NORTERRE.

PRINTED: 03/12/2026 FORM APPROVED Missouri Department of Health and Senior Services 3) DATE SURVEY STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION COMPLETED AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 03/05/2026 31005N B- WING STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE cp LIBERTY, MO 64068 NAME OF PROVIDER OR SUPPLIER PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A4797 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Wl This regulation is not met as evidenced by: Class || Based on observation, interview, and record review the facility failed to ensure all residents' medications were administered in accordance to physician's instructions when Certified Medication Technician (CMT) A administered medication to two of five sampled residents (Resident #1 and Resident #2) outside the allotted time frame of one hour before and one hour after the Missouri Department of Health and Senior Services IDER/SUPPLIER REPRESENTATIVE'S SIGNATURE If continuation sheet 425511 PRINTED: 03/12/2026 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 31005N — 03/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 (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) NORTERRE A4797 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if nota physician or a licensed nurse, shall be a certified medication technician or level | medication aide. IAI This regulation is not met as evidenced by: Class II Based on observation, interview, and record review the facility failed to ensure all residents’ medications were administered in accordance to physician's instructions when Certified Medication Technician (CMT) A administered medication to two of five sampled residents (Resident #1 and Resident #2) outside the allotted time frame of one hour before and one hour after the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 425511 If continuation sheet 1 of 5 PRINTED: 03/12/2026 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 31005N — 03/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 (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) NORTERRE Continued From page 1 prescribed time. The facility census was 53. The facility did not provide a policy regarding medication administration time frames. 1. Review of Resident #1's record showed diagnoses included diabetes (a chronic, manageable metabolic condition characterized by high blood sugar levels), high blood pressure, cognitive communication deficit, gastroesophageal reflux disease. (GERD - a chronic, more severe form of acid reflux occurring when stomach acid frequently flows back into the esophagus, irritating its lining), anxiety, depression, and general weakness. Review of the resident's March 2026 Physician's Order Sheet (POS) showed: -Ordered on 01/14/26, Bumetanide (medication used for fluid retention) 1 milligram (mg) once every Tuesday, Thursday, Saturday, and Sunday at 8:00 A.M.; -Ordered on 03/28/24, Calcitriol (medication used for endocrine support) 0.25 micrograms (mcg) once daily at 8:00 A.M.; -Ordered on 01/13/26, Glipizide (medication used for diabetes) 10 mg once daily at 8:00 A.M.; -Ordered on 03/28/24, Isosorbide Mononitrate (medication used for high blood pressure) 30 mg once daily at 8:00 A.M.; -Ordered on 07/19/25, Lorazepam (medication used for anxiety) 0.5 mg once daily at 8:00 A.M.; -Ordered on 05/14/25, Metamucil (medication used for constipation) one packet once daily at 8:00 A.M.; -Ordered on 03/28/24, Thiamine (supplement) 100 mg once daily at 8:00 A.M.; -Ordered on 03/07/25, Vitamin D3 (supplement) 250 mcg once daily at 8:00 A.M.; -Ordered on 06/20/25, Buspirone (medication Missouri Department of Health and Senior Services STATE FORM 6899 425511 If continuation sheet 2 of 5 PRINTED: 03/12/2026 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 31005N — 03/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 (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) NORTERRE Continued From page 2 used for anxiety) 10 mg twice daily at 8:00 A.M. and 8:00 P.M.; -Ordered on 05/10/24, Carvedilol (medication used for high blood pressure) 25 mg twice daily at 8:00 A.M. and 8:00 P.M.; -Ordered on 05/28/25, Docusate Sodium (medication used for constipation) 100 mg twice daily at 8:00 A.M. and 8:00 P.M.; -Ordered on 01/08/25, Omeprazole (medication used for GERD) 20 mg twice daily at 8:00 A.M. and 8:00 P.M.; -Ordered on 03/27/24, Hydralazine (medication used for high blood pressure) 100 mg three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M.. Observation of a medication pass on 03/05/26 at 10:47 A.M. showed CMT A prepared and administered the resident's 8:00 A.M. medications to the resident. 