SAGEGROVE AT STALEY HILLS.

PRINTED: 03/20/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc BWING 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EAGH 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) BENTON HOUSE OF STALEY HILLS 19 CSR 30-86,.047(5) Administrator - Licensed The operator shall designate an individual for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. Il This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure a licensed administrator was employed at the facility as required by the Missouri Board of Nursing Home Administrators (MBNHA). The census was 61. The facility did not provide a policy regarding employing a licensed Administrator. 1. Record review on 03/11/25 showed: -The Executive Director (ED) was the previous licensed Administrator; -The ED held a Temporary Emergency License (TEL) effective 11/06/24; -The ED's TEL expired 03/06/25; -No other individual was hired as a licensed Administrator. During an interview on 03/11/25 at 1:50 P.M. ED said: -He/She lost track of time, and did not realize his/her TEL expired until he/she received an email on 03/06/25 from the MBNHA indicating that it expired on that day; -He/She was planning to get his/her Administrator license but was not scheduled for testing until April 2025; -He/She was unsure what the company planned to do to rectify the problem, and to get someone in place. Missouri Department of Health and Senior Services { LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S $ G y (X6) DATE STATE FORM . f 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 11071 N WOODLAND AVE BENTON HOUSE OF STALEY HILLS KANSAS CITY, MO 64155 PRINTED: 03/20/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 03/11/2025 (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 1 During an interview on 03/11/25 at 1:59 P.M. the Regional Director said: -He/She was aware of the ED's TEL expiring; -He/She assumed they could extend the ED's TEL but found out on 02/28/25 that was not the case; -The Residential Service Director applied for a TEL after 03/06/25 and was denied due to the status of the ED's TEL already being expired; -He/She was still working on a plan to rectify the problem, and to find an Administrator that is already licensed, for the facility until the ED can get his/her license. MO250862 Missouri Department of Health and Senior Services STATE FORM 6899 KXC411 DEFICIENCY) If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Benton House of Staley Hills Name: Street Address, os 11071 Maplewoods PKWY, Kansas City, MO 64155 City, Zip: Date of Survey: March 11, 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 30774 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | On 3/11/25, the Interim Executive Director, received a copy of } the PSLG Executive Director job description which states”...will | 7 operate the community in conformity with the policies and 4 Il BD procedures of PSLG and with the state and local rules and regulations.” The Regional Director also reviewed the job description with the IED on 3/12/25 to ensure understanding of the contents of the job description. Effective 3/13/25, the Regional Director, employed a licensed b Administrator, Michelle Mincks license #4849, to serve as [AAD Administrator until Interim ED gets her official license. The Resident Service Director applied for her TEL on 3/14/25 and was approved, TEMP 1272, effective 3/17/25-7/15/25 which |-#. is now prominently displayed in the community. The expiration WH] 2e date has been added to the Executive Director and Regional Directors calendar to ensure there is no further lapse in licensure for the Administrator. A4703 All proper change of administrator/manager forms have been sent to the Dept. for notification of changes. 4 Ongsing POC: WF Should any other changes occur, the proper forms /notices will be sent by either the Regional Director or designee. Both the Resident Service Director and Interim ED are scheduled for their administrators tests in March and April to obtain a full administrators license. The Regional Director will continue to monitor the status of both applicants on their tests and progress to ensure this deficiency does not occur again. 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.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: B. WING NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A, BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A8025, 19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed If the administrator or other employee of a long-term care facility has reasonable cause to believe that a resident of the facility has been abused or neglected, the administrator or employee shall immediately report or cause a report to be made to the department. Any administrator or other employee of a long-term care facility having reasonable cause to suspect that a vulnerable person has been subjected to abuse or neglect or observes such a person being subjected to conditions or circumstances that would reasonably result in abuse or neglect shall immediately report or cause a report to be made to the department and to the Department of Mentai Health. I/II This regulation is not met as evidenced by: Class [I Based on interview and record review, the facility failed to follow facility policy to immediately report two allegations of misappropriation to the state survey agency, the Department of Health and Senior Services (DHSS), when two of five sampled residents (Resident #1 and Resident #2) reported fraudulent charges on their bank accounts and missing money. The facility census was 52. Review of the facility policy titled, "Reporting Abuse, Neglect, and Exploitation," dated 12/18/24 showed: -Any employee with knowledge of abuse or neglect of a resident was to report the information as soon as it became known directly to the Executive Director; -The Executive Director was to make a report to DHSS immediately or no later than end of f) Missouri Department ff Health and Senior Services, LABORATORY DIRECTOR'S OR PROVIY FR/SUPPLIPRREPRESENTATIVE'S SIGNATURE Lyra Mp IEtt d// STATE FORM 7 ™ 6808 PRINTED: 03/05/2025 FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 02/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE f (X6) DATE / SO MY IAC. LMCI ZMGI11 if continuation sheét 1 of PRINTED: 03/05/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (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) BENTON HOUSE OF STALEY HILLS Continued From page 1 business on the day of notification of the event. Review of the facility's investigation dated 01/31/25 showed: -The Regional Operations staff interviewed Resident #1 who reported fraudulent charges of $400 on his/her credit card at the local grocery store; -The Regional Operations staff interviewed Resident #2 who reported fraudulent charges of $400 and $800 at a couple different stores, in addition to missing $150 in cash; -The Regional Operations staff made a report to the local police department of these reports. