TIFFANY SPRINGS SENIOR CARE COMMUNITY.

An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 04/08/2025 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 30748N B. WING 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TIFFANY SPRINGS SENIOR CARE COMMUNIT 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. I/II This regulation is not met as evidenced by: Class II Based on record review and an interview on 10/9/24 this facility failed to have the complete fire alarm system inspected by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. The facility census was 76. This potentially affected 76 of 76 residents. Record review on 10/9/24 at 3:24 P.M. showed the last annual fire alarm system inspection was conducted on October 2, 2023. During an interview on 10/9/24 at 3:24 P.M. the Maintenance Director said he/she has contacted the fire alarm company twice and was told they are short handed and running behind. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 M48011 If continuation sheet 1 of 1

PRINTED: 01/08/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIEWCLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 4, BUILDING: (X3) GATE SURVEY COMPLETED 30745N 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSG IDENTIFYING INFORMATION} TAG CROSS-REFERENGED TO THE APPROPRIATE DATE DEFICIENCY) A2257 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class |{ Based on observation and interviews on 12/27/23, tne facility failed to ensure protection from fire hazards when the facility staff stored a gasoline filled lawnmower inside the building, outside of the kitchen entrance. This had potential to affect all residents in the building. The : facility census was 70. . An undated fire safety policy was provided but did not contain any relative information regarding fire hazards. Observation on 12/27/23 at 10:15 A.M., of the hallway outside the central kitchen showed a red Toro push lawnmower containing gas in the tank, sitting in the hallway unattended. During an interview on 12/27/23 at 10:18 A.M. Maintenance Assistant B said: -He/She was not sure who put the mower in the hallway; -He/She was unsure why the mower was left in the hallway; -He/She would ramove it from inside the building, back outside in the storage shed where it belonged. | | | Observation on 12/27/23 at 10:19 A.M. showed Maintenance Assistant B removing the lawnmower from the building and placing in the Missourl Department of Health and Sanior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X86) GATE STATE FORM anes souWwit li conlinualion shant } of 11 Oy ee \/22/24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 06/21/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED Cc 12/27/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II Based on observation and interviews on 12/27/23, the facility failed to ensure protection from fire hazards when the facility staff stored a gasoline filled lawnmower inside the building, outside of the kitchen entrance. This had potential to affect all residents in the building. The facility census was 70. An undated fire safety policy was provided but did not contain any relative information regarding fire hazards. Observation on 12/27/23 at 10:15 A.M., of the hallway outside the central kitchen showed a red Toro push lawnmower containing gas in the tank, sitting in the hallway unattended. During an interview on 12/27/23 at 10:18 A.M. Maintenance Assistant B said: -He/She was not sure who put the mower in the hallway; -He/She was unsure why the mower was left in the hallway; -He/She would remove it from inside the building, back outside in the storage shed where it belonged. Observation on 12/27/23 at 10:19 A.M. showed Maintenance Assistant B removing the lawnmower from the building and placing in the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 01/22/24 STATE FORM 6899 sSOoUW11 If continuation sheet 1 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 shed out in the courtyard. During an interview on 12/27/23 at 3:30 P.M. the Maintenance Director said: -He/She was conducting small engine maintenance inside the building. - Maintanence included assessing the facilities snow blowers and the lawn mower; -He/She would normally do maintenance on these pieces of equipment outside on the dock, but it was snowing at the time, so he brought the mower inside; -He/She was in the middle of maintenance on the lawn mower when he was called away, this is when he left it in the hallway; -He/She has has been allowed to bring the mower inside previously and was not aware he/she should not do so. During an interview on 12/27/23 at 4:30 P.M. the Executive Director said: -He did not know the facility had a lawnmower; -He was not sure why the lawnmower was inside the building; -He understands why the lawnmower should not have been in the building; -He would expect his staff to keep all unnecessary combustible materials outside of the building. 