WELLINGTON SENIOR LIVING,THE.

PRINTED: 03/26/2026 FORM APPROVED Missour| Department.of Healthy and Senior Services STATEMENT OF DEMICICNCIES {X1) PROVIDER/SUPPLIERICLIA AMD PLAN OF CORRECTION IDENTIFICAHON NUMBER (X%2) MULTIPLE CONSTRUCTION A. BUILDING {A3) DATEL SURVEY COMPLETED GB WING = 03/17/2026 NAME QF PROVIDER OR SUPPLIER STRFFT ADDRESS. CITY. SIATE, 411" CODE 1051 KENT STREET LIBERTY, MO 64068 WELLINGTON SENIOR LIVING, THE SUMMARY STATEMENT GF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x4) PREFIX (EACH DCFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY ORI SC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4798 19 CSR 30-86.047(47)(A) Physicians Orders A4798 Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be follawed {All : This regulation is not met as evidenced by: Class Ill Based on observation, interview, and record review the facility failed to ensure no treatment was administered without an order when the facility failed to obtain an order for Resident #1 to use oxygen. The facility census was 54 residents Review of the facility's policy titled, "Physician Move-In Orders/Verification Orders," dated 05/13/23, showed: -The admitting Wellness Nurse was responsible fer ensuring all resident's physician orders were obtained in writing at move-in; -The Wellness Nurse was responsible for | verifying orders. 1. Review of Resident #1's record showed: -He/She admitied to the facility on 08/26/25; -Diagnoses included respiratory failure: -He/She was wearing an oxygen nasal canula (NC) in his/her face sheet photo taken at admission. Review of the resident's March 2026 physician's order sheet (POS) showed no order far oxygen. Review of the resident's progress notes showed: -On 08/26/25 the resident admitted to the facility, requiring 5 liters of oxygen; -The resident received 3 liters of oxygen on enior Services PER/SUPPLIER REPRESENTATIVE'S BIGNAIWRE | 1g (X6) DATE a 04) a JAS AAW MIM? fis A 5CY011 lf continuation sheet | af 14 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 WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A4798 19 CSR 30-86.047(47)(A) Physicians Orders Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III This regulation is not met as evidenced by: Class III Based on observation, interview, and record review the facility failed to ensure no treatment was administered without an order when the facility failed to obtain an order for Resident #1 to use oxygen. The facility census was 54 residents. Review of the facility's policy titled, "Physician Move-In Orders/Verification Orders," dated 05/13/23, showed: -The admitting Wellness Nurse was responsible for ensuring all resident's physician orders were obtained in writing at move-in; -The Wellness Nurse was responsible for verifying orders. 1. Review of Resident #1's record showed: -He/She admitted to the facility on 08/26/25; -Diagnoses included respiratory failure; -He/She was wearing an oxygen nasal canula (NC) in his/her face sheet photo taken at admission. Review of the resident's March 2026 physician's order sheet (POS) showed no order for oxygen. Review of the resident's progress notes showed: -On 08/26/25 the resident admitted to the facility, requiring 5 liters of oxygen; -The resident received 3 liters of oxygen on Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (X6) DATE If continuation sheet 1 of 11 PRINTED: 03/26/2026 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 03/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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) WELLINGTON SENIOR LIVING, THE Continued From page 1 08/27/25, 08/28/26, and 08/29/26. Observation on 03/17/26 at 12:30 P.M. showed the resident wearing an oxygen nasal canula while in the dining room. During an interview on 03/17/26 at 1:52 P.M. the resident said: -He/She admitted to the facility requiring oxygen; -He/She required 3 liters of oxygen during the day, and 5 liters of oxygen at night; -His/Her spouse switched the oxygen levels each night and morning, and monitored the concentrator for him/her; -His/Her pulmonologist wrote the order for his/her oxygen and was not sure why the facility would not have that in their records. During an interview on 03/17/26 at 1:37 P.M. the Wellness Director said: -He/She knew the resident admitted to the facility using oxygen, but his/her orders must have been overlooked; -The nurse manager on duty the day the resident admitted would have sent the orders to the pharmacy who entered the orders into the system; -He/She just reviewed the order the resident provided at admission which were from his/her primary doctor and did not include the oxygen order from his/her pulmonologist; -He/She was unsure of how many liters the resident required. During an interview on 03/17/26 at 1:40 P.M. the Administrator said: -He/She knew the resident admitted to the facility using oxygen; -He/She did not know there was no order on file for the resident's oxygen; Missouri Department of Health and Senior Services STATE FORM 6899 5CY011 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: NAME OF PROVIDER OR SUPPLIER WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 -His/Her staff must have overlooked the orders when he/she admitted to the facility; -He/She would expect all residents to have orders for any medications or treatments they were receiving. 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III This regulation is not met as evidenced by: Class III Based on observation, interview, and record review the facility failed to ensure food was protected from potential contamination at all Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 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 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 WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 times when items being stored were left uncovered. The facility census was 54 residents. Review of the facility's undated policy titled, "Sanitation," showed the Culinary Director was responsible for providing a sanitary environment to protect residents from food-borne illnesses. 