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 12/14/24; -Diagnoses included prediabetes (a condition in which blood sugar levels are higher than normal but not high enough to be diagnosed as type 2 diabetes), hypertension (high blood pressure), and stage 3 renal inusfficiency (a condition where the kidneys are not functioning properly), dysphagia (difficulty swallowing foods or liquids), and anxiety. -His/Her son was his/her durable power of attorney. During an interview on 02/21/25 at 10:11 A.M. Resident #1 said: -The debit card was in his/her possession at all times, but got an alert on his/her phone of a fraudulent charge on his/her debit card; -His/Her son takes care of his/her finances; -He/She initially thought it was a staff member of the facility, but then he/she was being told it was possibly from having his/her card on file at the pharmacy where it could have been compromised; -He/She reported the missing money and Missouri Department of Health and Senior Services STATE FORM 6899 ZMGI11 If continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 fraudulent charges immediately to staff on 01/30/25. During an interview on 02/21/25 at 11:14 A.M. Resident #1's durable power of attorney said: -The transaction was canceled and the money was never removed from the resident's account; -The resident's card was canceled and a new one was ordered; -The old card was in the resident's possession at the time, but he/she now holds on to the new card as the resident has no need for it at the facility; -He/She was unsure of where the card information could have been compromised from. 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 09/25/24; -Diagnoses included aortic valve stenosis (a condition where the aortic valve, located between the left ventricle of the heart and the aorta, becomes narrowed or obstructed) and a pacemaker (a small, implantable medical device that helps regulate the heart's rhythm by sending electrical impulses); -He/She was his/her own person. During an interview on 02/21/25 at 10:33 A.M. Resident #2 said: -He/She called the bank regarding a charge he/she was not familiar with, but upon figuring that out, the bank immediately sent him/her to the fraud department for $400 and $800 charges on his/her debit card he/she did not authorize; -The card was canceled and the bank overnighted him/her a new card; -He/She was also missing $150 in cash; -He/She could not recall the last time seeing the money in his/her purse, but knew he/she had enough for a years worth of haircuts each month; -He/She always kept his/her purse behind the Missouri Department of Health and Senior Services STATE FORM 6899 ZMGI11 PRINTED: 03/05/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 closet door under a robe, a staff member would have had to be snooping to find it; -He/She reported the missing money and fraudulent charges immediately to staff on 01/30/25. During an interview on 02/21/25 at 9:25 A.M. the Administrative Assistant said: -He/She received the reports of missing money from Resident #1 and #2: -He/She immediately reported these reports to his/her superiors who investigated and called the police. During an interview on 02/21/25 at 10:22 A.M. the Regional Operations staff said: -He/She was advised of the reports of fraudulent charges and missing money by the Administrative Assistant; -He/She spoke with each resident and then made a police report; -He/She was not aware of the states' requirement to report to DHSS. During an interview on 02/21/25 at 12:28 P.M. the Executive Director said: -The Regional Operations staff was at the facility when the reports were made by Resident #1 and #2 so he/she handled the investigation; -He/She did not know to report to DHSS. MO248802 Missouri Department of Health and Senior Services STATE FORM 6899 ZMGI11 PRINTED: 03/05/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/21/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Benton House of Staley Hills Name: Street Address, City, Zip: 11071 Maplewoods Pkwy., Kansas City, MO 64155 Date of Survey: 2/21/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 30774 COMPLETION DATE PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG The Administrator was educated on 3/6/2025 by the Regional! Director on the state regulations as well as the company (PSLG) policy B3.1.2.1, Reporting abuse, neglect, and exploitation. Education included the notification of DHSS and the local police department, of any suspected or confirmed misappropriation, | ig ee neglect, or abuse. Ongoing Oversight: The Regional Director will ensure that the administrator completes training via Relias, at least annually, both the State regulations as well as policy B3.1.2.1 Reporting Abuse, Negject, and Exploitation. An all-staff in-service training was held on 2/21/2025 by the Administrator to educate all staff to immediately report any misappropriation, neglect, or abuse to the executive director or designee. Staff in attendance signed an acknowledgement of receipt of policy B3.1.2.1 Reporting Abuse, Neglect, and Exploitation. The signed acknowledgement was uploaded into Fle A8025 the employee’s electronic file. Staff not in attendance at the meeting will be educated in person by the Administrator or designee, on their next shift to ensure all current staff have been educated. All education will be completed by 3/21/2025. Ongoing Oversight: The Administrator or designee will monitor training compliance at least quarterly to ensure that all employees have completed this assigned topic in Relias. The plan of correction will be completed by 3/31/2025 with ongoing monitoring 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. PLAN OF CORRECTION Provider/Supplier Name: city zien 11071 Maplewoods Pkwy., Kansas City, MO 64155 Benton House of Staley Hills Date of Survey: 2/21/2025 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 The administrator will be educated on the correct policies and procedures of the state regulation and the company (PSLG) to Y, notify DHSS of any misappropriation, neglect, or abuse as well x as the local police department. Any current residents could potentially be affected by this deficient practice. An all-staff in-service will be held to educate all staff to immediately report any misappropriation, neglect, or abuse to the executive director. Staff in attendance will sign they AeA 25 received a copy of the policy B3.1.2.1 Reporting Abuse, Neglect, and Exploitation. Staff not in attendance wil! be educated on their next shift to ensure 100% of staff have been educated. A8025 ED and/or DON wilt conduct annual in-service on this policy B3.1.2.1 Reporting Abuse, Neglect, and Exploitation. Plan of correction will be completed by 3/14/2025 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.

