WEXFORD PLACE ASSISTED LIVING AND MEMORY SUPPORT BY SENIOR STAR.

PRINTED: 10/21/2025 FORM APPROVED Missouri Department of Health and Senior Services _ STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION —_ {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B. WING 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64154 (x4) 1D "SUMMARY STATEMENT OF DEFICIENCIES i PROVIDER'S PLANOF CORRECTION =| aX) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | comPLere TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE DATE : DEFICIENCY) WEXFORD PLACE ASSISTED LIVING AND MEMORY £ A4714) 19 CSR 30-86.047(13)(B) EDL Inquiry 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 empicyees hired ’ through or contracted from an employment | agency, the employment agency shall, prior to i sending a temporary employee to 2 facility: : (B) Make an inquiry te the depariment, as _ provided in section $60.375, RSMo, as to { whether the person is listed on the EGL. Each | facility shall maintain documents verifying that the ; EDL checks were requested, the date of each : such request, anc the nature of the response received for each such request. The inauiry may be made through the department's website; [All This regulation is not met as evidenced by: | Class H* | Based on interview and record review, the facility | failed to make an inquiry to the department i whether a person was listed on the Employee : Disqualification List (EDL) and document such ‘ requests, prior to allowing two of five sampled - employees (Medication Partner A and Cook A) to have contact with residents. The facility census | was 82, | The facility did not provide a policy regarding EDL | checks. : 1, Review of Medication Partner A's personnel record showed: -A hire date of 07/04/25; -His/Her first date of contact with residents indicated by his/her first clock in, was on 07/04/24; . “An EDL check was not requested until 07/12/24, Missouri Department of Health and Senior Services SV ALLOV ALAN PRESENTATIVE'S SIGNATURE TITLE (X6) DATE t f] ; WAVY A uy ____ Eaterim Administrator __-10/3'/goas STATE FORM va 6698 3CXB14 if continualloh sheet 1 of 2 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 WEXFORD PLACE ASSISTED LIVING AND MEMORY ¢ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 10/21/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 10/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4714 19 CSR 30-86.047(13)(B) EDL Inquiry 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: (B) Make an inquiry to the department, as provided in section 660.315, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department 's website; II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to make an inquiry to the department whether a person was listed on the Employee Disqualification List (EDL) and document such requests, prior to allowing two of five sampled employees (Medication Partner A and Cook A) to have contact with residents. The facility census was 82. The facility did not provide a policy regarding EDL checks. 1. Review of Medication Partner A's personnel record showed: -A hire date of 07/04/25: -His/Her first date of contact with residents indicated by his/her first clock in, was on 07/04/24; -An EDL check was not requested until 07/12/24, Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 3CXB11 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: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 WEXFORD PLACE ASSISTED LIVING AND MEMORY ¢ (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 after the employee had already begun having contact with residents. 2. Review of Cook A's personnel record showed: -A hire date of 11/25/24: -No EDL check was found. During an interview on 10/08/25, at 1:45 P.M., the Administrator said: -He/She did not realize Medication Partner A's EDL check was completed after he/she had already begun contact with residents; -He/She did not realize there was no EDL on file for Cook A; -He/She expected all staff to have an EDL check completed and in their file prior to their first day of employment. *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 3CXB11 PRINTED: 10/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Nanna? Wexford Place Assisted Living and Memory Support Street Address, City, Zip: 6460 N. Cosby Ave Kansas City MO 64151 October 8, 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 28861 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Fo What corrective actions will be accomplished: P EDL inquiry submitted via the DHSS portal confirming the individual was not listed. Documentation of the EDL result was placed in the employee’s personnel file Measures that will be put into place or systematic changes to