1. Observation of the kitchen on 03/17/26 at 10:06 showed: -A pan of cooked hamburgers, a pan of biscuits, a pan of sausage patties, a pan of gravy, a pan of grits, and a pan of oatmeal uncovered in the warmer; -A large pan of left over blueberry cobbler in the bottom of the cooler, uncovered; -A pan of snickerdoodle banana cake in the refrigerator, uncovered; -A box of beef patties, a bag of catfish fillets, a bag of sweet potato fries, a bag of french fries, and a bag of onion rings in the upright freezer next to the fryer, uncovered/open to air; -Eleven bowls of mixed fruit in the drink station refrigerator uncovered with no label or date. During an interview on 03/17/26 at 11:00 A.M. the Culinary Director said: -He/She was not aware of all the uncovered food in the warmer, cooler, and refrigerator; -He/She expected all kitchen staff to keep food covered at all times to prevent contamination. During an interview on 03/17/26 at 2:30 P.M. the Administrator said he/she expected all food to be kept covered at all times when being stored. 19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 11 PRINTED: 03/26/2026 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 03/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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) WELLINGTON SENIOR LIVING, THE Continued From page 4 Ventilation hoods and devices shall be designed to prevent grease or condensation from collecting on walls and ceilings and from dripping into food or onto food-contact surfaces. Filters or other grease-extracting equipment shall be readily removable for cleaning and replacement if not designed to be cleaned in place. Ill This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure the ventilation hood filters were kept clean and free of grease build up. The facility census was 54 residents. The facility did not provide a policy regarding vent hood cleaning. 1. Observation of the kitchen on 03/17/26 at 10:07 A.M. showed: -The hood vent filters over the stove and grill were black with grease built up. During an interview on 03/17/26 at 11:00 A.M. the Culinary Director said: -He/She cleaned the hood vent filters each week himself on Friday's; -He/She did clean them last Friday. During an interview on 05/14/25 at 11:49 A.M. the Administrator said: -He/She expected vent hoods to be cleaned weekly and as needed to keep them free from build up; -It was the responsibility of all kitchen staff to ensure these were kept clean. Missouri Department of Health and Senior Services STATE FORM 6899 5CY011 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: NAME OF PROVIDER OR SUPPLIER WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily The food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens shall be cleaned at least once a day, except that this shall not apply to hot oil-cooking equipment and hot oil-filtering systems. The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. III This regulation is not met as evidenced by: Class III Based on observation, interview, and record review the facility failed to ensure food-contact surfaces of the grill was cleaned at least once a day to keep it free from accumulation of grease deposits. The facility census was 54 residents. Review of the facility's undated policy titled, "Sanitation," showed the Culinary Director was responsible for providing a sanitary environment to protect residents from food-borne illnesses. 1. Observation of the kitchen on 03/17/26 at 10:08 A.M. showed the grill covered in black and white charred build up. During an interview on 03/17/26 at 11:00 A.M. the Culinary Director said: -He/She expected his/her night cook to clean and scrub the grill each night, but was unsure if he/she was completing that task; -Looking at the grill it did not appear the grill had been cleaned properly in quite some time; -He/She was unsure of the last time the grill was cleaned. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 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 PRINTED: 03/26/2026 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 03/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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) WELLINGTON SENIOR LIVING, THE Continued From page 6 During an interview on 03/17/26 at 2:30 P.M. the Administrator said he/she expected all food-contact surfaces of the stove, grill, and flat top griddle to be cleaned at least daily and as needed to keep them free from grease build up. 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 Based on observation, interview, and record review the facility failed to ensure all nonfood-contact surfaces of equipment were kept clean and free from accumulation of dust, dirt, food particles, and other debris. This had the potential to affect all residents. The facility census was 54 residents. Review of the facility's undated policy titled, "Sanitation," showed the Culinary Director was responsible for providing a sanitary environment to protect residents from food-borne illnesses. 1. Observation of the kitchen on 03/17/26 at 10:07 A.M. showed: -The back splash behind the grill and griddle covered in splatter and grease; -The side of the oven next to the stove top with sticky yellow grease build up and debris; -Smudges on the glass door of the cooler; -Spillage and debris on the bottom shelf inside Missouri Department of Health and Senior Services STATE FORM 6899 5CY011 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: NAME OF PROVIDER OR SUPPLIER WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 the cooler; -Food and debris covered the lids of the bulk bins holding par boiled rice, panko bread, salt, cornmeal, flour, sugar, and powdered sugar bin; -White splatter and spillage running down the front bottom area of the oven; -The side of the fryer nearest the upright freezer and the side of the upright freezer were corroded with a greasy/sticky substance; -The front of the upright freezer was corroded with dirt and food debris During an interview on 03/17/26 at 11:00 A.M. the Culinary Director said: -He/She took care of most of the cleaning, except the grill area was supposed to