HIGHLAND CREST ASSISTED LIVING.

THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) PRINTED: 10/29/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 16785C — 10/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) HIGHLAND CREST ASSISTED LIVING 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shail inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. Wil This regulation is not met as evidenced by: Class Il Based on record review, and interview the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was nineteen (19). This affected nineteen (19) of nineteen (19) residents. Record review on 10-27-2025, at 12:30 P.M., showed on the annual sprinkler system report dated, 7-22-2025 stating that the system was due for their 5 year internal inspection. The last 5 year internal inspection was completed in August 2020. During an interview on 10-27-2025 at 12:30 P.M. with the administrator,she stated she was going to call and get on the schedule to get the 5 year inspection completed. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE STATE FORM 6898 XKO7 lf continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 16785C NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 10/29/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED 10/27/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET HIGHLAND CREST ASSISTED LIVING KIRKSVILLE, MO 63501 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/Ill This regulation is not met as evidenced by: Class Hl Based on observation and interview during the fire safety inspection process, the facility failed to ensure only one appliance shail be connected to one extension cord and only two electrical appliances may be served by one duplex receptacie. The facility also failed to ensure appliances were directly plugged into the wall outlet. Facility census was nineteen (19). This affected nineteen (19) of nineteen (19) residents. Observation on 10-27-2025 starting at 11:00 A.M. through 12:30 P.M. showed the following: -1 two-way adapter with multiple items plugged into it being used in resident room #D5 -2 a power strip with mini fridge plugged into it in resident room #D6 -3 a power strip with a coffee pot and microwave plugged into it in resident room #A3 During an interview on 10-27-2025 at 12:30 P.M. with the administrator, she stated she would get those iterns removed and/or plug items directly into the wall. Missouri Department of Health and Senior Services STATE FORM 899 XKO711 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 2 of 2

PRINTED: 05/06/2024 ; ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 16785C B. WING 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 HIGHLAND CREST-ASSISTED LIVING BY AMEi (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 LSC IDENTIFYING INFORMATION} TAG i CROSS-REFERENCED TO THE APPROPRIATE : DATE DEFICIENCY) H A4724 19 CSR 30-86.047(19) TB Screen Residents & A4724 Staff The facility shall sereen residents and staff for tuberculosis as required for long-term care | facilities by 18 CSR 20-20,100. Il This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to ensure a two-step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) test was completed as required upon hire for four of five sampled employees i (Maintenance Director, Certified Medication Technician (CMT) A, Housekeeper B and Housekeeper (C). The facility census was 20. i t i The general requirements for TB testing for ; employees in Long-Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their staff for tuberculosis using the Mantoux method PPD five tuberculin unit test. Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained; , ~All employees are required to obtain Mantoux | PPD two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given within one to three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; and ~Employees with an initial zero to nine millimeters TB two-step test shalf have one step tuberculin testing annually and the results recorded ina Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X6} OATE sty 05.14. 24 STATE FORM 6ang 76S8J11 If continuation sheet 1 of 4 PRINTED: 05/06/2024 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 16785C B. WING 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES i ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) : AG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) HIGHLAND CREST-ASSISTED LIVING BY AME: A4724| 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. Il This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to ensure a two-step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) test was compieted as required upon hire for four of five sampled employees (Maintenance Director, Certified Medication Technician (CMT) A, Housekeeper B and Housekeeper C). The facility census was 20. The general requirements for TB testing for employees in Long-Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their staff for tuberculosis using the Mantoux method PPD five tuberculin unit test. Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained; -All employees are required to obtain Mantoux PPD two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given within one to three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years: and -Employees with an initial zero to nine millimeters TB two-step test shali have one step tuberculin testing annually and the results recorded in a Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {X6) DATE NUNS EI En NT NTO vee STATE FORM 6899 ZGSJ11 if continuation sheet 1 of 4 PRINTED: 05/06/2024 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 16785C B.WING 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID i PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL : PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 1 TAG i CROSS-REFERENCED TO THE APPROPRIATE DATE HIGHLAND CREST-ASSISTED LIVING BY AMEi DEFICIENCY) Continued From page 1 permanent record. Review of the facility policy, Employee TB Testing, undated, showed the following: -It is the Administrator's responsibility to assure | the TB test is administered and results read prior | to an employee beginning employment, and to | assure annual testing is completed; -Purpose: To assure that employees have been tested for tuberculosis prior to working and do not have active disease along with annual surveillance in order to be in compliance with state regulations; -All prospective employees will have the first TB test administered prior to day 1 of employment. The TB test result may be read on the first day of employment. Review of the facility's employee handbook, dated January 2020, showed the following: -TB Testing: -All new employees, including temporary staff and volunteers, who come in contact with residents must be screened for TB; -TB screening may be conducted on a continuing basis throughout employment according to corporation standards or state requirements. 