2. Review of Resident #2's record showed diagnoses included osteoarthritis (chronic joint disease, where protective cartilage cushioning the ends of bones wears down over time), altered mental status, anxiety, depression, and general weakness. Review of the resident's March 2026 POS showed: -Ordered on 07/12/25, Furosemide (medication used for swelling) 40 mg once daily at 8:00 A.M.; -Ordered on 09/23/25, Potassium Chloride (supplement) 10 meq once daily at 8:00 A.M.; -Ordered on 07/12/25, Tramadol (medication used for pain) 50 mg once daily at 8:00 A.M.; -Ordered on 05/16/25, Enalapril Maleate (medication used for high blood pressure) 5 mg twice daily at 8:00 A.M. and 8:00 P.M.; -Ordered on 05/14/25, Voltaren External Gel 1% (topical cream used for pain) 2 grams applied Missouri Department of Health and Senior Services STATE FORM 6899 425511 If continuation sheet 3 of 5 PRINTED: 03/12/2026 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 31005N — 03/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 (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) NORTERRE Continued From page 3 topically twice daily at 8:00 A.M. and 8:00 P.M.; -Ordered on 07/01/25, Acetaminophen (medication used for pain) 100 mg three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M.. Observation of a medication pass on 03/05/26 at 11:16 A.M. showed CMT A prepared and administered the resident's 8:00 A.M. medications to the resident. During an interview on 03/05/26 at 11:20 A.M. CMT A said: -He/She usually worked night shift, but helped out on the day shift once a week; -He/She usually had time to pass all medications on time, but he/she got busy this morning; -Resident #1 and Resident #2 like to sleep in and wake up late, which was why they had not got heir medications yet; -He/She was expected to pass medication within the alotted time frame, one hour before and one hour after the prescribed time. During an interview on 03/05/26 at 3:00 P.M. the Administrator said: -He/She expected all medications to be passed in accordance to the physician's orders; -He/She expected all medications to be passed within the alotted time frame, one hour before and one hour after the prescribed time; -He/She was unaware Resident #1 and Resident #2's medications were passed late; -He/She knew Resident #1 and Resident #2 liked to sleep in, and had not thought to consult with their doctors to change the administration times to meet their liking; -He/She expected medication staff to get a nurse to assist in finishing a medication pass if they felt they were not going to complete the pass within the alotted time. Missouri Department of Health and Senior Services STATE FORM 6899 425511 If continuation sheet 4 of 5 PRINTED: 03/12/2026 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 31005N — 03/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 (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) NORTERRE Missouri Department of Health and Senior Services STATE FORM 6899 425511 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Name: Norterre The laurel Street Address, | 55.89 Norterre Circle Liberty, MO 64068 City, Zip: Date of Survey: 3/5/2026 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 Resident #1 and Resident #2 were immediately assessed to ensure no adverse effects occurred related to the late ma ag 3/05/2026 medication administration. No negative outcomes were identified. The attending physician and pharmacy were notified of the 3/05/2026 medication administration timing variance. Orders were reviewed to determine whether medication administration times required modification based on resident 3/9/2026 routines and preferences. MARs for Resident #1 and Resident #2 were reviewed to confirm ail subsequent medications were administered within the 3/13/2026 required time frame Certified Medication Technician (CMT) A received immediate re- education from Admin regarding procedures to follow if medication pass cannot be completed within the required time 3/5/26 frame. | The Administrator and Licensed Nurse conducted a 100% audit of all resident MARs for the previous 7 days to determine if any additional medications were administered outside the allowable 3/16/26 administration window. The facility also reviewed medication administration practices for all residents to ensure medication administration times align with resident routines when possible, ensuring a liberalized medication | The facility revised orders and reimplemented a liberalized medication administration policy defining that medications must be administered within one hour before or one hour after the 3/20/26 | scheduled administration time, unless otherwise ordered by the physician. All medication administration staff (CMTs and nurses) will receive mandatory in-service training on medication timing requirements, procedures to follow if medication administration is delayed 3/27/26 And escalation procedures when assistance Is needed during medication pass The Director of Nursing or designee will complete weekly MAR audits for four weeks, then monthly audits for two months, reviewing medication administration times to ensure compliance with the allowable administration window. Audit results will be reported to the Administrator and reviewed during the facility's Quality Assurance and Performance 3/27/26 3/27/26 3/27/26 and corrective action as appropriate 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: 12/11/2024 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 31005N B. WING 11/26/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 NAME OF PROVIDER OR SUPPLIER NORTERRE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4755. 