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 II Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (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 interview and record review, the facility failed to ensure the required two step tuberculosis (TB) screening test was completed prior to the first day of duty, for six of six sampled staff members (Certified Nursing Assistant (CNA) A, CNAB, Dietary Server A, Dietary Server B, Dietary Aide A, and Maintenance Assistant A). The facility census was 70. General requirements for TB testing for staff in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long Term Care Employees and Volunteers. All new long-term care facility employees and volunteers who work ten (10) or more hours per week are required to obtain a Mantoux Purified Protein Derivative (PPD) (Mantoux, TB skin test, tuberculin skin test, and PPDs are often used interchangeably. Mantoux refers to the technique for administering the test. Tuberculin (also called PPD) is the solution used to administer the test) two (2)-step tuberculin test within one (1) month prior to starting employment in the facility. If the initial test is Zero to nine millimeters (0-9 mm), the second test should be given as soon as possible within three (3) weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two (2) years. It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status. (E) Employees and volunteers with an initial zero to nine millimeters (0-9 mm) Mantoux PPD two (2)-Step test shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 11 PRINTED: 06/21/2024 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 30748N — 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE 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) TIFFANY SPRINGS SENIOR CARE COMMUNITY Continued From page 3 The facility did not provide a policy regarding staff TB Screening. 1. Record review of CNAA's personnel file showed: -Hire date of 02/06/23; -The initial step was administered on 11/27/23 and read on 11/29/23, results were negative; -The second step was administered on 12/18/23 and read on 12/2023, results were negative. 2. Record review of CNA B's personnel file showed: -Hire date of 08/07/23; -The initial step was administered on 11/15/23 and read on 11/17/23, results were negative; -The second step was administered on 12/04/23 and read on 12/06/23, results were negative. 3. Record review of the Dietary Server A's personnel file showed: -Hire date of 05/01/23; -No TB test was found for the staff member. 4. Record review of the Dietary Server B's personnel file showed: -Hire date of 09/01/23; -No TB test was found for the staff member. 5. Record review of the Dietary A's personnel file showed: -Hire date of 07/10/23; -No TB test was found for the staff member. 6. Record review of the Maintenance Assistant A's personnel file showed: -Hire date of 08/07/23: -No TB test was found for the staff member. During an interview on 12/27/23 at 4:30 P.M., the Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 If continuation sheet 4 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Executive Director said: - All employees should have had a two-step TB test completed prior to their first day on duty; - He was not aware staff member TB screenings were not completed prior to their first day on duty. 19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (1) Written statement signed by a licensed physician or physician ' s designee indicating the person can work in a long-term care facility and indicating any limitations; III This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to ensure four of six sampled staff members (Certified Nursing Assistant (CNA) A, CNAB, Dietary Server A, and Dietary Server B) had a written statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and indicating any limitations. The facility census was 70. The facility did not provide a policy. 1. Record review of CNAA's personnel file showed: -Hire date of 02/06/23; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person can work ina Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 long-term care facility and indicating any limitations. 2. Record review of CNA B's personnel file showed: -Hire date of 08/07/23; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person can work ina long-term care facility and indicating any limitations. 3. Record review of the Dietary Server A's personnel file showed: -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person can work ina long-term care facility and indicating any limitations. 4. Record review of the Dietary Server B's personnel file showed: -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the person can work ina long-term care facility and indicating any limitations. During an interview on 12/27/23, at 4:30 P.M., the Executive Director said he expected all employees to have a written and signed statement from a licensed physician or designee prior to their first day on duty. 19 CSR 30-87.030(18) Refrigerator Temperatures, Thermometers Enough conveniently located refrigeration facilities or effectively insulated facilities shall be Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 6 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 provided to assure the maintenance of potentially hazardous food at required temperatures during storage. Each mechanically refrigerated facility storing potentially hazardous food shall be provided with a numerically scaled indicating thermometer, accurate to plus or minus three degrees Fahrenheit (+3°F), located to measure the air temperature in the warmest part of the refrigerated facility and located to be easily readable. Recording thermometers, accurate to plus or minus three degrees Fahrenheit (+3°F), may be used in lieu of indicating thermometers. HT This regulation is not met as evidenced by: Class III Based