1. Review of the Maintenance Director's employee file showed the following: -Hire date: 01/16/23; -First contact date: 01/16/23; -TB first step date: 01/17/23; -TB first read and result date: 01/19/23 (three days after first date of resident contact). Review of CMT A's employee file showed the following: -Hire date: 09/08/23; -First contact date: 09/08/23; Missouri Department of Health and Senior Services STATE FORM 6899 ZGSJ11 If continuation sheet 2 of 4 PRINTED: 05/06/2024 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 16785C B.WING 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION {X5} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL H (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE DATE i i DEFICIENCY) HIGHLAND CREST-ASSISTED LIVING BY AME: Continued From page 2 -TB first step date: 09/08/23; -TB first read and result date: 09/11/23 (three days after first date of resident contact). Review of housekeeper B's employee file showed the following: -Hire date: 04/15/24: -First contact date: 04/15/24; -TB first step date: 04/19/24: -TB first read and result date: 04/22/24 (seven days after first date of resident contact). Review of housekeeper C’s employee file showed the following: -Hire date: 03/29/24. -First contact date: 03/29/24. -TB first step date: 03/29/24; -TB first read and result date: 04/01/24 (three days after first date of resident contact). During an interview on 04/23/24 at 4:30 P.M., the Director of Nurses (DON) said the following: -The first day of orientation is the first day of compensation; -The first TB test is administered on the first day of orientation; -New employees come into the facility for orientation; -She was not aware that the first TB test had to be read by the first date of compensation/date of orientation. During an interview on 04/23/24 at 4:30 P.M., the assistant administrator said the following: -She was not aware that the TB test had to be done and read prior to an employee being in the facility or having contact with the residents. During an interview on 04/30/24 at 1:45 P.M., the administrator said the following: Missouri Department of Health and Senior Services STATE FORM 6899 768311 ff continuation sheet 3 of 4 PRINTED: 05/06/2024 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 16785C B.WING 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID i PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREEX | {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS-REFERENCED TO THE APPROPRIATE DATE : i DEFICIENCY) HIGHLAND CREST-ASSISTED LIVING BY AME! Continued From page 3 -The DON is responsible for obtaining the two-step TB tests for new employees; -The DON is responsible for reading the results of the two-step TB tests for new employees; -She was not aware that new employees had been in contact with residents prior to the first TB test being completed and read: -She was not aware that the facility policy indicated that the administrator was responsible “to assure the TB test is administered and results read prior to an employee beginning employment, and to assure annual testing is completed"; -lt was her expectation that the first TB test be completed prior to the first contact with residents, and that a second TB test be completed within 30 days of hire. Missouri Department of Health and Senior Services STATE FORM 6899 Z2GS8J11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: | Highland Crest- Assisted Living by Americare Street Address, City, Zip: | 2204 South Halliburton Street, Kirksville, MO 63501 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER REF ID PREFIX TAG PROVIDER’ PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) aie ION The filing of this plan of correction does not constitute any admission of the facility regarding the alleged violation stated in the summary Statement of Deficiencies dated May 6, 2024 by the Department of Health and Senior Services. This plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. On the initial employment offer date, the DON or assigned designee will administer the first step test of the two-step (Mantoux Method). After a minimum of seventy-two hours and a negative TB test result, the new employee will be allowed to begin their on-site orientation and first day of compensation. The DON wiil conduct the second part of their TB testing one to three weeks after the new employee's first day and ensure that test result is negative as well. Annual TB testing and result determination for all employees will be conducted by the DON and monitored by the Administrator on an on-going basis. A4724 05/15/2024 TO prevent reoccurrence, a systemic onboarding change has been made beginning May 15, 2024 to ensure compliance. Upon an offer being made to the new hire, the DON will conduct a TB test and complete an orientation schedule. The first date of on-site orientation will be scheduled for seventy-two hours after the first step of the initial administration of the TB test to ensure the DON can determine a negative TB result prior to beginning their orientation and training. The Administrator will hoid an in- service on the new TB timing policy for all administrative staff including but not limited to the DONs and the Assistant Administrator. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approvai of the plan of correction being submitted on this form.