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA \ND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING PRINTED: 11/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/14/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A7026 19 CSR 30-87.030(24) Hot Food-140 Degrees or Above/Transport | The internal temperature of potentially hazardous foods requiring hot storage shall be one hundred forty degrees Fahrenheit (140°F) or above, except during periods of preparation. Potentially hazardous food to be transported shall be held at a temperature of one hundred forty degrees Fahrenheit (140°F) or above. |/Il This regulation is not met as evidenced by: Class II Based on observation the facility failed to hold | food to be transported and served to the memory care unit residents at one hundred forty degrees Fahrenheit (140°) or above. This affected one | (Resident #1) of five sampled residents and potentially affected all memory care residents. | The facility census was 56. 1. Review of Resident #1 Face Sheet showed: -Admit date was 10/14/21; -Diagnoses included: Dementia (a disease of the brain that causes memory and reasoning impairment), with Behavioral Disturbances. | Review of the resident's Individualized Service Plan ((ISP)Planning document which outlines a _ resident's needs and preferences, goals, and services to be provided) showed: -He/She was on a regular diet; -He/She was only able to mumble and was not able to verbalize his/her needs or wants. Observation on 11/14/24 at 11:00 A.M. of the posted daily menu showed lunch included black bean soup, salad, tuna casserole, bread stick, and cherry pie. Missouri Department of Health and Senior Services | LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRES#NTATIVE'S SI x MM YU Ler ATURE TE FORM PREFIX TAG A7026 ALL | 2NN611 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) TITLE (x8) COMPLETE DATE (x6) DATE (EA If continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 11071 N WOODLAND AVE BENTON HOUSE OF STALEY HILLS KANSAS CITY, MO 64155 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 1 Observation on 11/14/24 at 12:22 P.M. showed the Dietary Supervisor prepared and plated food on ten individual plates and covered them with a plate cover to be transported to the memory care unit. Observation on 11/14/24 at 12:32 P.M. showed Level One Medication Aide (LIMA) A transported the ten covered individual plates to the memory care unit on a metal rolling cart. Observation on 11/14/24 at 12:36 P.M. showed the last plate was served to Resident #1 which contained only tuna casserole, the temperature of the casserole was one hundred nineteen degrees Fahrenheit (119°). During an interview on 11/14/24 at 12:40 P.M., LIMAA said: -He/She did not know what temperature food should be held and served at; -The Dietary Supervisor recorded the temperature of the food prior to it being transported to the memory care unit. During an interview on 11/14/24 at 3:30 P.M., the Administrator said: -She expected food to be served at one hundred forty degrees Fahrenheit (140°) according to regulation. MO244217 Missouri Department of Health and Senior Services STATE FORM 6899 2NN611 (X2) MULTIPLE CONSTRUCTION PRINTED: 11/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/14/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Na vae: Benton House of Staley Hills Assisted Living and Memory Care Street Address, City, Zip: 11071 Maplewoods Pkwy, Kansas City, MO 64155 Date of Survey: Nov. 14, 2024 —— —| PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Education of hot food service will be done with staff to ensure A7026 food is being served at the approved temp of 120 degrees or 11/15/2024 above at the time the resident is being served. Approved hot box will remain in memory care and turned on in the am by overnight staff to be at correct temp. in time for 11/15/2024 breakfast and shut off after dinner service by evening staff. Kitchen staff have been educated they are to plate and wrap/cover each plate for memory care, transport immediately after plating, and put each plate in the hot box in memory care for the staff to then be able to serve directly from hot box to residents. Food temp will be 140 degrees or higher at the time of service. 11/15/2024 Food temps will be taken 3-4 times per week to ensure the food is being served at the correct temps. of 120 or above per state regulations. — nt AN 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.