on observation, record review, and interview, the facility failed to ensure placement of a thermometer in the refrigeration and freezer compartments of each refrigerator/freezer in the kitchen to maintain an acceptable food storage temperature. This had potential to affect all residents. The facility census was 70. Review of the facility's undated policy regarding refrigerator and freezer temperature checks showed: -Temperatures should have been checked twice daily at opening and closing of the department; -Temperatures were to be taken from the thermometer located inside the unit. 1. Observation of the facility's central kitchen on 12/27/23 at 10:05 A.M., showed: -The refrigerated prep station below the griddle, with raw meats and vegetables inside, had no thermometer present; -The refrigerator below the prep station had no thermometer present. Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 7 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 2. Observation of the facility's assisted living kitchen on 12/27/23 at 10:20 A.M., showed the refrigerator below the prep station had no thermometer present. 3. Observation of the facility's memory care kitchen on 12/27/23 at 11:30 A.M., showed the standing refrigerator without thermometer present, while storing dairy products. During an interview on 12/27/23 at 10:10 A.M., the Executive Chef said; -All refrigerators and freezers should have had thermometers so temperatures could be checked daily in accordance to the facility policy; -He did not realize thermometers were missing from a few of the refrigerators. During an interview on 12/27/23 at 4:30 P.M., the Executive Director said; -He expected all temperatures to be checked daily, using thermometers placed inside the refrigerator; -He was unsure why some of the facility's refrigerators did not have thermometers. 19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. III This regulation is not met as evidenced by: Class III Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 8 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 Based on observation, record review, and interviews, the facility failed to keep nonfood-contact surfaces of equipment clean free from dust, dirt, food particles, and buildup. This had potential to affect all residents. The facility census was 70. Review of the facility's undated policy regarding cleaning, showed: -Exterior of large appliances should be cleaned daily; -Shelves, and ovens should be cleaned weekly; 1. Observation of the facility's central kitchen on 12/27/23 at 10:05 A.M., showed: -Exterior of two freezer's with grime on the doors and handles; -Exterior of two food warmers with grime on the front and sides; -Exterior of the oven with grime on its surfaces; -The prep drawer doors below the griddle were covered in grime; -The ice machine exterior had grime and dust. 2. Observation of the facility's assisted living kitchen on 12/27/23 at 10:20 A.M., showed: -Bottom shelves in the prep area with dust and food particles; -The ice machine exterior with grime and dust; -Standing water with white buildup on the counter under the juice machine; -Exterior of two refrigerators with grime on the surfaces; -The sides of the fryer were covered in built up grease. During an interview on 12/27/23 at 10:10 A.M., the Executive Chef said; -The surfaces should all be wiped down daily; -All kitchen staff were expected to help keep Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 9 of 11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30748N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 TIFFANY SPRINGS SENIOR CARE COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 equipment cleaned and wiped down; -It was not acceptable for the exterior of the equipment to not be cleaned. During an interview on 12/27/23 at 4:30 P.M., the Executive Director said: -He expected all nonfood-contact surfaces to be cleaned according to the facility cleaning policy; -He expected all nonfood-contact surfaces to be kept clean and free from debris. 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 Ill Based on record review and interview, the facility failed to ensure the resident or legally authorized representative was informed upon admission and at least annually of the individual's rights and responsibilities of a resident for two of six sampled residents (Resident #1 and #2). The facility census was 70. The facility did not provide a policy regarding review of resident rights. 1. Record review of Resident #1's file showed: -Date of admission 02/18/20; Missouri Department of Health and Senior Services STATE FORM 6899 SOUW11 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 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 10 of 11 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: 30748N NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE TIFFANY SPRINGS SENIOR CARE COMMUNITY KANSAS CITY, MO 64154 PRINTED: 06/21/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 12/27/2023 (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 10 -Resident rights dated 01/28/20 was found; -No documentation of resident rights being reviewed with the resident, or legally authorized representative in 2021, 2022, or 2023. 