PRINTED: 12/14/2023 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 16785C B. WING 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE ere REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE HIGHLAND CREST-ASSISTED LIVING BY AMERICARI 19 GSR 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. |/H This regulation is not met as evidenced by: Class 1I. Based on observation and interview on 11/30/23, the facility failed to prohibit the storage of unnecessary combustible materials in any part of a building in which a licensed facility is located. The census was nighteen (19). This deficiency affects nineteen (19) of nineteen (19). Observation on 11/30/23 from 11:13 a.m. to 11:30 a.m. found the storage in the front hallway and back hallway closets had combustible materials placed directly next to the water heaters. During Interview on 11/30/23 at 12:15 p.m.: the maintenance director stated he would remind everyone of the clearance required and work on moving the items. 19 CSR 30-86.032(23)} Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. E/N This regulation is not met as evidenced by: Class lll. Based on observation and interview on 11/30/23, facility fails to keep rooms neat and orderly. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REP. Conad NTATIVE'S SIGNATURE TITLE (X6) DATE dratec 12.21.2023 8899 IZ1S11 If continuation sheet 1 of 2 STATE FORM PRINTED: 12/14/2023 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 16785C BWINGO 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2204 SOUTH HALLIBURTON STREET KIRKSVILLE, MO 63501 (<4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %s) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE adil TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE HIGHLAND CREST-ASSISTED LIVING BY AMERICAR! Continued From page 1 Facility census was nineteen (19). This deficiency affects nineteen (19) of nineteen (19) residents. Observation on 11/30/23 at 11:30 showed room D8 with an excessive amount of items that covered roughly 65% of the room causing a high fuel load as well as hindering the path of egress in an emergency situation. Resident did state, she'd been getting rid of some items. Interview on 11/30/23 at 12:15 p.m. with the maitenance director and administrator, stated they would work with her to get some other storage ideas and items moved. . Missouri Department of Health and Senior Services STATE FORM Sees 1z1814 if continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name; Kirksville Residential, LLC d/b/a Highland Crest assisted living by Americare Street Address, City, Zip: 2204 South Halliburton Street Kirksville, MO 63501 Date of Survey: 11/30/2023 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 The filing of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the summary Statement of Deficiencies dated December 14, 2023 by the Missouri Department of Public Safety, Division of Fire Safety. This plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. jA2257 | 19 CSR30-86.022(10(B) ss C:~—“*‘s*SCSCSCCC*dSCONSCSCSCSSC‘(CX Administrator will re-educate staff on importance of appropriate storage of all combustible material with specific focus directed to 12/28/2023 water heaters/storage closets. Designated staff will complete a complete building wide cioset/storage “reset” discarding unnecessary combustible items and providing adequate clearance from water heaters. Assistant | 12/28/2023 Administrator will conduct weekly rounds to prevent reoccurrence. Administrator will re-educate staff on the importance of keeping A3224 resident rooms neat, orderly and clean. Additionally, staff will be re-educated on importance of keeping the path of egress clear at all times. Administrator spoke to resident regarding a plan to clean, store and manage items thru the utilization of under bed storage bins, ridding room of unnecessary accumulated items and the possibility of using an off- site storage unit if necessa Designated staff will assist resident with sorting and storing items in room using appropriate options and removing any unnecessary combustible items. Staff will also prepare and deliver any items to be placed in off- site storage. Director of Nursing will monitor all rooms on an on-going basis to assure compliance. 12/28/2023 12/06/2023 01/02/2024 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.