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 B. WING 10/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS GITY, MO 64155 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION xB} 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} BENTON HOUSE OF STALEY HILLS A6012} 19 CSR 30-87.020(12) Floor Surfaces All floors in the facility shall be clean and shall be maintained in good repair. Floors and floor coverings of all food-preparation, food-storage and utensil-washing areas, and the floors of all walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealed concrete, terrazzo, ceramic tile, durable grades of linoleum or plastic, or tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip floor covering in areas where necessary for safety reasons. Ill This regulation is not met as evidenced by: Class III Based on observations and interview, the facility failed to ensure the floor in the kitchen was kept clean and free from dirt and debris, The facility census was 46, 1, Observation on 10/8/24 at 11:10 A.M. of the kitchen floor showed: -It felt greasy and slick when walked on; -There were empty boxes scattered throughout; -There was a large build up of grease behind and on the sides of the grill; -There were several sheets of parchment paper next to the food warmer; -There were food particles, dirt, and other debris throughout the kitchen floor. During an interview on 10/8/24, at 11:15 A.M., the Food Service Director said: -He knew the kitchen was "definitely not in the best condition"; -The kitchen including the floors should be kept {X86} DATE 6-262 STATE FORAY s ‘ 6690 IF BST ? if continuation sheet 7 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 During an interview on 10/8/24, at 1:30 P.M. the Administrator said: -She was aware the kitchen was not as clean as it should be; -She expected the kitchen, including the floors to be well kept and clean. MO242295 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III This regulation is not met as evidenced by: Class II* Missouri Department of Health and Senior Services STATE FORM 6899 IF8S11 PRINTED: 01/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Based on observation and interview the facility failed to ensure food was protected from potential contamination and spoilage when they did not cover and/or store food at a safe temperature. The facility census was 46. Observation of the kitchen on 10/8/24 at 11:00 A.M. showed: -A rack holding several plates with an apple dessert on them that were uncovered and not labeled; -A rack holding a sheet pan with slices of cake on it that was uncovered and not labeled; -A Ziplock bag in the refrigerator labeled turkey meat with a date of 9/13/24; -A container of sour cream in the refrigerator with a red dried on substance on the top and sides of it; -A full pan of cooked bacon that was at room temperature sitting on the counter uncovered; -A container of melted butter sitting on the counter uncovered; -A pan containing sixteen biscuits sitting on the counter uncovered; -A container of pasta salad sitting on the counter at room temperature; -A package of sliced cheese sitting on the counter at room temperature and open to air. During an interview on 10/8/24, at 11:15 A.M., the Food Service Director said: -He knew the kitchen was "definitely not in the best condition"; -All food should be kept at the appropriate temperature and covered to protect it from contamination. During an interview on 10/8/24, at 1:30 P.M. the Administrator said: -She was not aware that food was left out open to Missouri Department of Health and Senior Services STATE FORM 6899 IF8S11 PRINTED: 01/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 air and at room temperature; -All food should be kept at a safe temperature and protected from debris and other contamination. *The higher classification merited due to the extent of the violation. MO242925 19 CSR 30-87.030(54) Nonfood Contact Surfaces, Cleaning Surfaces of equipment not intended for contact with food, but which are exposed to splash or food debris or which otherwise require frequent cleaning, shall be designed and fabricated to be smooth, washable, free of unnecessary ledges, projections or crevices, and readily accessible for cleaning, and shall be of such material and in a repair as to be easily maintained in a clean and sanitary condition. Ill This regulation is not met as evidenced by: Class Ill Based on observation, interview, and record review the facility failed to ensure all non-food contact surfaces were kept clean when multiple non-food contact surfaces were found to be covered in food debris and sticky substances. The facility census was 46. 1. Observation on 10/8/24 at 11:00 A.M. of the kitchen showed: -The front and sides of the grill area were splattered with food, grease, and other debris; -The back splash had a white sticky substance splattered that appeared to be running down; Missouri Department of Health and Senior Services STATE FORM 6899 IF8S11 PRINTED: 01/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 -The top of the food warmer had food crumbs and a sticky residue on it. Review of the weekly kitchen cleaning checklist dated 5/15/05 showed the following should be cleaned each week; -All walls; -Shelves and cabinets; -Toaster; -Inside and outside of stove hood; -The oven and food warmers. During an interview on 10/8/24, at 11:15 A.M., the Food Service Director said: -He knew the kitchen was "definitely not in the best condition"; -The kitchen including the non-food contact surfaces should be kept clean. During an interview on 10/8/24, at 1:30 P.M. the Administrator said: -She was aware the kitchen was not as clean as it should be; -She expected the kitchen, including the non-food contact surfaces to be well kept and clean. MO242925 Missouri Department of Health and Senior Services STATE FORM 6899 IF8S11 PRINTED: 01/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/08/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: [son House of Staley Hills Street Address, City, Zip: 11071 N Woodland Ave, Kansas City MO 64155 Date of Survey: 10/8/2024 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A6012 A7015 30774 COMPLETION DATE This kitchen floor was scrubbed and pressure washed on 10/10/24, Boxes were cleared by the end of the shift at 3pm. The grill was cleaned and scrubbed on 10/10/2024. Parchment paper was moved from beside the food warmer and kitchen The apple desserts were disposed of and substituted with a fruit cup. All food that was out and not covered or labeled or out of reorganized for efficiency. Any current residents could potentially be affected by this deficient practice. The kitchen staff will be educated over the expectation of daily cleaning of the kitchen. A new daily checklist will be implemented to turn in to the dining supervisor and the ED dally. ED will monitor the kitchen staff daily for compliance with cleaning schedule and daily completion of duties. Plan of Corrections will be completed by 10/45/2024, date range was disposed of in the garbage. Any current residents could potentially be affected by this deficient practice. Dining staff were educated about food protocols for storing, labeling, covering, date and disposal of expired items. ED will monitor the kitchen with a daily checklist and observation of the kitchen during food service, prep and cleanup. Plan of Corrections will be completed by 10/15/2024. | The kitchen was deep cleaned on 10/10/2024. This was a 2 day process performed by the management and dining staff. Any current residents could potentially be affected by this deficient practice. A7056 The dining staff were educated regarding cleaning schedules and a daily checklist implemented. The ED will monitor the daily kitchen cleaning and review the checklist for compliance. Plan of Corrections will be completed by 10/15/2024. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 08/20/2024. FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1}) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B. WING |__' 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (X4) 1D , SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) PREFIX (EAGH DEFICIENCY MUST BE PREGEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BENTON HOUSE OF STALEY HILLS 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 wastebaskeis shall be used for trash. |] This regulation is not met as evidenced by: Class It Based on observations and an interview on 8/13/24 the facility faited to insure ail the wastebaskets were the approved types allowed. The facility census was 47. This potentially affected 47 of 47 residents. Observations during the 8/13/24 walkthrough showed non-approved type wastebaskets in the following areas; In Room 102 had one, Room 104 had one, Room 113 had one, Room 204 had one, Room 205 had four, Room 206 had two, Room 213 had one, Room 216 had two, Room 222 had one, Room 223 had one, Room 230 had two, Room 231 had three, Room 302 had two, and Room 305 had one. During an interview on 8/13/24 at 12:15 P.M. the Maintenance Director stated he/she would work at getting the proper wastebaskets in place and get with housekeeping again to get them trained on spotting the non-approved types of wastebaskets. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. I/II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPFLIER REPRE TWE'S SIGNATURE (X6) DATE “STATE FORM 6899 Y3N911 (Reontinuation sheet Tof 3 PRINTED: 08/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION {X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B. WING 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X65) 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) BENTON HOUSE OF STALEY HILLS Continued From page 1 This regulation is not met as evidenced by: Class Ill Based on observation and an interview on 8/13/24 the facility failed to provide a proper oxygen storage room in accordance with NFPA 99, 1999 Edition. The facility census was 47. This potentially affected 47 of 47 residents. Observation on 8/13/24 at 12:32 P.M. showed the oxygen storage room did not have a constantly on positive ventilation fan. During an interview on 8/13/24 at 12:32 P.M. with the Maintenance Director he/she said he/she would get one installed that would constantly pull air up into the attic area. 19 CSR 30-86.032(3)(B)(1 - 6) Adult Day Care Requirements Only activities necessary to the administration of the facility shall be contained in any building used as a long-term care facility excepi as follows: (8) Adult day care may be provided for four (4) or fewer participants without prior written approval of the department if the long-term care facility meets the following stipulations: 1. The operation of the adult day care business shall not interfere with the care and delivery of services to the long-term care residents; 2. The facility shall only accept participants in the adult day care program appropriate to the level of care of the facility and whose needs can be met; 3. The facility shail not change the physical layout of the facility without prior written approval of the department; A. The facility shall provide a private area for adult Missouri Department of Health and Senior Services STATE FORM 8899 Y3N911 If continuation sheet 2 of 3 PRINTED: 08/20/2024 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 30774 Be WING eee ere 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD 8E COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BENTON HOUSE OF STALEY HILLS Continued From page 2 day care residents to nap or rest; 5. Adult day care participants shall not be included in the census, and the number of adult: day care participants shall not be more than four (4) above the licensed capacity of the facility; and 6. The adult day care participants, while on-site, are to be included in the determination of staffing paiterns for the long-term care facility; [JAI This regulation is not met as evidenced by: Class Ii Based on observations and an interview on 8/13/24 the 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 47. This potentially affected 47 of 47 residents. Observations during the 8/13/24 walkthrough showed Rooms 202 and 304 with mechanical wedges stuck under the resident room corridor doors blocking them open. These doors were originally constructed with door closers in place to help protect the resident (evacuation) corridors and areas of refuge from the effects of fire and smoke. NOTE: NFPA 101 does permit these types of doors to be held open with friction type holders that release with a simple pull on the door handle During an interview on 8/13/24 at 11:50 A.M. the Maintenance Director stated he/she had installed magnetic holds on some of the resident's room doors and indicated they were to notify him/her if other residents wished to keep their doors open during the day. Missouri Department of Health and Senior Services STATE FORM 699 Y3N911 If continuation sheet 3 of 3 | PLAN OF CORRECTION Provider/Supplier Benton House of Staley Hills Name: Street Address, City, Zip: 11071 N Woodland Ave, Kansas City MO 64155 Date of Survey: 8-13-2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Staff meeting will be held on 8/22/24 to go over trash cans which is approved and not. They will be collecting trash bins from the A2286 rooms that do not have the right ones. Family email went out on 8/23/24 8/23/24 letting families know they have to have metal trash cans. Fire approved bins. Approved contractor will be scheduled to come in and put in A2298 ventilation fan in Oxygen room Pending Staff meeting on 8/22/24 informed all staff that nothing can prop 8/23/24 and A3203 open doors other than magnetic door stop. Magnetic door stops on going will be installed by maintenance The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the pian of correction being submitted on this form. | i