be cleaned by the line cooks; -He/She expected all nonfood-contact surfaces to be kept free from debris and build up; -He/She personally tried to clean each piece of equipment at least weekly. During an interview on 03/17/26 at 2:30 P.M. the Administrator said: -The kitchen staff had daily and weekly cleaning tasks that the above listed concerns were apart of; -He/She expected all kitchen staff to assist in keeping all nonfood-contact surfaces clean and free of debris and build up. 19 CSR 30-87.030(68) 3 Compartment Sink-Wash/Rinse/Sanitize For manual washing, rinsing and sanitizing of utensils and equipment, a sink with not fewer than three (3) compartments shall be provided and used. Sink compartments shall be large enough to permit the accommodation of the Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 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: NAME OF PROVIDER OR SUPPLIER WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 equipment and utensils and each compartment of the sink shall be supplied with hot and cold potable running water, except that in an existing licensed facility, the use of a two (2)-vat sink and a supplementary portable container to be used for sanitization is acceptable. Fixed equipment and utensils and equipment too large to be cleaned in sink compartment shall be washed manually or cleaned through pressure spray methods. III This regulation is not met as evidenced by: Class III Based on observation and interview facility staff failed to wash dishes in memory care using a dishwasher or a sink with three (3) compartments. This had the potential to effect all residents residing on the Memory Care Unit (MCU). The facility census was 54. The facility did not provide a policy regarding dishwashing. 1. Observation in the MCU on 03/17/2026 at 11:07 A.M., showed: -Memory Care Homemaker (IMCH) A washing dishes in the one compartment sink in the MCU kitchen; -The sink was half full of soapy water; -Dishes and silverware were submerged in the sink of soapy water; -MCH A took the dishes and silverware out, shook them off, and stacked them on the adjacent dish shelf to dry. During an interview on 03/17/2026 at 11:10 A.M., Care Partner A said: -He/She was washing dishes by hand because the MCU dishwasher was broken; Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 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: NAME OF PROVIDER OR SUPPLIER WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 -The dishwasher had been broken for approximately two weeks; -He/She soaked the silverware in hot soapy water for 20-30 minutes and them pulled them out, shook the suds off, and then put them on the dish drying shelf; -He/She used a scrubber on the dishes, rinsed the suds off, and then placed them on the dish drying shelf. During an interview on 3/17/26 at 2:30 P.M., the Administrator said: -He/She was aware that staff were washing dishes by hand in the MCU kitchen; -He/She knew three compartment sinks should have been used when washing dishes; -The facility was waiting for a part to repair the dishwasher in the MCU. 19 CSR 30-87.030(87) Glasses/Cups/Utensils Storage Glasses and cups shall be stored inverted. Other stored utensils shall be covered or inverted, wherever practical. Facilities for the storage of knives, forks and spoons shall be designed and used to present the handle to the employee or consumer. Unless tableware is prewrapped, holders for knives, forks and spoons at self-service locations shall protect these articles from contamination and present the handle of the utensil to the consumer. III This regulation is not met as evidenced by: Class III Based on observation, interview and record review the facility failed to ensure all glassware and glasses were stored inverted to prevent Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 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 AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER 1051 KENT STREET WELLINGTON SENIOR LIVING, THE LIBERTY, MO 64068 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 10 contamination. The facility census was 54 residents. Review of the facility's undated policy titled, "Sanitation," showed the Culinary Director was responsible for providing a sanitary environment to protect residents from food-borne illnesses. 1. Observation of the kitchen on 03/17/26 at 10:08 A.M. showed: -Several stacks of white ceramic plates and bowls on the shelves under the preparation table were stored upright and not covered; -One pot, twelve white ceramic bowls, and ten metal bowls were on a metal shelf in the dish room stored upright and not covered. During an interview on 03/17/26 at 11:00 A.M. the Culinary Director said he/she expected dishes to be stored inverted at all times. During an interview on 03/17/26 at 2:30 P.M. the Administrator said he/she expected dished to be stored inverted at all time to prevent contamination. Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 5CY011 PRINTED: 03/26/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/17/2026 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 11 of 11 PLAN OF CORRECTION Provider/Supplier Narre: The Wellington Senior Living Street Address, City, ap 1051 Kent St., Liberty, MO 64068 Date of Survey: March 17, 2026 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETI ON DATE This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of — correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. Correction of Cited Deficiency: Resident #1’s physician was contacted, and orders were obtained for 3/26/2026 oxygen. 