2. Record review of Resident #2's file showed: -Date of admission 05/06/21; Resident rights dated 04/23/21 was found; -No documentation of resident rights being reviewed with the resident, or legally authorized representative in 2022 or 2023. During an interview on 12/27/23 at 4:30 P.M., the Executive Director said: -He knew resident rights should be reviewed upon admission and annually for each resident; -He did not know resident rights had not been reviewed with residents #1 and #2 since they were admitted to the facility. Missouri Department of Health and Senior Services STATE FORM 6899 souWw11 DEFICIENCY) If continuation sheet 11 of 11 PLAN OF CORRECTION Provider/Supplier | Name: Tiffany Springs Senior Living ; Street Address, Fie 9101 N Ambassador Ave, Kansas City MO 64154 City, Zip: Date of Survey: 12.27.2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE This serves as the allegation of compliance for Tiffany Springs Senior Care. Tiffany Springs Senior Care asserts that all corrections described on this Plan of Correction have been implemented. Regarding the specific deficiencies, we have outlined our corrective and continued interventions to assure compliance with regulations and our plan of action. The staff at Tiffany Springs Senior Care is committed to delivering high quality healthcare to its Residents to obtain their highest level of physical, mental, and psychosocial functioning. We respectfully submit that Tiffany Springs Senior Living is in substantial compliance as set forth below, and we are confident that we will be found in substantial compliance with regulations upon re-survey. The statements made on the Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies. Tiffany Springs Senior Care has completed the following interventions as a result of the findings from the survey exiting on 12.27.2023 A2257 Immediate actions taken for the Resident to have been affected include: The equipment was immediately removed. Identification of other Residents having the potential to be affected was accomplished by: Audit was completed on 12.27.23 of all other storage and maintenance areas to ensure that no other small engines were on the interior of the building and no combustibles were inappropriately stored. Actions taken/systems put into place to reduce the risk of future occurrence include: Maintenance and housekeeping teams re-educated on the use 12.27.23 and storage of combustibles in the building. How the corrective actions will be monitored to ensure the practice will not recur: Admin or designee will audit service hallway and maintenance shop daily for one week, then 1x/week for 4 weeks, then 1x/month for 1 month to ensure appropriate use and storage of small engines and other combustibles. The QA Committee will review this plan of correction until such a time consistent, substantial compliance has been met as determined by the QA Committee. Audit findings will be discussed by the QA Committee and monitoring will be adjusted as determined by the QA Committee. Immediate actions taken for the Resident to have been affected include: Dietary Server A, Dietary Server B, Dietary A, and Maintenance Assistant A will all have 2 step completed by 2.16.24. Identification of other Residents having the potential to be affected was accomplished by: Audit of all current staff was completed by admin on 1.12.24 to identify those missing TB immunizations and/or screening. Actions taken/systems put into place to reduce the risk of future occurrence include: All staff missing TB immunizations and/or screenings will have screening conducted and first step given by 2.2.24. Second step will be completed for all staff by 2.16.24. How the corrective actions wiil be monitored to ensure the practice will not recur: Admin or Designee will ensure each new hire meets with nurse to complete screening and receive first step prior to first shift. 2.16.24 Admin or Designee will ensure that first step is read within 72 hours of immunization. Admin Designee will review staff roster for any and all staff in need of second step or any subsequential screenings or TB immunizations in daily staffing meeting 3x/week for 4 weeks. Amin will perform a monthly audit of staff immunizations 1x/month for 3 months. Moving forward, during the month of January each year we will hold a facility wide immunization clinic. Staff will be required to attend to complete the annual TB screening and immunization as appropriate. Current staff educated on annual TB process on 1.19.23. New staff will be educated on the immunization process upon hire. The QA Committee will review this plan of correction until such a time consislenl, subslarilial Gonipliance has been met as determined by the QA Committee. Audit findings will be discussed by the QA Committee and monitoring will be adjusted as determined by the QA Committee. Immediate actions taken for the Resident to have been affected A7020 include: CNA A, CNA B, Dietary Server A, and Dietary Server B will have Physician Statement completed by 1.26.24. Identification of other Residents having the potential to be affected was accomplished by: An audit of all employee files was conducted on 1.12.24 to identify any additional personnel files that are missing physician statement documentation. Actions taken/systems put into place to reduce the risk of future occurrence include: All staff missing physician statements will have screening conducted and completed by 1.26.24, How the corrective actions will be monitored to ensure the practice will not recur: Admin or Designee will ensure each new hire meets with physician or physician's designee to complete screening prior to fist shift. Admin or Designee will review personnel files for all new hires 1x/week for 6 weeks to verify physician statements. After 6 weeks, Admin or Designee will audit all new hires personnel files 1x/month for 3 months. The QA Committee will review this plan of correction until such a time consistent, substantial compliance has been met as determined by the QA Committee. Audit findings will be discussed by the QA Committee and monitoring will be adjusted as determined by the QA Committee. 