documentation. The DON or designee will ensure completion of the monthly summaries for all AL residents prior to the 15" of each month. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The DON or designee to audit resident charts: 5 charts weekly x 4 weeks, 5 charts bi-weekly x 4 weeks, 5 charts monthly x 2 months to ensure monthly summaries are completed. Results of these audits will be provided to QA committee for review to ensure sustained compliance. 11/13/2025 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.

- PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X17} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (3) DATE SURVEY {X2} MULTIPLE CONSTRUCTION COMPLETED A, BUILDING: 8. WING 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE §559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 PRIMROSE RETIREMENT COMMUNITY OF KANSAS ¢ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) 1D PREFIX TAG 18 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 candition which may require a change in services; Il 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 which may have required a change in services with four of four sampled residents (Resident #2, #3, #4, and #7). The facility census was 31 residents. Review of the facility's Mobility/Fall Managernent policy dated 05/31/23 showed: -Upon move-in and all routine and change of condition assessments, residents should have been assessed for mobility challenges and needs; -After a fall or for a new resident with a history of falls, in addition to a mobility assessment completed, interventions were to be added to the resident's service plan. 1. Review of Resident #2's record showed: -He/She was admitted to the facility on 12/01/19; -Diagnoses included periprostetic (near an implant) fracture of right hip joint, congestive Missouri Departaent of Healih and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUP, a REPRESENTATIVES SIGNATUR ; THLE (X6) DATE STATE FO os casa LaGo WFeontinugtion shel 1 of 8 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 (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) PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ Continued From page 1 heart failure (a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs), and atrial fibrillation (a heart condition that causes an irregular heartbeat). Review of Resident #2's progress notes showed he/she experienced falls on 05/05/24, 05/27/24, 06/01/24, 11/15/24, and 12/22/24. Review on 01/16/25 of Resident #2's current and past ISP's showed: -The only ISP found was the current ISP dated 12/23/24; -The 12/23/24 ISP indicated Resident #2 was a high fall risk, however no interventions were listed out; -Interventions for Resident #2 included "staff to regularly perform fall risk interventions’; -The only additional comment for falls/safety category on the 12/23/24 ISP said, "10"; -The resident's ISP was not updated with interventions after his/her falls on 05/05/24, 05/27/24, 06/01/24, 11/15/24, or 12/22/24. The resident was unavailable for interview. 2. Review of Resident #3's record showed: -He/She was admitted to the facility on 09/22/24: -Diagnoses included a history of falls, chronic kidney disease, cerebral infarction (a medical condition that occurs when blood flow to the brain is disrupted, causing brain cells to die), and morbid obesity (a severe form of obesity that's characterized by a body mass index (BMI) of 40 or higher). Review of Resident #3's progress notes showed he/she experienced falls on 09/28/24 and 09/29/24. Missouri Department of Health and Senior Services STATE FORM 6899 L8G011 If continuation sheet 2 of 8 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 (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) PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ Continued From page 2 Review on 01/16/25 of Resident #3's current and past ISP's showed: -An ISP was completed on 10/15/24, but it did not include specific interventions for falls; -The most recent ISP was dated 11/26/24, but it did not include specific interventions for falls; -The resident's ISP was not immediately updated with interventions after his/her falls on 09/28/24 or 09/29/24. The resident was unavailable for interview. 3. Review of Resident #4's record showed: -He/She was admitted to the facility on 01/23/22: -Diagnoses included cognitive impairment (a term used to describe a person's difficulty with thinking, learning, remembering, and making decisions), hypothyroidism (abnormally low activity of the thyroid gland), and hypertension (high blood pressure). Review of Resident #4's progress notes showed he/she experienced a fall on 06/05/24. Review on 01/16/25 of Resident #4's current and past ISP's showed: -A previous ISP was completed on 03/19/24; -The current ISP was dated 10/07/24 and did not include specific interventions for falls; -The resident's ISP was not updated with interventions immediately after his/her fall on 06/05/24. Observation on 01/16/25 at 12:00 P.M. of Resident #4 showed: -The resident at the lunch table, unable to stay awake, barely capable of interacting with staff attempting to get him/her to eat; -He/She was not interviewable. Missouri Department of Health and Senior Services STATE FORM 6899 L8G011 If continuation sheet 3 of 8 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 (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) PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ Continued From page 3 4. Review of Resident #7's record showed: -He/She was admitted to the facility on 11/01/23; -Diagnoses included dementia (a general term for a decline in mental abilities that affects a person's daily life). Review of Resident #7's progress notes showed he/she experienced a fall on 01/11/25 with an injury to his/her head. Review on 01/16/25 of Resident #7's current and past ISP's showed: -The most recent ISP was completed on 07/09/24: -The resident's ISP had not been updated with interventions since his/her fall on 01/11/25. Observation on 01/16/25 11:10 A.M. of Resident #7 showed: -He/She had a gash with staples on the top of his/her head; -He/She was confused and unable to answer questions. During an interview on 01/21/25 at 1:17 P.M. the Director of Nursing said: -He/She was in charge of updating ISP's for all residents; -He/She did not know what the intervention, "staff to regularly perform fall risk interventions" meant; -He/She was not aware of a list posted somewhere that included specific fall risk interventions for staff to follow; -He/She did not know the ISP review requirements. During an interview on 01/21/25 at 1:20 P.M. the Administrator said: -He/She did not realize falls were considered a change of condition, which required ISP's to be Missouri Department of Health and Senior Services STATE FORM 6899 L8G011 If continuation sheet 4 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 01/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 updated; -He/She was also unaware that there were no specific interventions listed in Resident #2, #3, #4 or #7's ISP's. 19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources Food shall be in sound condition, free from spoilage, filth or other contamination and shall be safe for human consumption. Food shall be obtained from sources that comply with all laws relating to food and food labeling. The use of food in hermetically sealed containers that was not prepared in a food-processing establishment is prohibited. Nothing in this section shall prohibit facilities from using fresh vegetables or fruits purchased from farmers ' markets or obtained from the facility garden or residents ' family gardens. |/II This regulation is not met as evidenced by: Class II Based on observation, interview, and record review the facility failed to ensure food was obtained from sources that were in compliance with all laws relating to food and food labeling. This had the potential to affect all residents. The facility census was 31 residents. Review of the facility's food labeling and dating policy dated 11/06/24 showed: -A date marking system was to be established which included a label with the product name and the date it was prepared or opened; -A designated employee was to check daily to verify that foods were dated and marked appropriately, and would discard any foods that Missouri Department of Health and Senior Services STATE FORM 6899 L8G011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 01/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 were not date marked. 1. Observations of the walk-in cooler in the kitchen on 01/16/25 at 9:45 A.M. showed: -Four trays holding 16 prepared cups of fruit each, stacked on top of each other, with no date or label; -Nine prepared cups of raw vegetables were on a tray with no date or label: -A container of german potato salad was opened and half gone, but not dated; -A container of chicken gravy was labeled, but did not have a date; -A container with an unknown red sauce was not labeled or dated. During an interview on 01/21/25 at 1:20 P.M. the Administrator said: -He/She expected all food to be labeled and dated; -The prepared cups of fruit and vegetables were prepared that morning and served for lunch, he/she did not realize these should have been dated and labeled; -All dietary staff were responsible for ensure food was labeled and dated. 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/III Missouri Department of Health and Senior Services STATE FORM 6899 L8G011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 8 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: PRINTED: 01/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 This regulation is not met as evidenced by: Class II Based on interview, record review, and observation, the facility failed to ensure resident rights were reviewed upon admission and annually for six of six sampled residents (Resident #1, #2, #3, #4, #5, and #6) and/or his/her next of kin, legally authorized representative or designee. The facility census was 31. Review of the facility's Resident Rights policy dated 08/04/23 showed: -Each resident was to receive a copy of the Resident Rights upon entering into an Occupancy Agreement; -Each resident was to sign a copy of the Resident Rights to indicate their receipt and review. Observation on 01/16/25 showed the Resident Rights poster posted in the hallway on the second floor near the nurses station. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 12/17/24; -No resident rights were found for this resident. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 12/01/19; -No resident rights were found for this resident. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 09/22/24: -No resident rights were found for this resident. 