ensure that the deficient practice does not reoccur: | Date of Survey: 10/15/25 HR Specialist and hiring managers trained on the EDL process for onboarding and new hires. Refresher training will be provided annually or with regulation changes. Include a checklist item for EDL verification in onboarding documentation. Mandatory EDL verification confirmed and documented prior to any associate having contact with residents. a How you will identify other residents having the potential to be affected by the same deficient practice: PF EDL inquiry submitted via the DHSS portal for all associates. Documentation reviewed by Administrator. a How the Facility plans to monitor its performance to make sre thatsoutone resumed. | sure that solutions are sustained. eae. Community to implement monthly EDL checks for all associates every month for the first 4 months then quarterly thereafter. HR Specialist to conduct monthly audits of personnel files. Audited results will be reviewed quarterlt by the Administrator/Quality Assurance Committee. Any descripencies will be addressed immediately and documented 10/15/25 And Ongoing 10/17/25 10/17/25 And Ongoing PRINTED: 02/04/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING: (X3)} DATE SURVEY COMPLETED R 12/03/2025 28861 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NAME OF PROVIDER OR SUPPLIER WEXFORD PLACE ASSISTED LIVING AND MEMORY & A8025' 19 CSR 30-88.010(25) Report A/N fo 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 adrninistrator 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 | shail immediately report or cause a report to be made to the department and to the Deparimnent of | Mental Health. Il This regulation is not met as evidenced by: Class Hl Based on interview and record review, the facility failed fo immediately report or cause a report to the Department of Health and Senior Services (DHSS) upon having reasonable cause to suspect one resident (Resident #1) had been subjected to verbal abuse by Care Partner (CP) A. The facilily census was 85. Review of the facility's Abuse and Neglect policy revised on 07/24/24 showed: -The facility had a zero tolerance for resident mistreatment or abuse; -All allegations of mistreatment would be investigated; -Abuse was defined as any intentional act that could cause harm to a resident. Review of the facility's policy titled "Reporting of Pertinent Information" dated 11/28/18 showed: Missouri Department of Health and Senjor Services LABORATORY DIRKCFOR'S OR PROYJZER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE AS NN A deny Sony “He? STATE FORM 6593 3CXB12 tf continuation sheet 1 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: PRINTED: 02/04/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED R 12/03/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 WEXFORD PLACE ASSISTED LIVING AND MEMORY ¢ (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 Mental Health. I/II This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to immediately report or cause a report to the Department of Health and Senior Services (DHSS) upon having reasonable cause to suspect one resident (Resident #1) had been subjected to verbal abuse by Care Partner (CP) A. The facility census was 85. Review of the facility's Abuse and Neglect policy revised on 07/24/24 showed: -The facility had a zero tolerance for resident mistreatment or abuse; -All allegations of mistreatment would be investigated; -Abuse was defined as any intentional act that could cause harm to a resident. Review of the facility's policy titled "Reporting of Pertinent Information" dated 11/28/18 showed: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM bae9 3CXB12 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A8025 TITLE (X6) DATE If continuation sheet 1 of 5 PRINTED: 02/04/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WEXFORD PLACE ASSISTED LIVING AND MEMORY ¢ Continued From page 1 -All employees were to immediately report any situation that could result in harm to another person to his/her supervisor; -Written reports of any significant and/or unusual actions/reactions affecting the mental/physical condition/stability of each resident was to be maintained; -A significant event included suspected or confirmed abuse; -The Administrator was to be immediately notified if there was suspected or confirmed abuse. Review of the facility's investigation dated 11/17/25 showed: -The Administrator was notified on 11/16/25 at 10:30 P.M. by CP B of CP A using inappropriate language towards Resident #1, and shared the video of the interaction he/she was referring to; -On 11/17/25 CP B provided a written statement to the Administrator of the event that was being reported; -CP A was