AUTUMN COURT HEALTHCARE CENTER LLC.

PRINTED: 03/18/2026 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 cS 20809C B.WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 (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) AUTUMN COURT HEALTHCARE CENTER LLC A4703) 19 CSR 30-86.047(5) Administrator - Licensed The operator shall designate an individual for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. Il This regulation is not met as evidenced by: Based on observation, interview, and record review, the facility failed to designate a currently licensed individual by the Missouri Board of Nursing Home Administrators as the facility administrator. The facility census was 16. Review showed the facility did not provide a policy regarding administrator requirements for the facility. 1. Observations on 03/04/26, at 9:36 A.M., showed a posted copy of an administrator's license for the facility. Review showed the facility could not provide documentation of the administrator's start date with the facility. During an interview on 03/04/26, at 1:32 P.M., the Manager said the following: -He/She was given a temporary emergency administrator license that expired last month; -He/She was unable to find a copy; -He/She was unaware when the new administrator would be taking over the position. During an interview on 03/05/26, at 10:16 A.M., the Regional Director of Operations (RDO) D said the following: -The current manager's temporary emergency administrator's license expired on 02/28/26; -The new administrator was on vacation but has Missouri Department of Health and Senior Services LAI TORY DIRECTOR'S-OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ULCM11 If continuation sheet 1 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 1 accepted position and will discuss start date upon return. 19 CSR 30-86.047(13)(A) Criminal Background Check Requirements Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (A) Request a criminal background check for the person, as provided in section 660.317, RSMo. Each facility shall maintain documents verifying that the background checks were requested, the date of each such request, and the nature of the response received for each such request. II This regulation is not met as evidenced by: Based on interview and record review, facility staff failed to document a request for a criminal background check for two staff members (Manager and LIMA C) of three sampled newly hired staff members prior to the staff member beginning employment with resident contact. The facility census was 16. Review showed the facility did not provide a policy regarding completion of criminal background checks. 1. Review of the Manager's personnel record showed the following: -Hire and start date of 08/07/25; -The file contained a Family Care Safety Registry (FCSR - a criminal background check is Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 2 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 2 completed as part of this process) paperwork with a request dated of 02/26/26 (over six months after the hire date). 2. Review of Level One Medication Aide (LIMA) C's personnel record showed the following: -Hire and start date of 09/01/25; -The file did not contain any criminal background checked to date. During an interview on 03/04/26, at 11:30 A.M., the LIMA C said he/she was not aware of having any background checks. 3. During an interview on 03/04/26, at 1:32 P.M., the Manager said the following: -He/She was responsible for completing criminal background checks for new hires; -He/She had a background check done but was unable to provide a copy/documentaion. 19 CSR 30-86.047(13)(B) EDL Inquiry Prior to allowing any person who has been hired in a full-time, part-time, or temporary position to have contact with any resident, the facility shall, or in the case of temporary employees hired through or contracted from an employment agency, the employment agency shall, prior to sending a temporary employee to a facility: (B) Make an inquiry to the department, as provided in section 660.315, RSMo, as to whether the person is listed on the EDL. Each facility shall maintain documents verifying that the EDL checks were requested, the date of each such request, and the nature of the response received for each such request. The inquiry may be made through the department's website; I/II Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 3 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 3 This regulation is not met as evidenced by: Class II* Based on interview and record review, facility staff failed to document a check of the employee disqualification list (EDL - a list of individuals unable to work in long-term care settings) prior to the staff member beginning employment with resident contact for three staff members (Manager, Level One Medication Aide (LIMA) C, and Cook/Patient Care Aide (PCA) E) of three sampled newly hired staff members. The facility census was 16. Review of the facility policy titled "Employee Disqualification List/Abuse Registry," dated 05/10, showed the following: -All employees are expected to not have been placed on the EDL by the Missouri Department of Health and Senior Services; -Go online to www.dhss.mo.gov/EDL/ and follow prompts to obtain verification that the employee is clear on the EDL list; -Once verification is obtained, print and place in the yellow employee file if hired; -Check the EDL on a quarterly basis to ensure no current employees have been added to the list. 1. Review of the Manager's personnel record showed the following: -Hire and start date of 08/07/25; -No documentation of an EDL check. 2. Review of LIMA C's personnel record showed the following: -Hire and start date of 09/01/25; -No documentation of an EDL check.. 3. Review of Cook/Patient Care Aide E (PCA) Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 4 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 4 personnel record showed the following: -Hire and start date of 01/07/26; -No documentation of an EDL check. 4. During an interview on 03/04/26, at 1:32 P.M., the Manager said the following: -He/She thought he/she did complete the EDL's on the employees; -He/She did not have documentation to show that EDL's were completed. *The higher class merited due to the extent of the violation and impact when combined with other deficiencies. 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Based on interview and record review, the facility failed to screen staff for tuberculosis (TB -a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) as required when staff failed to complete the two step screening test timely upon hire for one staff member (Manager). The facility census was 16. General requirements for Tuberculosis Testing for Residents and Staff in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -All new long term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD (TB skin test) two-step tuberculin test within one month Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 5 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 5 prior to starting employment in the facility; -If the initial test is zero to nine millimeters, the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two (2) years; -It is the responsibility of each facility to maintain a documentation of each employee 's and volunteer ' s tuberculin status Review showed the facility did not provide a policy regarding employee TB testing. 