7 Assessment to Identify other Residents that may be affected: Physician orders and CBA documentation were audited and reviewed for accuracy. Two additional residents were identified using oxygen in 3/26/2026 the community, and both had corresponding orders documented in the MAR and reflected in their service plans. Procedure to ensure on-going compliance: The Director of Wellness or designee will conduct weekly reviews of all new orders to verify that residents receiving oxygen therapy have 4/14/2026 proper physician orders and that this information is accurately documented in their service plans. _ ; Monitoring for on-going compliance: The Director of Wellness will review weekly audit findings during one- on-one meetings with the Executive Director for a duration of three months to ensure continued compliance. Correction of Cited Deficiency: All food in both warmers, refrigerators and coolers are covered 3/18/2026 consistently with regulation standards — - | _ Assessment to Identify other Residents that may be affected: | 3/18/2026 — 4/14/2026 | An audit of all stored food was conducted by the Culinary Director and _|_no other food items were identified as being uncovered. Procedure to ensure on-going compliance: All Culinary staff will receive an in-service training to ensure a clear understanding of food covering guidelines and expectations. A daily audit will be conducted by the Culinary Director or their designee to ensure compliance 4/15/2026 Monitoring for on-going compliance: The Culinary Director will review audit results weekly during one-on-on meetings with the Executive Director for a period of 3 months. 4/10/2026 Correction of Cited Deficiency: The Culinary Director thoroughly cleaned all ventilation hoods. 3/20/2026 Assessment to Identify other Residents that may be affected: The Culinary Director thoroughly cleaned the ventilation hoods. 3/20/2026 Procedure to ensure on-going compliance: An in-service will be provided to all staff to ensure understanding of cleaning processes and expectations. The Culinary Director will ensure weekly cleaning of the hoods is completed. The Culinary Director and Plant Operations Director will work collaboratively to ensure that the | outside cleaning company completes by the scheduled date. 4/15/2026 Monitoring for on-going compliance: The Culinary Director will review compliance of weekly hood cleaning with the Executive Director, bringing pictures each week during their 1:1 meeting to include a visual inspection of the hoods in the kitchen for 8 weeks. 4/10/2026 Correction of Cited Deficiency: The Culinary Director thoroughly cleaned the grill and ensured that the drip trays were changed out in accordance with state standards. Assessment ta Identify other Residents that may be affected: The Culinary Director and staff thoroughly cleaned the grill. 3/17/2026 3/17/2026 Procedure to ensure on-going compliance: An in-service will be provided to all staff to ensure understanding of cleaning processes and expectations. The Culinary Director will ensure | daily cleaning of the grill is completed. 4/15/2026 A/066 Monitoring for on-going compliance: The Culinary Director or designee will review compliance of daily grill | cleaning with the Executive Director each week during their 1:1 meeting to include a visual inspection of the hoods in the kitchen for 8 weeks. A7067 AT067 | Correction of Cited Deficiency: The Culinary Director thoroughly cleaned non-food contact surfaces to | ensure compliance with state regulatory standards. 4/10/2026 3/17/2026 Assessment to Identify other Residents that may be affected: The Culinary Director thoroughly cleaned all non-food contact surfaces to ensure compliance. A067 3/17/2026 Procedure to ensure on-going compliance: Ail Culinary staff will participate in an in-service training to ensure they understand cleaning procedures and expectations. The Culinary Director or Sous Chef will be responsible for verifying that daily cleaning of non-food contact surfaces is completed, both by reviewing the Culinary Task Form and through visual inspection. A7067 Monitoring for on-going compliance: The Culinary Director will review compliance with the daily culinary task, checking twice daily to ensure completion form with the Executive | 4/15/2026 4/10/2026 Director each week during their 1:1 meeting to include a visual inspection of the non-food contact surfaces in the kitchen for 8 weeks. Correction of Cited Deficiency: A7070 The dishwasher in Memory Care has been fixed and is confirmed to be in working order. : A7070 Assessment to Identify other Residents that may be affected: _ The Plant Operations Director has fixed the dishwasher. 3/26/2026 3/26/2026 Procedure to ensure on-going compliance: The Memory Care staff will receive an in-service regarding the expectation that if the dishwasher breaks, they must wash their dishes | in the dishwasher located in the main kitchen. A7070 4/15/2026 Monitoring for on-going compliance: The Memory Care Director will review staff compliance on a daily basis and provide immediate in-service if this process is not followed. The Plant Operations Director will monitor the dishwasher monthly to ensure it is in working order and immediately notify the Executive | Director if it is out of service or a part needs to be ordered. A7070 4/10/2026 Correction of Cited Deficiency: All dishes have been inverted. Assessment to Identify other Residents that may be affected: A7089 This has the potential to impact all residents. All dishes have been | inverted. ee Procedure to ensure on-going compliance: All Culinary staff will participate in an in-service to ensure they A7089 A7089 understand the expectation that all dishes be inverted. The Culinary Director or their designee will be responsible for daily verification that dishes are inverted through visual inspection. Monitoring for on-going compliance: A7089 The Culinary Director or their designee will review compliance of inverting the dishes with the Executive Director each week during their 1:1 meeting for a duration of 8 weeks. _ 3/31/2026 3/31/2026 4/15/2026 4/10/2026 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: 07/17/2025 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 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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 GR LSC {DENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WELLINGTON SENIOR LIVING, THE | A2286) 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 shail be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and an interview on 5/6/2025 this facility failed to ensure all wastebaskets were metal, UL or FM fire resistant rated. The