suspended on 11/17/25 pending investigation; -The Administrator collected statements from CP A and other staff through the investigation; -The Administrator caused a report on 11/18/25 at 12:47 A.M. to DHSS of the abuse allegations; -The Administrator's investigation confirmed the allegations of inappropriate language from CP A, and terminated CP A on 11/20/25. Review on 11/25/25 at 11:46 A.M. of the undated video of the reported incident on showed: -Only audio, as the video phone that captured the video was placed in CP B's pocket; -Resident #1 can be heard asking for help repeatedly, at which time CP A responds to the resident with "shut the fuck up", "don't say shit else to us", "shut up", "shut up"; -Resident #1 can be heard still grumbling in the Missouri Department of Health and Senior Services STATE FORM 6899 3CXB12 If continuation sheet 2 of 5 PRINTED: 02/04/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WEXFORD PLACE ASSISTED LIVING AND MEMORY ¢ Continued From page 2 background, and CP A stated, "| don't want to be here because you are here", at which time Resident #1 apologized saying "I'm sorry I'm here": -CP A goes on to say "I should go get another resident, and let him/her have at you", in which Resident #1 did not respond; -CP B suggested getting the resident in the shower to clean him/her up, and CP A said, "We are not doing a shower, the resident would end up on the floor, and CP A would say he/she just fell”. 1. Review of Resident #1's record showed diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), depression, failure to thrive, and mild cognitive impairment. During an interview on 11/25/25 at 1:23 P.M. Resident #1 said he/she had no memory of staff yelling or cursing at him/her and questioned if that had happened. During an interview on 12/01/25 at 11:15 A.M. CP A said: -He/She never yelled or cursed at any residents, including Resident #1, and unsure why others would say that he/she had; -He/She said it was never okay to yell or curse at a resident; -He/She had not witnessed other staff abusing or neglecting a resident, but knew to report immediately if he/she had. During an interview on 11/25/25 at 12:20 P.M. Medication Partner A said: -He/She had heard CP A tell Resident #1 to "shut Missouri Department of Health and Senior Services STATE FORM 6899 3CXB12 If continuation sheet 3 of 5 PRINTED: 02/04/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED R 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WEXFORD PLACE ASSISTED LIVING AND MEMORY ¢ Continued From page 3 up"; -He/She never reported this cursing to management; -Yelling and cursing at residents would be considered abuse, and he/she should have reported anytime he/she witnessed CP A yell and curse at the resident; -There was a in-servicing completed in the last week, but he/she could not recall what was said about abuse and neglect. During an interview on 11/25/25 at 11:46 A.M. the Administrator said: -Without seeing a face in the video, he/she recognized CP A's voice, as well as Resident #1 to confirm that was who was involved; -The video was recorded on 09/27/25 but was not brought to his/her attention until 11/16/25; -CP B claimed to not immediately report in fear of retaliation from CP A; -Upon initially watching the video himself/herself, he/she thought the language CP A used towards Resident #1 was extremely inappropriate and did not align with the facility's policies; -He/She conducted his/her investigation on 11/17/25, but did not report to DHSS until 11/18/25; -He/She did not report until 11/18/25, because while the language was inappropriate it was not until interviewing other staff that he/she felt this might not be a one time incident, and ultimately reported to DHSS because CP A's verbiage towards Resident #1 was negligent; -He/She expected all residents to be treated with respect, which did not include being yelled or cursed at; -He/She expected all staff to report any incidents of abuse or neglect immediately for investigation; -He/She had begun in-servicing with all staff but had only in-serviced a some of the staff. Missouri Department of Health and Senior Services STATE FORM 6899 3CXB12 If continuation sheet 4 of 5 PRINTED: 02/04/2026 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: ee COMPLETED R 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6460 NORTH COSBY AVENUE KANSAS CITY, MO 64151 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WEXFORD PLACE ASSISTED LIVING AND MEMORY ¢ A8025 Continued From page 4 MO259387 Missouri Department of Health and Senior Services STATE FORM 6899 3CXB12 If continuation sheet 5 of 5 THE PLAN OF CORRECTION WAS REJECTED AND NEVER APPROVED, THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)