19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements : The facility may admit or retain an individual for : residency in an assisted living facility only if the ‘ individual does nat require hospitalization or : skilled nursing placement as defined in this rule, and only if the facility: (H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident "s condition which may require a change in services; Il This regulation is not met as evidenced by: Class II Based on interview and record review the facility failed to ensure Individual Service Plans (ISP) were reviewed when there was a significant ; change in a resident's condition which may have | required a change in services, for three of five | sampled residents (Resident #1, #2, and #3). The i facility census was 48. Review of the facility's “Fall” policy dated 06/21/21 showed: -Following any falis, the facility staff were to completed an occurrence report which included details of the fall and potential causal factors identified and investigated: -Interventions were to be implemented and the ISP updated. 1. Review of Resident #1's record showed: -He/She was admitted to the facility on 02/27/24; -Diagnoses included compression fracture (a type of broken bone that occurs when pressure ; causes a bone to collapse) of fourth lumbar ' vertebra (bones in back), repeated falls, . Alzheimer's (a brain disorder that causes the Missouri Department of Health and Senior LABORATORY DIRECTOR'S OR PRO Services STATE FORM $1Pu11 If continuatian sheet 1 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31005N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2580 NORTERRE CIRCLE NORTERRE LIBERTY, MO 64068 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 gradual destruction of memory and thinking skills), muscle weakness, unsteadiness on feet, dementia (a general term for a range of neurological conditions that cause a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life), and vertigo (dizziness). Review on 11/26/24 of the facility's fall report for the last 90 days showed: -Resident #1 experienced a fall on 10/08/24: -Resident #1 experienced a fall on 11/02/24: -Resident #1 experienced a fall on 11/19/24. Review of two progress notes for Resident #1 dated 10/08/24 showed: -The resident was found by a medication technician laying on the floor in front of his/her wheelchair facing the wheelchair in his/her bedroom; -Two cushions were noted on top of the wheelchair, floor free of clutter and lighting was adequate; -Resident stated he/she slid out of their wheelchair on the way to the bathroom due to too many cushions on his/her wheelchair; -The second note indicated the resident was experiencing a change in condition due to a non-injury fall. Review of two progress notes for Resident #1 dated 11/02/24 showed: -Resident was found seated in front of his/her wheelchair that was facing his/her bed; -Resident stated he/she had got up to go to the bathroom and when pivoting into the chair his/her bottom got stuck on the arm of the wheelchair and he/she fell down; -Abrasion to left side of forehead noted; -The second noted indicated the resident was Missouri Department of Health and Senior Services STATE FORM 6899 S1PJ11 PRINTED: 12/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/26/2024 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 7 PRINTED: 12/11/2024 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 31005N — 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 (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) NORTERRE Continued From page 2 experiencing a change in condition due to a fall with an abrasion to forehead. Review of two progress notes for Resident #1 dated 11/20/24 showed: -The resident was found laying on his/her back on the floor in his/her personal dining area; -Resident had on non-slid socks, floor was free of clutter, and lighting was adequate, wheelchair noted to be off to the side of the resident; -The resident stated thought he/she would get up to use the bathroom and thought he/she was in the bathroom, and passed out; -The second note indicated the resident was experiencing a change in condition due to a non-injury fall. Review of the resident's ISP dated 09/09/24 showed: -Resident was a risk for falls; -Interventions for falls included anti-roll backs on wheelchair, dated 02/27/24; pendant within reach, dated 02/27/24; Dycem under wheelchair cushion, dated 5/28/24; appropriate footwear, dated 02/27/24; personal items within reach, dated 02/27/24; and physical therapy/occupational therapy evaluation, dated 02/27/24; -No revisions or new interventions had been put into place after the resident's three recent falls. During an interview on 11/26/24 at 1:00 P.M. Resident #1 said: -He/She did not have falls, instead, he/she passed out and ends up on the floor; -He/She indicated he/she passed out often when he she was served acidic foods; -He/She was not sure if the staff could do anything to keep him/her safe except for not serving him/her anymore acidic foods. Missouri Department of Health and Senior Services STATE FORM 6899 S1PJ11 If continuation sheet 3 of 7 PRINTED: 12/11/2024 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 31005N — 11/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CIRCLE LIBERTY, MO 64068 (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) NORTERRE Continued From page 3 2. Review of Resident #2's record showed: -He/She was admitted to the facility on 12/16/19; -Diagnoses included osteoporosis (bones become brittle and fragile from loss of tissue, ) with pathological fracture, history of falls, muscle weakness, dementia, and anxiety. Review on 11/26/24 of the facility's fall report