facility census was 62. This potentially affected 62 of 62 residents. _ Observation on 5/6/2025 the following rooms had non-approved wastebaskets: Room 102 had two metal wastebaskets fitted with a non-fire resistant rated plastic removable liners Room 104 had one non-fire resistant rated plastic wastebasket Room 113 had two non-fire resistant rated plastic wastebasket Room 117 had one non-fire resistant rated plastic wastebasket Room 119 had one metal wastebasket fitted with a hon-fire resistant rated plastic removable liner Room 123 had one metal wastebasket fitted with non-fire resistant rated plastic removable liner Room 134 had twa metal mesh wastebaskets Roam 137 had one metal wastebasket fitted with a non-fire resistant rated plastic removable liner and two non-fire resistant rated plastic wastebaskets Room 136 had one non-fire resistant rated plastic wastebasket Room 139 had one non-fire resistant rated plastic wastebasket Room 138 had one one metal wastebasket fitted with a non-fire resistant rated plastic removable gnd Senior Services i OVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE ‘ (XB) DATE SAWUNISWAR 2 Nk F7NB11 If continuation’sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 07/17/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 05/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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. Il This regulation is not met as evidenced by: Class II Based on observation and an interview on 5/6/2025 this facility failed to ensure all wastebaskets were metal, UL or FM fire resistant rated. The facility census was 62. This potentially affected 62 of 62 residents. Observation on 5/6/2025 the following rooms had non-approved wastebaskets: Room 102 had two metal wastebaskets fitted with a non-fire resistant rated plastic removable liners Room 104 had one non-fire resistant rated plastic wastebasket Room 113 had two non-fire resistant rated plastic wastebasket Room 117 had one non-fire resistant rated plastic wastebasket Room 119 had one metal wastebasket fitted with a non-fire resistant rated plastic removable liner Room 123 had one metal wastebasket fitted with non-fire resistant rated plastic removable liner Room 134 had two metal mesh wastebaskets Room 137 had one metal wastebasket fitted with a non-fire resistant rated plastic removable liner and two non-fire resistant rated plastic wastebaskets Room 136 had one non-fire resistant rated plastic wastebasket Room 139 had one non-fire resistant rated plastic wastebasket Room 138 had one one metal wastebasket fitted with a non-fire resistant rated plastic removable Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 F7NB11 If continuation sheet 1 of 4 PRINTED: 07/17/2025 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 05/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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) WELLINGTON SENIOR LIVING, THE Continued From page 1 liner and one metal mesh wastebasket Room 145 had one metal wastebasket fitted with non-fire resistant rated plastic removable liner Room 142 had one non-fire resistant rated plastic wastebasket During an interview on 5/6/2025 at 2:15 P.M. the Plant Operations Director said he/she would get the proper wastebaskets ASAP. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III Based on observations and an interview on 5/6/2025 the facility failed to provide proper oxygen cylinder storage in accordance with NFPA 99, 1999 Edition. The facility census was 62. This potentially affected 62 of 62 residents. Observation on 5/6/2025 at 12:30 P.M. showed five oxygen bottles, not properly secured, stored in Room 8. Observation on 5/6/2025 at 1:04 P.M. showed one oxygen bottle, not properly secured, stored in Room 112. During an interview on 5/6/2025 at 2:30 P.M. the Plant Operations Director said he/she would get the extra oxygen bottles removed from room 8 Missouri Department of Health and Senior Services STATE FORM 6899 F7NB11 If continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER WELLINGTON SENIOR LIVING, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 and properly secure the extra oxygen bottle in Resident Rooms 8 and 112. 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) 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/III This regulation is not met as evidenced by: Class III Based on observation on 5/6/2025 the facility did not ensure all electrical extension cords and/or power strips were used in a safe manner. The facility census was 62. This potentially affected 62 of 62 residents. Observation at 12:35 P.M. in Resident Room 12, a power strip was suspended in air by an electric light cord. Observation at 12:50 P.M. in Resident Room 104, a non-approved extension cord was in use. Observation at 12:58 P.M. in Residnet Room 110, an unprotected six (6) way multi-plug adapter was in use. Observation at 1:27 P.M. in Resident Room 127, an unprotected six (6) way multi-plug adapter was in use with two appliance cords plugged into it. Observation at 1:42 P.M. in Resident Room 137 a Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 F7NB11 PRINTED: 07/17/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET WELLINGTON SENIOR LIVING, THE LIBERTY, MO 64068 PRINTED: 07/17/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/06/2025 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE Continued From page 3 multi-plug adapter was in use. Observation at 1:57 P.M. in Resident Room 141 a power strip was suspended in air by multiple appliance power cords. During an interview on 5/6/2025 at 2:30 P.M. the Plant Operations Director said he/she would remove the non-approved extension cords and properly attach the suspended power strips as soon as possible. Missouri Department of Health and Senior Services STATE FORM oeee F7NB11 DEFICIENCY) If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Name: The Wellington Senior Living Street Address, City, Zip: 1051 Kent St. Liberty, MO 64068 Date of Survey: 5/6/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the ity or affiliated companies. Correction of Cited Deficiency: The apartments previously A2286 cited for having non-fire-rated trash cans have had those removed and replaced with fire-rated trash cans. COMPLETION DATE 8/1/2025 Assessment to Identify other areas that may be affected. A community-wide apartment inspection was conducted to verify that all residents had the appropriate trash cans in place. The Executive Director sent a letter to residents and their families, informing them of the requirement for fire-rated trash cans and offering to provide them upon request. 