4. Review of Resident #4's record showed: -He/She was admitted to the facility on 01/23/22: -No resident rights were found for this resident. Missouri Department of Health and Senior Services STATE FORM 6899 L8G011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 8 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 01/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 01/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 8559 NORTH LINE CREEK PARKWAY KANSAS CITY, MO 64154 PRIMROSE RETIREMENT COMMUNITY OF KANSAS C€ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 5. Review of Resident #5's record showed: -He/She was admitted to the facility on 11/08/21; -No resident rights were found for this resident. 6. Review of Resident #6's record showed: -He/She was admitted to the facility on 11/21/24; -No resident rights were found for this resident. During an interview on 01/16/25 at 3:00 P.M. The Administrator said: -He/She did not have anything signed by residents showing resident rights were reviewed with them annually; -Residents typically signed their resident rights upon admission when signing their admission agreement; -He/She did not know Resident Rights needed to be reviewed and signed annually with each resident or their designee. *Higher class merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 L8G011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 8 PLAN OF CORRECTION Provider/Supplier Name: Primrose Retirement Community Street Address, 8559 N Line Creek Parkway City, Zip: Kansas Cily, MO 64154 Date of Survey: January 21, 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 e What corrective action(s) will be accomplished for those A4755 residents who found to have been affected by the deficient practice? Records for those residents found to have deficiencies (2, 3, 4, & 7) have had the ISP’s reviewed and updated to include 2/5/25 appropriate interventions for each resident. e How will you identify other residents having the potential All resident records will be reviewed to determine the need for change of condition or individual interventions related to fall risk. 3/1/25 Those at high risk of falls will be updated according to our policy. to be affected by the same deficient practice? « What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not occur? The review of the Mobility/Fall Management Policy was completed without change. Education will be provided by DON to clinical staff on policy and appropriate post fall interventions for those at high risk of falls. DON will review all 2/11/25 fall incidents for appropriate interventions and update ISPs as applicable. Resicents at high risk for falls will be identified at move-in, all routine evaluations or with a change of condition. e How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The DON or designee will audit resident records based on specific interventions identified on the resident evaluation/service plan for those with fall risk. Audit of 5 charts weekly x 4 weeks, then 5 charts bi-weekly x 4 weeks, then 5 charts monthly x 1 month and provide findings during the community monthly QA meetings to ensure compliance. A7013 e What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The observed food (cups of fresh fruit and raw vegetables) was immediately labeled and dated. The German potato salad, 4/21/25 chicken gravy and red sauce was disposed of. e How will you identify other residents having the potential to be affected by the same deficient practice? All food items were audited and every item that was not labeled, dated and/or sealed properly was discarded. e What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not occur? The community policy, “Storage of Products”, was reviewed without change. The dining service manager will in-service all kitchen employees on this policy. The Dining Manager will ensure all food items are properly stored, labeled, and dated. e¢ How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The Dining Manager or designee will conduct observation audits of food storage 5X weekly X2 weeks, then 3X weekly X2 weeks, then 1X weekly ongoing to ensure all food items are properly 2/10/25 stored, labeled, and dated. Results of these audits will be reported to the monthly QA X3 months to ensure compliance. 215/25 2/11/25 e What corrective action(s) will be accomplished for those A8&004 residents found to have been affected by the deficient practice? The Executive Director or designee will review resident rights and obtain signatures from residents and/or his/her legally 3/1/25 responsible party, or designee. e How will you identify other residents having the potential to be affected by the same deficient practice? All resident files will be reviewed to ensure all signed 3/1/25 acknowledgement of receiving resident rights has been entered e What measures will be put into place or what systemic changes will you make fo ensure that the deficient practice does not occur? The Executive Director or designee will review resident rights and obtain signatures annually and place copy in resident file. e How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The Executive Director or designee will audit resident records to ensure copy of Resident Rights has been signed by resident/responsible party. Audit of 5 charts bi-weekly x 8 weeks, then 5 charts monthly x 1 month. Findings will be provided to the monthly QA to ensure compliance. 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.