for the last 90 days showed: -Resident #2 experienced a fall on 11/03/24; -Resident #2 experienced two falls on 11/20/24. Review of a progress note for Resident #2 dated 11/03/24 showed: -Staff heard a loud thump from the hall, that came from the resident's room, upon entry, staff found the resident on the floor directly in front of the bathroom with his/her head by the wall and feet facing toward the bathroom; -No injuries noted, only increase blood pressure. Review of progress notes for Resident #2 dated 11/20/24 showed: -At 1:50 A.M. resident was laying in bed with non-slid socks and light on when nurse entered and resident reported a fall; -Floor free of clutter and call light within reach; -Resident stated he/she did not remember what he/she was doing; -Increased blood pressure noted and medication administered, pain rated 9/10 all over body; -The second note indicated the resident was experiencing a change in condition due to a non-injury fall with pain 9/10 all over; -At 7:22 A.M. on 11/20/24 the resident was found sitting on his/her buttocks in front of his/her couch in his/her room; -Medication technician found resident laying on his/her left side upon entry; Missouri Department of Health and Senior Services STATE FORM 6899 S1PJ11 If continuation sheet 4 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31005N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2580 NORTERRE CIRCLE NORTERRE LIBERTY, MO 64068 (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 wearing day time clothing and non-slid socks, floor free of clutter and walker not beside the resident; -Resident stated he/she was going to sit on his/her couch; -The fourth note indicated the resident was experiencing a change in condition due to a non-injury fall without pain. Review of the resident's ISP dated 12/01/23 showed: -Resident #2 was a risk for falls; -Interventions for falls included assessing for urinary tract infection (UTI), dated 10/13/23; assist resident to bathroom every 2-3 hours, revised on 12/03/23; pendant within reach, revised on 08/14/23; familiarize with resident's routine and anticipate daily needs, revised on 01/17/23; remind resident to use pendant, revised on 10/13/23; encourage resident's participation in activities to promote strength and balance building, revised on 08/14/23; -No revisions or new interventions have been implemented since Resident #2's recent falls. This resident was not present at the facility for an interview. 3. Review of Resident #3's record showed: -He/She was admitted to the facility on 04/12/24: -Diagnoses included altered mental status, repeated falls, unsteadiness on feet, and myopathy (a disease of muscle tissue). Review on 11/26/24 of the facility's fall report for the last 90 days showed: -Resident #3 experienced a fall on 10/11/24: -Resident #3 experienced a fall on 11/01/24; -Resident #3 experienced a fall on 11/24/24. Missouri Department of Health and Senior Services STATE FORM 6899 S1PJ11 PRINTED: 12/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/26/2024 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 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31005N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2580 NORTERRE CIRCLE NORTERRE LIBERTY, MO 64068 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 Review of two progress notes for Resident #3 dated 10/11/24 showed: -Resident was found on the floor next to bed, with bowel movement incontinence at time of fall: -Resident stated he/she was trying to reposition and sit, lost balance and fell into his/her walker and onto floor, denied hitting head and abrasion to both knees noted; -A second note indicated the resident was experiencing a change in condition due to an unwitnessed fall. Review of a progress note for Resident #3 dated 11/01/24 showed: -Resident was found on the floor on his/her back with feet out in front of him/her and head by the outer door; -Resident noted to have no shoes or socks on, and four ice creams and several packages of crackers were around him/her on the floor; -Resident denied hitting head, or hurting, and insisted he/she was fine, to help him/her up, and give him/her the snacks. Review of a progress note for Resident #3 dated 11/07/24 showed: -The resident was found laying at the end of his/her bed with his/her head towards the wall and feet dangling off the bed; -Resident advised he/she got up and lost his/her balance, landing on his/her bed; -Resident had blood on bedding and found he/she reopened an abrasion from prior fall; -Staff assisted resident up, and found feces on his/her clothing and bedding. Review of two progress notes for Resident #3 dated 11/24/24 showed: -Resident was found sitting up on buttocks, leaning on side of bed in personal room; Missouri Department of Health and Senior Services STATE FORM 6899 S1PJ11 PRINTED: 12/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/26/2024 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 6 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 31005N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 2580 NORTERRE CIRCLE NORTERRE LIBERTY, MO 64068 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 -Resident was wearing daytime clothing that were wet, adequate lighting and floor was free of clutter; -Abrasion to left knee noted; -A second note indicated the resident was