8/1/2025 Procedure to ensure on-going compliance: The Plant Operations Director or their designee will conduct weekly audits of all resident apartments to verify that all trash cans are fire-rated. Any non-compliant trash cans will be promptly removed. Audit findings will be reviewed with the Executive Director during weekly one-on-one meetings for a period of eight weeks. 8/1/2025 Monitoring for on-going compliance: The Plant Operations Director will review the room audit results with the Department Directors during the monthly Department Director Meeting for the next two months. 8/1/2025 A2298 Correction of Cited Deficiency: The extra oxygen tanks in Apartment 8 have been removed, and the resident's necessary oxygen tanks are now secured in an approved oxygen holder. In Apartment 112, the resident’s oxygen tank has been properly secured in an approved holder. 7/18/2025 Assessment to Identify other Residents that may be affected: The Executive Director and Wellness Director reviewed oxygen needs for all residents and removed all extra oxygen tanks. Portable oxygen racks were ordered for and placed in apartments of residents with oxygen tanks. 7/18/2025 Procedure to ensure on-going compliance: The Wellness Director or their designee will audit the apartments of residents using oxygen to ensure proper storage within the apartments weekly for the next 4 weeks then monthly for 2 additional months. 8/1/2025 Monitoring for on-going compliance: Wellness Director will review the audit at the monthly Department Director Meeting for | the next 3 months. 8/6/2025 A3219 Correction of Cited Deficiency: Plant Operations Director reviewed all apartments cited for having unapproved extension cords, power strips and multi-plug adapters and made corrections necessary to meet regulatory requirements. Assessment to Identify other areas that may be affected: Plant Operations Director and Executive Director conducted an audit of all apartments to ensure compliance with standards. The Executive Director sent a letter to residents and their families, informing them of the requirement of approved electrical cords. 7/30/2025 7/30/2025 Procedure to ensure on-going compliance: Plant Operations Director or designee will conduct a monthly audit of all apartments to ensure ongoing compliance with the use of UL rated extension cords if required. Plant Operations Director will review audit results with the Executive Director during weekly one-on-one meetings for eight weeks. 8/1/2025 Director will review audit during the monthly Department Director meeting for the next two months. Monitoring for on-going compliance: Plant Operations 8/6/2025

An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 09/17/2024 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 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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) WELLINGTON SENIOR LIVING, THE 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. Il This regulation is not met as evidenced by: Class II Based on observations and an interview on 8/28/24 this facility failed to ensure all the wastebaskets were the approved types allowed. The facility census was 60. This potentially affected 60 of 60 residents. Observations on 8/28/24 during the fire safety portion of the licensure inspection the following rooms had non-approved wastebaskets in them: Room 138 had one, Room 136 had five, Room 137 had two, Room 134 had two, Room 131 had one, Room 118 had one, Room 116 had one, Room 112 had one, Room 111 had one, Room 108 had one, Room 1 had one, Room 5 had one, Room 14 had one and Room 16 had one. During an interview on 8/28/24 at 11:21 A.M. the Plant Operations Director said he/she would get with the Administrator to get the proper ones. He/she also indicated he/she would review with housekeeping on identifying the wrong ones. 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ELJ911 If continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET WELLINGTON SENIOR LIVING, THE LIBERTY, MO 64068 PRINTED: 09/17/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/28/2024 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE Continued From page 1 This regulation is not met as evidenced by: Class III Based on observations and an interview on 8/28/24 this facility failed to provide a proper oxygen storage room in accordance with NFPA 99, 1999 Edition. The facility census was 60. This potentially affected 60 of 60 residents. Observation on 8/28/24 at 11:24 A.M. showed three oxygen bottles stored in Room 143. Observation on 8/28/24 at 11:47 A.M. showed two oxygen bottles stored in Room 137. During an interview on 8/28/24 at 11:24 A.M. the Plant Operations Director said he/she did not currently have an Oxygen storage room set up, but he/she would establish one and get the extra oxygen bottles removed from the resident's rooms. Missouri Department of Health and Senior Services STATE FORM oeee ELJ911 DEFICIENCY) If continuation sheet 2 of 2