1.26.24 Immediate actions taken for the Resident to have been affected include: On 12.27.23 thermometers were placed into prep station below griddle in central kitchen, refrigerator below prep station in main kitchen, prep station below refrigerator in AL kitchen, and standing refrigerator in MC kitchen. identification of other Residents having the potential to be affected was accomplished by: All other refrigerators and refrigerated prep stations were checked to verify thermometers were placed effectively. Actions taken/systems put into place to reduce the risk of future occurrence include: Dietary staff in-serviced on the placement of thermometers and facility policy for checking and documenting temperatures each day. How the corrective actions will be monitored to ensure the practice will not recur: Admin or admin designee to audit each refrigerator 5x/week for 1 week, 4x/month for 1 month, and 1x/ month for 3 months. The QA Committee will review this plan of correction until such a | time consistent, substantial compliance has been met as 12.27.23 determined by the QA Committee. Audit findings will be discussed by the QA Committee and monitoring will be adjusted as determined by the QA Committee. A7067 A8004 Immediate actions taken for the Resident to have been affected include: The exterior of all appliances and equipment in the facilities central kitchen was cleaned on 12.27.23, The exterior of all appliances and equipment in the facilities assisted living kitchen was cleaned on 12.27.23. Identification of other Residents having the potential to be affected was accomplished by: All 3 of the facilities kitchens were inspected by Admin and Dietary Director on 1.08.24 to ensure all were neat and clean as outlined in facility policy. Actions taken/systems put into place to reduce the risk of future occurrence include: Dietary staff re-educated on the facilities daily/weekly kitchen cleaning schedule and duties. 01,08.24 How the corrective actions will be monitored to ensure the practice will not recur: Admin or designee will inspect all facility kitchens 5xAveek for 1éiveek, 1xAveek for 4 weeks, then 1x/month for 3 months. The QA Committee will review this plan of correction until such a time consistent, substantial compliance has been met as determined by the QA Committee. Audit findings will be discussed by the QA Committee and monitoring will be adjusted as determined by the QA Committee. Immediate actions taken for the Resident to have been affected include: Resident Rights were reviewed and signed with Resident #1 and Resident #2. Identification of other Residents having the potential to be affected was accomplished by: | DON, DON Designee and Admin completed an audit of all current Residents to identify any discrepancies and verified that each current Resident has had an up-to-date review of Resident Rights. 01/16/2024 Actions taken/systems put into place to reduce the risk of future occurrence include: DON and DON Designee will continue to verify completion of Resident Rights upon each new admission. DON, DON Designee and Admin will review Resident Rights with each “current Resident of DPA annually if the month of January. How the corrective actions will be monitored to ensure the practice will not recur: Admin will audit all move ins 1x/month for 12 months to ensure all new Resident Rights are reviewed and signed. An audit will be conducted each January to review and renew each Resident Rights for all Current Residents. The QA Committee will review this plan of correction until such a time consistent, substantial compliance has been met as determined by the QA Committee. Audit findings will be discussed by the QA Committee and monitoring will be adjusted as determined by the QA Committee. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 04/08/2025 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 30748N B. WING 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TIFFANY SPRINGS SENIOR CARE COMMUNIT 19 CSR 30-86.022(10)(I1) Smoke Section Partitions > than 20 beds Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class II Based on observations and interview on 7/20/23 the facility failed to ensure each door in a smoke section / area of refuge was capable of self-closing. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observations during the 7/20/23 walkthrough showed Room 1406 had a mechanical wedge blocking the door open, Room 2433 had a mechanical wedge blocking the door open and Room 3408 had a mechanical wedge blocking the door open. NOTE: These door stops could potentially prevent quick door closure and expose the evacuation corridor / Area of Refuge to smoke and fire if there was a fire within a resident's room whose door was mechanically blocked open. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 7V6Z11 If continuation sheet 1 of 5 PRINTED: 04/08/2025 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 30748N B. WING 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TIFFANY SPRINGS SENIOR CARE COMMUNIT Continued From page 1 During an interview on 7/20/23 at 10:55 A.M. the maintenance person assisting stated door hold magnets were already installed on most of the resident's doors, some were not holding like they should be and a few more rooms needed to have them installed still. Observation on 7/20/23 at 11:21 A.M. showed the fire doors on one side in the corridor by Room 2400 hanging up on the carpet preventing it from closing when released. Observation on 7/20/23 at 12:11 P.M. showed the fire doors on one side in the corridor by Room 2416 hanging up on the carpet preventing it from closing when released. Observation on 7/20/23 at 1:26 P.M. showed the fire doors on one side in the corridor by Room 3404 hanging up on the carpet preventing it from closing when released. During an interview on 7/20/23 at 12:11 P.M. the Maintenance Director stated he/she would get the bottoms of the doors shaved to prevent them from rubbing and sticking on the carpet. 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II Missouri Department of Health and Senior Services STATE FORM 6899 7V6Z11 If continuation sheet 2 of 5 PRINTED: 04/08/2025 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 30748N B. WING 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TIFFANY SPRINGS SENIOR CARE COMMUNIT Continued From page 2 This regulation is not met as evidenced by: Class II Based on observations, interviews and record review on 7/20/23 the facility failed to ensure the monthly pressure gage readings and valve position checks of the sprinkler system was done as required in accordance with NFPA 13, 1999 edition. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observations during the 7/20/23 walkthrough showed monthly sprinkler valve and pressure gage checks being done at all the sub risers in the stairwells, but not at the main risers in the riser room. Record review on 7/20/23 at 2:37 P.M. showed documentation of monthly riser checks printed off from tells for the main riser, but know pressure readings were recorded. During an interview on 7/20/23 at 2:37 P.M. the Maintenance Director stated he/she would set up a clip board in the main riser room to properly record and compare the pressure gauge readings from month to month. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview on 7/20/23 Missouri Department of Health and Senior Services STATE FORM 6899 7V6Z11 If continuation sheet 3 of 5 PRINTED: 04/08/2025 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 30748N B. WING 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TIFFANY SPRINGS SENIOR CARE COMMUNIT Continued From page 3 the facility failed to insure all the wastebaskets were the approved types allowed. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observations during the 7/20/23 fire safety inspection walk through non-approved wastebaskets were found in the following rooms; In Room 1403 had two wastebaskets, Room 1425 had one wastebasket, Room 1440 had one wastebasket, Room 1430 had two wastebaskets, Room 2401 had two wastebaskets, Room 2408 had two wastebaskets, Room 2411 had three wastebaskets, Room 2414 had three wastebaskets, Room 2426 had two wastebaskets, Room 2430 had one wastebasket, Room 2419 had one wastebasket, Room 2416 had one wastebasket, Room 3407 had one wastebasket, Room 3408 had one wastebasket, Room 3404 had two wastebaskets, Room 4404 had three wastebaskets, Room 4411 had one wastebasket, and Room 4413 had two wastebaskets. During an interview on 7/20/23 at 11:41 A.M. with the maintenance director he/she said he/she would arrange to get the proper ones and work with housekeeping to be able to identify the non-approved types. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III Missouri Department of Health and Senior Services STATE FORM 6899 7V6Z11 If continuation sheet 4 of 5 PRINTED: 04/08/2025 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 30748N B. WING 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9101 N AMBASSADOR DRIVE KANSAS CITY, MO 64154 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TIFFANY SPRINGS SENIOR CARE COMMUNIT Continued From page 4 This regulation is not met as evidenced by: Class III Based on observation and interview on 7/20/23 the facility failed to ensure oxygen was stored as required in accordance with NFPA 99, 1999 Edition. The facility census was seventy (70). This potentially affected seventy (70) of seventy (70) residents. Observation on 7/20/23 at 11:01 A.M. showed four spare oxygen bottles and one in use, in Room 1403. Observation on 7/20/23 at 11:32 A.M. showed seven spare oxygen bottles, one in use and a concentrator in Room 2406. Observation on 7/20/23 at 1:29 P.M. showed an unracked spare oxygen bottle free standing in Room 3401. During an interview on 7/20/23 at 1:29 P.M. the maintenance director stated he/she would get the excess oxygen bottles in the resident's rooms moved to the oxygen storage closet, be sure all spare bottles in the residents rooms were properly racked and would be sure to let staff know only one bottle in use and one spare bottle is permitted in a resident ' s room. Missouri Department of Health and Senior Services STATE FORM 6899 7V6Z11 If continuation sheet 5 of 5