experiencing a change in condition due to an unwitnessed fall. Review of the resident's undated ISP showed: -Resident #3 was a risk for falls; -Interventions for falls included ensuring assistive devices were within reach, revised on 09/09/24: pendant within reach and used, revised on 09/09/24; physical therapy and occupational therapy evaluation, dated 06/04/24; -No revisions or new interventions had been implemented since Resident #3's recent falls. During an interview on 11/26/24 at Resident #3 said: -He/She did not experience falls that concerned him/her. During an interview on 11/26/24 at 1:57 P.M. the Director of Nursing said: -The on duty nurse was to implement appropriate interventions after assessing the resident and incident, and update the ISP with these changes. During an interview on 11/26/24 at 1:55 P.M. the Executive Director said: -ISP's should have been updated after each fall and its investigations to find the appropriate interventions to put into place; -ISP's were to be updated with any change. MO245255 Missouri Department of Health and Senior Services STATE FORM 6899 S1PJ11 PRINTED: 12/11/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 11/26/2024 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 7 of 7 Provider/Supplier Name: Street Address, City, Zip: PLAN OF CORRECTION Norterre ALF-The Laurel Assisted Living 2580 Norterre Circle, Liberty, MO 64068 Date of Survey: 41/26/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 31005N ID PREFIX TAG A4755 PROVIDER'S PLAN OF CORRECTION: {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Preparation and/or execution of this plan of correction in general, or this corrective action, does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state laws. This facility wishes to request paper compliance. COMPLETION DATE Actions Taken residents #1, #2, #3 ISPs were all updated to match their service plan. All residents who reside in the facility had ISPs audited. 11/26/2024 All residents have the potential to be affected. 11/26/2024 All Nurse management and Nurses have been educated on updating ISPs due to significant change of condition that requires a change in services. 11/27/2024 Facility will have ISPs updated at least annually or when there is a significant change in the resident's condition which may require a change in services. 12/19/2024 The Administrator or Designee will audit all ISPs for residents with a fall/and or change of condition to ensure all ISPs are updated for new interventions and or when there is a significant change in the resident’ s condition which may require a change in services for the next 90 days. 12/19/2024 12/19/2024 Any concerns will be immediately addressed and corrected. Results of the monitoring will be reviewed at the quarterly QAPI meeting or AD HOC 12/19/2024 This plan of correction constitutes our credible allegation on 12/19/2024 compliance with all regulatory requirements. Our date of pliance is 12/19/2024. 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: 01/09/2024 FORM APPROVED artment of Health and Senior Services (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: Missouri De STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED (XZ) MULTIPLE CONSTRUCTION A. BUILDING: 12/27/2023 B. WING ——— 31005N NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2580 NORTERRE CiRCLE R BORTERAE LIBERTY, MO 64068 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} (x5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (4) 1D PREFIX TAG A2217] 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. IN/III This regulation is not met as evidenced by: Class Ill Based on record review and interview on 12/27/23 the facility failed to produce documentation of at least one fire drills being conducted on each shift every other month in the last year. The facility census was 52. This potentially affected 52 of 52 residents. Record review on 12/27/23 at 2:00 P.M. showed only three of the twelve fire drills done in the last twelve months were done on the second shift. During an interview on 12/27/23 at 2:00 P.M. the maintenance director said he/she knew he/she was not alternating the drills properly and would make sure in the future to alternate back and forth every other month. Missouri Department of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPR LE (X68) DATE STATE FORM id 823014 lfcontinuation sheet 1 of 1 PLAN OF CORRECTION Provider/Supplier Norterre Laurel Name: Street Address, City, Zi 2580 Norterre Circle Liberty, Mo 64068 n ity, Zip: Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 31005N SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The facility will ensure Fire drills are held in accordance with the requirements of the life safety code of the national fire protection Association. The facility will conduct monthly fire drills on varying dates on alternate shifts. 1/12/2023 The maintenance director or designee will ensure completed documentation showing the fire drills have been conducted as required, 4/12/2023 om” 8 8 Compliance will be monitored by the administrator and/or designee by reviewing the monthly fire drill documentation at monthly safety meeting. The maintenance director will report findings to the Admin 1/12/2023 Immediately and the QA committee quarterly. 1/12/2023 , 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.