PRINTED: 04/22/2024 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: COMPLETED A. BUILDING: Cc 33016 i ————_<$<=<——$———=—<——— 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WELLINGTON SENIOR LIVING, THE A4508) 19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. Ata minimum the evacuation plan shall include the following components: C. The plan shall evaluate the resident for his or her location within the facility and the proximity to exits and areas of refuge. The plan shall evaluate the resident, as applicable, for his or her risk of resistance, mobility, the need for additional staff support, consciousness, response to instructions, response to alarms, and fire drills; Il This regulation is not met as evidenced by: Class Il Based on observation, interview, and record review, the facilty failed to ensure residents who required more than minimal assistance to safely evacuate the facility had an individualized evacuation plan (IEP) (the planning document prepared by an assisted living facility which outlines the plan to safely evacuate the resident out of the facility in the event of an emergency), which evaluated the resident for his/her location within the facility, proximity to exits and areas of refuge (AOR}, the resident's risk of resistance, mobility, need for additional staff support, consciousness, and response to instructions alarms and fire drills for three of eight sampled residents (Resident #1, #2, and #3). The facility census was 58, Review of the facility's IEP policy dated 05/31/23 Missouri Department of Health and Senior Services LABORATORY DIRE PROVIDE) S UPPLIER REPRESENTATIVE'S SIGNATURE (%6) DATE STATE FORM N66T11 HFcontiquatién she&t 1 of 6 PRINTED: 04/22/2024 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 c B.WING 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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 APPRGPRIATE DATE DEFICIENCY} WELLINGTON SENIOR LIVING, THE 44508 | Continued From page 1 showed: -The IEP should have included: responsibilities of specific staff positions, fire protection interventions needed, evaluation of the residents location within the community and proximity to exits, evaluation of the resident for risk of resistance, mobility, consciousness, response to instructions, response to alarms, and additional staff support needed. 1. Review of Resident #1's record showed: -Admitted to the facility on 07/11/23; -Diagnoses included pulmonary embolism (condition where one or more arteries in the lungs become blocked by a blood clot), cardiamyopathy (condition which makes it hard for the heart to deliver blood to the rest of the body), depression, and cerebral infarction (also known as a stroke, which occurs when there is a lack of blood supply to brain cells). Review of the resident's April Physician Order Sheet (POS) showed: -The resident's order for a mechanical lift (an assistive device that allows a person to transfer by use of electrical or hydraulic power) began 02/12/24. Review on 04/16/24 of the resident's current IEP dated 01/30/24 showed: -For all shifts, the care partner and/or medication partner were to transfer resident into wheelchair with proper transfer techniques and equipment and then propel resident in wheelchair to area designated as safe location; -The IEP failed to specifically identify the use of a mechanical lift in transferring the resident into his/her wheelchair; -The IEP failed to identify where the designated safe location was located: Missouri Department of Health and Senior Services STATE FORM 6599 N6é8T14 If continualion sheel 2 of 6 PRINTED: 04/22/2024 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 Cc 04/16/2024 B. WING NAME GF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CQDE 1051 KENT STREET LIBERTY, MO 64068 {X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5) 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} WELLINGTON SENIOR LIVING, THE Continued From page 2 -The IEP failed to identify how to get to the designated safe location; -The IEP failed to identify any resistance the resident may give during an evacuation; -The IEP failed to identify the resident's consciousness and if the resident would offer any assistance in his/her transfer. During an interview on 04/16/24 at 2:05 P.M. Resident #1 said: -He/She was always in his/her reclining chair; -Two people always assisted when transferring him/her, Observation of the resident during the interview showed the resident was sitting in his/her recliner chair, not able to move much, if at all, he/she spoke in a soft raspy voice, and answered questions with one word responses. 2. Review of Resident #2's record showed: -Admitted to the facility on 10/21/22; -Diagnoses included frontotemporal neurocognitive disorder (condition including unusual behaviors such as emotional, communications, and mobility), dementia (condition which interferes with daily functioning including memory loss and judgment), unspecified abnormalities of gait and mobility, and generalize muscle weakness. Review of the resident's April POS showed: -The resident's order for a hospital bed, Broda chair (durable medical wheelchair used for easier transferring in a long term care setting), and a mechanical lift began 10/03/23. Review on 04/16/24 of the resident's current IEP dated 10/20/23 showed: -For all shifts, the Care Partner and Nurse were Missouri Department of Health and Senior Services STATE FORM ga99 N66T11 If continuation sheet 3 of & PRINTED: 04/22/2024 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 Cc 04/16/2024 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} WELLINGTON SENIOR LIVING, THE Continued From page 3 to physically assist to transfer the resident out of his/her bed/chair and into his/her wheelchair, and then the Care Partner would propel the resident in the wheelchair to the closest area of refuge; -The resident had dementia therefore needed to be told what was happening and the staff would perform the tasks due to his/her inability to; -The IEP failed to specifically identify the use of a mechanical lift in transferring the resident into his/her wheelchair; -The IEP failed to identify where the designated safe location was located; -The IEP failed to identify how to get to the designated safe location; -The IEP failed to identify any resistance the resident may give during an evacuation. Observation of this resident on 04/16/24 at 2:15 P.M. showed: -Resident #2 laying awake in his/her bed, not moving; -Unable to provide a response to yes/no questions, 3. Review of Resident #3's record showed: -Admitted to the facility on 10/27/22; -Diagnoses included obstructive pulmonary disease (condition that makes it difficult to breathe}, morbid obesity, depression, and a history