PRINTED: 05/15/2024 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 B.WING 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (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) BENTON HOUSE OF STALEY HILLS A4777| 19 CSR 30-86.047(36) Proper Care Per Individual Service Pian Residents shall receive proper care as defined in the individualized service plan. WII This regulation is not met as evidenced by: Class II Based on interview and record review, facility staff failed to provide proper and timely care for two of four sampled residents plus four others when they failed to answer residents call lights in a timely manner. The facility census was fifty-two (52). 1, Review of Resident #1's medical record showed: -Admit date was 11/19/23; ~Diagnoses included: Type || diabetes (a disease in which the body does not process blood sugar properly), and a history of a stroke with right side paralysis. During an interview on 5/6/24 at 1:35 P.M., Resident #1 said: -It took a long time for staff to answer the call light; -He/She has waited an hour or more on a few occasions but did not remember when; -It made him/her feel helpless when he/she had to wait a long time for the call light to be answered; -He/She felt staff should answer the call tight within 15 minutes. 2. Review of Resident #2's medical record showed: -Admit date was 12/14/23; -Diagnoses included: Type II diabetes, stroke with affects to vision and foot drag. Missouri Depaftment of Health and Senior Services LABORA aly RCTOR'S,OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE Offs) DATE Kae a DIVINE L222 f\ DRI [2024 STAIE.EORM 5899 JK4G14 {f continuation sheet 1 of S PRINTED: 05/15/2024 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 05/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (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) BENTON HOUSE OF STALEY HILLS Continued From page 1 During an interview on 5/6/24 at 12:40 P.M., Resident #2 said: -It took longer than it should for his/her call light to be answered; -Sometimes it took 30 minutes or more for it to be answered; -He/She felt the call light should be answered within 5 minutes; -It made him/her feel frustrated when it took a long time for the call light to be answered. Review of the Daily Stand -Up report generated on 5/6/24 showed in the previous twenty-four (24) hours the following rooms had a call light on for 20 or more minutes: -Room 231 had a call light on for 22 minutes on 5/6/24 at 7:57 A.M.; -Room 226 had a call light on for 20 minutes on 5/6/24 at 9:16 A.M.; -Room 210 had a call light on for 42 minutes on 5/5/24 at 7:11 P.M.; -Room 230 had a call light on for 88 minutes at on 5/5/24 7:38 P.M. -Room 202 had a call light on for 47 minutes on 5/5/24 at 8:35 P.M.; -Room 231 had a call light on for 20 minutes on 5/5/24 at 9:29 P.M. During an interview on 5/6/24, at 2:22 P.M., Certified Medication Technician (CMT) A said the facility expected staff to answer call lights within 5 minutes. During an interview on 5/6/24, at 2:22 P.M., CMT B said the facility expected staff to answer call lights within 5 minutes. During an interview on 5/6/24 at 2:10 P.M., the director of nursing (DON) said: Missouri Department of Health and Senior Services STATE FORM 6899 JK4G11 If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 -She was aware there was a problem with the amount of time it took for some call lights to be answered; -She had recently spoke with staff regarding the amount of time it took; -She expected all call lights to be answered within 3-5 minutes, but no more than 10 minutes. During an interview on 5/6/24 at 2:10 P.M., the Administrator said: -She expected all call lights to be answered within 3-5 minutes, but no more than 10 minutes. MO234847 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it Missouri Department of Health and Senior Services STATE FORM 6899 JK4G11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 05/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 3 deems necessary to protect the residents. II/III This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed ensure they served food under safe, sanitary conditions when staff did not ensure food was served at a safe temperature. This had the potential to affect all facility residents. The census was 52. 1. Review of Resident #1 medical record showed: -Admit date was 11/19/23; -Diagnoses included: Type II diabetes (disease in which the body does not process blood sugar properly), and a history of a stroke with right side paralysis. During an interview on 5/6/24 at 1:35 P.M., Resident #1 said: -The food was never as warm as it should be. 2. Review of Resident #2's medical record showed: -Admit date was 12/14/23; -Diagnoses included: Type II diabetes, stroke affecting the vision and caused right foot drag. During an interview on 5/6/24 at 1:35 P.M., Resident #2 said: -The food was cold and bland. 3. Review of Resident #3' medical record showed; -Admit date was 6/12/23; -Diagnoses included: heart disease and type II diabetes. During an interview on 5/6/24 at 12:40 P.M., Missouri Department of Health and Senior Services STATE FORM 6899 JK4G11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 05/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11071 N WOODLAND AVE KANSAS CITY, MO 64155 BENTON HOUSE OF STALEY HILLS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Resident #2 said: -The food was okay most of the time; -Often the food was barely warm. During an interview on 5/6/24 at 1:15 P.M., the Food Service Director said: -He checked the temperature of the food, but never logged it; -He knew hot food should be 140 degrees and cold food should be 41 degrees. -He was not aware he was supposed to check the food temperatures and record the temperature of all foods before the food was served to the residents. During an interview on 5/6/24 at 2:10 P.M., the Administrator said: -She expected kitchen staff to check the food temperatures and record the reading of the temperatures to ensure they were being served at the appropriate temperatures. MO234847 Missouri Department of Health and Senior Services STATE FORM 6899 JK4G11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 05/06/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Benton House of Staley Hills Name: Street Address, City, Zip: 11071 Maplewood’s Pkwy Kansas City, MO 64155 Date of Survey: 5-6-2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 19 CSR 30-87.030(13) ED immediately had meetings with kitchen staff and made binder with all policy's, including everything needed for them to run efficiently and correctly. Educated staff that all items are to remain in binder to keep all items on record. Items disused are listed - A?015 * Daily log for Sanitizer Test Strip 5/13/2024 * Daily communication Log * Menu substitution Log * Cooking Temps * High Temp Dish Washer * Refrigerator/Freezer Temp Log ED will be checking items weekly to insure they are being done correctly and to ensure the safety of all residents. 19 CSR 30-86.047(36) ED has had multiple meetings with all staff and has posted to our staff communication platform to ensure everyone has seen messages about proper response time to resident pendants. Issue’s addressed and talked about in Daily Huddle, with all ailress AAT? shifts. 5/9/2024 . . : . 