of a stroke causing hemiplegia (complete loss of strength) and hemiparesis (mild loss of strength) of right side and aphasia (language disorder affecting a person's ability to communicate). Review of the resident's April POS showed: ~The resident admitted to the facility with an order for his/her motorized wheelchair. Review on 04/16/24 of the resident's current IEP Missourj Department of Health and Senior Services STATE FORM casa N66T14 If continuation sheet 4 of & PRINTED: 04/22/2024 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 33016 ; 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET 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) WELLINGTON SENIOR LIVING, THE Continued From page 4 dated 10/29/23 showed: -For all shifts, the care partner/nurse were to assist the resident into his/her motorized wheelchair, and then the resident can get himselffherself to the area of safety with verbal direction from the staff; -The IEP did not identify that the resident would need help opening and holding doors open for him/her; -The IEP failed to identify where the designated safe location was located; -The IEP failed to identify how to get to the designated safe location; -The IEP failed to identify any resistance the resident may give during an evacuation. During and interview on 04/16/24 at 1:27 P.M. Resident #3 said: -He/She needed help from one staff member getting out of bed and into his/her motorized wheelchair; -He/She could then wheel himself/herself to safety, but often had difficulty opening doors and would need help opening doors. During an interview on 04/16/24 at 1:18 P.M. Care Partner A said: -IEP's are located in the facility's electronic medical records system; -During an evacuation he/she has been told to evacuate all who are capable to evacuate, and to put a blue cross with tape on the door for the two residents who use mechanical lifts; -She was unsure of where the blue tape could be found. During an interview on 04/16/24 at 2:51 P.M. the Director of Wellness (DOW) said: -She completed the initial IEP for all residents at move in that needed one, and her nursing staff Missouri Department of Health and Senior Services STATE FORM sees N66T11 ff conlinualion sheet 5 of 6 PRINTED: 04/22/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B, WING 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1051 KENT STREET LIBERTY, MO 64068 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WELLINGTON SENIOR LIVING, THE Continued From page 5 completed the updated IEP's; -Staff had been directed to place a blue cross on the two residents’ doors whom use a mechanical lift, which indicated to firefighters who was still in their room and needed evacuated. During an interview on 04/16/24 at 4:42 P.M. the Executive Director said: -The DOW and nursing staff were responsible for completing and updating all IEP's; -She expected IEP's to include what type of assistance the resident needed, including verbal commands and any physical assistance; -She never thought about needing to identify where the safe location for each resident was or how to get there, because she assumed her staff could use common knowledge; -She did not think about needing the specific instructions for staff unfamiliar with the building, such as agency which were often working at the facility; -She understood why the IEP's needed to have more details which identified the safe locations, how to get there, any risks of resistance to alarms by the resident, and the specific devices when applicable used in transferring residents. MO233797 Missouri Department of Health and Senior Services STATE FORM bao8 N66T11 If cantinuatian sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier wane: The Wellington Senior Living Street Address, City, Zip: 1051 Kent St., Liberty, MO 64068 Date of Survey: April 16, 2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency cited are correctly applied. Any changes to the community policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the community or any employee, agent, officer, director, attorney, or shareholder of the community or affiliated companies. Correction of Cited Deficiency: All Individualized Evacuation Plans have been updated in compliance with Missouri State Regulation 19 CSR 30-86.045. The Director of Wellness and Executive Director are now the only two individuals who can create Individualized Evacuation Plans in the community. The Director of Wellness received an in-service on Missouri State Regulations which details the requirements for Individualized Evacuation Plans. COMPLETION DATE A4508 Resident #1- IEP updated to include use of 2 staff members, 4/29/2024 mechanical lift and propelling wheelchair to closest area of refuge. Resident #2- IEP updated to include use of 2 staff members, mechanical lift and propelling broda chair to closest area of refuge. Resident #3- IEP updated to include staff assist with opening door for evacuation and verbal prompting to evacuate towards closest area of refuge. Assessment to Identify other Residents that may be affected: A4508 All residents who necessitate more than minimal assistance 4/17/2024 would be affected by any non-compliance. The Director of Wellness, or Executive Director will review all Individualized Evacuation Plans for accuracy and will update if necessary. Identification of new residents that require an Individualized Evacuation Plan will be identified through the monthly wellness visits and a Community Based Assessment review that is completed every 6 months and upon significant change in condition. Procedure to ensure on-going compliance: Each Tuesday, the Director of Wellness and Executive Director A4508 will review any new or revised Individualized Evacuation Plans 4/29/2024 to ensure they follow standards as outlined in the State Regulations, __ Monitoring for on-going compliance: Each Tuesday, the Director of Wellness and Executive Director A4508 will review any new or revised Individualized Evacuation Plans 4129/2024 to ensure they follow standards as outlined in the State Regulations. 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.