5/10/2024 ED is pulling report every morning Monday to Friday and pull 5/17/2024 weekend report on Monday. ED is to review report and match On going with schedule. ED will address excessive response times with team member if needed and provide corrective action. ED is to keep all reports in folder. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 12/05/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 30774 B. WING 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) (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) BENTON HOUSE OF STALEY HILLS A4778 19 CSR 30-86.047(37) Appropriate Action & Notification In case of behaviors that present a reasonable likelihood of serious harm to himself or herself or others, serious illness, significant change in condition, injury or death, staff shall take appropriate action and shall promptly attempt to contact the person listed in the resident’ s record as the legally authorized representative, designee or placement authority. The facility shall contact the attending physician or designee and notify the local coroner or medica! examiner immediaiely upon the death of any resident of the facility prior to transferring the deceased resident to a funeral home, HII This regulation is not met as evidenced by: Class I] Based on interview and record review, the facility failed to contact ane resident's legally authorized representative after the resident (Resident #1} was involved in a resident to resident altercation resulting in him/her being transferred to a hospital due to the reasonable likelihood of injury. The facility census was 55. Review of facility policy on reporting changes in resident condition dated 1/1/22 showed in part: - That any changes in resident condition should be recorded in the communications log or nursing notes; ~ If change of conditions warrants immediate medical interventions, 911 guidelines should be followed; - Resident physician and responsible party should be contacted. 1) Review of Resident #1's undated medical Missouri Department of Health and Senior Services ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNARURE (X6} DATE aBoa JE6514 If continuation sheet 1 of 4 PRINTED: 12/05/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc BN en 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (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) BENTON HOUSE OF STALEY HILLS Continued From page 1 record showed: - His/Her admission on 8/3/23; ~ Diagnoses of dementia (a disease in which the brain does not function properly that often causes confusion, and loss of reasoning), generalized anxiety disorder, depressive disorder. Review of the resident's recent leave record showed: ~ A transfer to a hospital for health concerns on 41/16/2023 at 6:00 P.M. - Areturn from the hospital on 11/16/2023 at 40:09 P.M. Review of the resident's contact information sheet showed: ~ Public Administrator (PA), listed at the resident's emergency contact, guarantor, health care proxy, legal conservator, legal custodian, legal guardian, responsible party, and financially responsible party; - Anote stating the PA is the only person to call. Call the PA for everything. Review of the resident's daily communications log showed: - On 11/46/23 at 5:57 P.M. the resident had an unwitnessed fall; - The Resident #1 was observed on floor in dining room and said he/she was pushed by Resident #2: ~ The incident was observed by third party family member, Witness #1; - Witness #1 said Resident #1 and Resident #2 were having verbal argument; ~ Resident #2 pushed Resident #1's chair; - Resident #1 fell back and hit his/her head on nearby wall; -Resident #1 complained of head and left hip pain; — Missouri Department of Health and Senior Services STATE FORM asga 1E6511 If continuation sheet 2 of 4 PRINTED: 12/05/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED c B.WING 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (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) BENTON HOUSE OF STALEY HILLS Continued From page 2 -Resident #1 was transferred out of facility to hospital; ~ Notification of incident was made to executive director, director of nursing, Resident #2's wife, and each resident's nurse practitioner; - No documentation showing notification to Resident #1's responsible party. During an interview on 11/27/23 at 14:30 A.M., Resident Assistant A said: - He/She was not working during the altercation; - In the event of an altercation, he/she would notify a supervisor or the person in charge; ~ He/She would try to calm and redirect the residents, During an interview on 11/27/23 at 11:36 A.M. Medicine Technician A said: ~ He/She was not working during the altercation; - [n the event of an altercation, he/she would notify the resident service director; - He/She would try to calm and redirect the residents; ~ He/She would begin checking vitals and assessing the involved residents. During an interview on 11/27/23 at 12:40 P.M. the Resident Services Director said: - In the event of a resident to resident altercation he/she would make sure residents are separated; - He/She would being the investigation process and obtain the specifics about what occurred; ~ He/She would notify the Executive Director, the state hotline, resident physicians, and resident representatives; - Resident #1's responsible party is a public administrator; ~ Resident #1's public administrator responsible party was not notified until 11/20/23; - Resident #1 was transferred to the hospital on Missouri Department of Health and Senior Services STATE FORM bese 126511 if continuation sheet 3 of 4 PRINTED: 12/05/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED C 30774 B. WING 11/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X8) 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} BENTON HOUSE OF STALEY HILLS Continued From page 3 11/16/23 because he/she hit his/her head; ~ It is the facilities policy to send all head injuries to the hospital due to the potential for unobservable serious injury. During an interview on 11/27/23 at 4:39 P.M. the Executive Director said: - The Resident Services Director should notify him/her of resident to resident altercations; ~ Notifications should be made to the state hotline, resident physicians, and resident representatives; - Resident #1's public administrator and legal representative should have been notified of the incident and transfer on the day of the altercation. MO227711 Missouri Department of Health and Senior Services STATE FORM Bee8 1E6511 lf continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Benton House of Staley Hills Name: Street Address, oa: 11071 N Woodland Ave, Kansas City, MO 64155 City, Zip: Date of Survey: 11/27/2023 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 All staff have been informed of steps to be taken and who to notify when something happens with a resident. Staff know to contact RSD, ED, Doctor and family member- Staff | 12/12/2023 AATT8 is to document everyone that was contacted while writing the and ongoing documentation. All staff will be trained upon hire if they will be working the med cart and the steps to take when documenting on any resident 12/12/2023 A4778 ron : incidents and who has to be contacted. and ongoing ED wil! educate all staff during the monthly staff meeting on A4778 12/22/2023 and have a sign off list for staff to sign that they all 12/22/2023 understand the correct steps to notify and how to document it. and ongoing RSD/ED will review every nursing observation made previous A4778 day to ensure all correct steps were taken for documeniation 12/12/2023 and al! follow up is being done correctly and timely. and ongoing

PRINTED: 08/01/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDING: COMPLETED BWING 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (X8) (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) j BENTON HOUSE OF STALEY HILLS 19 CSR 30-86.047(13)(A) Criminal Background Check Requirements Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the person, as provided In section 660.317, RSMo. Each facility shall maintain documents verifying that the background checks were requested, the date of each such request, and the nature of the response received for each such request. I] This regulation is not met as evidenced by: Class II Based on interview and record review, facility staff failed to request a criminal background check (CBC) and document with the date of request, date received, and nature of the response for one of three newly hired staff members. The facility census was 56, Record review showed the facility did not provide | policy regarding completion of criminal background checks. 1, Record review of Level One Medication Aide (L1MA) A's personnel record showed: -A hire date of 11/4/22: -No CBC completed. During an interview on 7/19/23, at 3:12 P.M., the Administrator said: -CBC's should be completed for all employees prior to their start date; Missour Department of Health and Sentor Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNA TITLE {X8) DATE Srocudive Ditecdsr %-3-23 ba99 PDGP14 tf continuation sheet 4 of 4 STATE FORM PRINTED: 08/01/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED BWING 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (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) BENTON HOUSE OF STALEY HILLS Continued From page 1 -He was not aware CBC's had not been done for all newly hired employees. 19 CSR 30-87 .020(9) Air Ducts-Maintain Intake and exhaust air ducts shall be maintained to prevent the entrance of dust, dirt and other contaminating materials. III This regulation is not met as evidenced by: Class Ill Based on observation and interview, facility staff failed to maintain intake air vents to prevent the entrance of dust, dirt, and other contaminating materials. The facility census was 56. 1. Observation of the kitchen on 7/19/23 at 10:44 A.M. showed: -An approximately 2 foot X 2 foot intake air vent above the stand mixer corroded in dust and dirt; -An approximately 2 foot X 2 foot intake air vent above the handwashing sink corroded in dust and dirt. During an interview on 7/19/23, at 11:05 A.M. Cook A sald: -The kitchen does have a routine deep cleaning schedule; ~He/She was unsure of the last time the intake alr vents were cleaned. During an Interview on 7/19/23 at 3:41 P.M., the Administrator said: -All air vents should be kept clean and free of dust and dirt; ~He was unsure of the last time the intake air vents were cleaned, Missourl Department of Health and Senior Services STATE FORM asa9 PDGP11 H continuation shest 2 of 4 PRINTED: 08/01/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDING: COMPLETED B.WING 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x6) (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) BENTON HOUSE OF STALEY HILLS Continued From page 2 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 This regulation is not met as evidenced by: Class II* Based on record review and interview, the facility staff failed to ensure the resident, or legally authorized representative or designee, was informed of his/her rights and responsibilities at least annually for four of five sampled residents (Residents #1 #2, #3, and #4). The facility census was 56. Review showed the facility did not provide a policy regarding reviewing annual resident rights. 1. Review of Resident #1's medical record showed: -Admission date of 1/31/22) -No documentation of resident rights being reviewed with the resident, or legally authorized representative in 2022 or 2023, 2, Review of Resident #2's medical record showed: -Admission date of 4/14/22; -No documentation of resident rights being reviewed with the resident, or legally authorized representative in 2022 or 2023. Missouri Department of Health and Senior Services STATE FORM E88 PDGP11 Hf continuation sheet 3 of 4 PRINTED: 08/01/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED BWING 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11071 N WOODLAND AVE KANSAS CITY, MO 64155 (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-REFERENGED TO THE APPROPRIATE : DATE DEFIC}ENCY) BENTON HOUSE OF STALEY HILLS Continued From page 3 3. Review of Resident #3's medical record showed: -Admission date of 11/15/19; -No documentation of resident rights being reviewed with the resident, or legally authorized representative in 2022 or 2023. 4, Review of Resident #4's medical record showed: -Admission date of 12/23/22; -No documentation of resident rights being reviewed with the resident, or legally authorized representative in 2022 or 2023. During an interview on 7/19/23, at 3:12 P.M., the Administrator said: -Resident rights should be reviewed upon admission and annually; -He was not aware resident rights had not been reviewed with all residents in 2022 or 2023. *The higher classification merited due to the extent of the violation and impact when combined with other deficiencies. Missouri Department of Health and Senior Services STATE FORM e839 PDGP14 lf continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Benton House at Staley Hills Name: Street Address, . 11071 N. Woodland Ave, Kansas City MO, 64155 City, Zip: Date of Survey: 7/19/23 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG All employee files are updated. Employee in question is completed. See attachment 1-A ED will review all documentation prior to new hires starting employment. COMPLETION DATE The air ducts in question have been taken down and cleaned thoroughly. Air ducts are to be cleaned Monthly, documented, and inspected by the ED. See attachment 2-A, 2-B, and 2-C. 8/1/23 All residents and families were contacted and provided the Chapter 88 Resident Rights. All forms were signed either by residents (if own DPOA) or by family. These documents are shared every year, signed, and filed at Benton House. See attachment 3-A Residents #2 - #5 completed. Resident #1 — Deceased. All other residents completed as well. Documentation available per request. the plan of correction being submitted on this form. 8/1/23 ~ The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of