1. Review of Manager's personnel record showed the following: -Hire and start date of 08/07/25; -Staff did not have documentation of the required two-step TB screening at hire or a history of prior TB screening tests. During an interview on 03/04/26, at 1:32 P.M., the Manager said the following: -He/She did remember doing the TB testing, but did not have documentation of it; -The Administrator was responsible for TB testing. 19 CSR 30-87.020(11) No Deodorizers/Sprays to Eliminate Odors Deodorizers or sprays shall not be used to cover up odors. Odors shall be eliminated to the source by prompt cleaning of bedpans and commodes, floors, furniture and equipment and by proper ventilation. II/III Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 6 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 6 This regulation is not met as evidenced by: Class II* Based on observation, interview, and record review, the facility failed to ensure odors were elimated at the source when one resident (Resident #1) requested to be moved to another room due to persistent odors from the roommate's incontinence. The facility census was 16. 1. Review of Resident #'1's face sheet showed the following: -Admission date of 11/01/25. -Diagnoses included Type 2 diabetes, insomnia, spinal stenosis (the narrowing of spaces within the spine, causing pressure on the spinal cord or nerves), and depression. Observation on 03/04/26, at 12:00 P.M., showed the following: -Strong odors of urine present in the resident's room; -A yellowish - orange staining on toilet and in the floor within the bathroom area consistent with urine; -Area near the roommate's bed had some staining in the carpet with a strong pungent odor consistent with urine. During an interview on 03/04/26, at 12:10 P.M., the resident said the following: -He/She had made several requests to be moved to another room; -He/She was told no rooms were available for him/her to go; -He/She purchased air fresheners and was told he/she could not use them; -He/She requested room to be cleaned more often and was told it would be done once a day. Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 7 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 7 During an interview on 03/04/26, at 11:07 A.M., the Director of Care (DOC) B said the following: -He/She was aware of the requests made by the resident to be moved, but they don't have anywhere else to put him/her; -The vacants rooms were used for storage or had maintenance issues; -They must complete all duties for residents including cooking/housekeeping as they don't have a budget to hire additional employees to assist so they can get behind on some things. During an interview on 03/04/26, at 1:32 P.M., the Manager said the following: -He/She was aware the resident wanted to be moved due to odors from roommates; -The facility didn't have another room for her; -The entire staff had been making sure that their the resident's room was cleaned daily. Complaint MO00260924 and MO00260556 *The higher classification merited due to the extent of the violation and impact on the resident. 19 CSR 30-87.020(12) Floor Surfaces All floors in the facility shall be clean and shall be maintained in good repair. Floors and floor coverings of all food-preparation, food-storage and utensil-washing areas, and the floors of all walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealed concrete, terrazzo, ceramic tile, durable grades of linoleum or plastic, or tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip floor covering in Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 8 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 8 areas where necessary for safety reasons. Ill This regulation is not met as evidenced by: Based on observation, interview, and record review, the facility staff failed to ensure floors were clean and in good repair. The facility census was 16. Review showed the facility did not provide a policy regarding floor maintenance. 1. Observations on 03/04/26, at 9:50 A.M., showed the following: -The carpeting throughout lobby and dining area had several areas with a silver tape placed covering frayed and open seams; -The kitchen floor tile had debris and greasy like substance around cabinets and prep areas; -The kitchen and pantry floors also had broken and very worn tiles; -The laundry room floor had lint debris, fabric softener sheets, and broken tiles throughout; -The sunroom/storage area floor had large areas within the concrete with flaking paint like debris upon entry way. During an interview on 03/04/26, at 11:07 A.M., Director of Care (DOC) B said the following: -They have been trying to organize and keep up with everything; -They all work as a team and split duties when time allows; -They must complete all duties for residents including cooking/housekeeping as they don't have a budget to hire additional employees to assist so they can get behind on some things. During an interview on 03/04/26, at 11:30 A.M., the Level One Medication Aide (LIMA) C said the following: Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 9 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 9 -They did not have a cleaning schedule; -They do what cleaning they have time for or any urgent items; -They all work together to try to get the cleaning and maintenance completed as they don't have a designated housekeeper or maintenance person. 19 CSR 30-87.020(31) Kitchen Waste Containers Covered Waste containers used in food-preparation and utensil-washing areas shall be kept covered when not in actual use. III This regulation is not met as evidenced by: Based on observation, interview, and record review, showed the facility failed to ensure the waste container used in food-preparation and utensil-washing areas was kept covered when not in use. The facility census was 16. Review showed the facility did not provide a policy regarding waste containers in the kitchen. 1. Observation on 03/04/26, at 10:17 A.M., of the food-preparation and utensil-washing areas of the facility kitchen showed the following: -One large round trash can was located by the wall oven and utensil-washing area to the left upon entrance of kitchen; -The waste container was lined with a removable bag; -The waste container contained food waste and other trash; -The waste container was not being actively used; -No lid was present. During an interview on 03/04/26, at 11:30 A.M., the Level Once Medication Aide (LIMA) C said the Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 10 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 10 following: -He/She was not aware that the waste container had to be covered when not in use; -He/She believed there was a lid that could be used. 19 CSR 30-87.030(17) Food Stored in Identifying Containers Unless its identity is unmistakable, bulk food, such as cooking oil, syrup, salt, sugar or flour not stored in the product container or package in which it was obtained, shall be stored ina container identifying the food by common name. lil This regulation is not met as evidenced by: Based on observation, and interview, the facility failed to ensure all bulk food items, not in the original container or package, was stored ina container identifying the food by common name. The facility census was 16. Review showed the facility did not provide a policy regarding storage of bulk foods. 1. Observation of the kitchen on 03/04/26, at 10:22 A.M., showed the following: -Two large plastic dry bulk food containers within the pantry at the back of the kitchen; -Both containers contained a different consistencies with white powdery substances; -Neither container was labeled. During an interview on 03/04/26, at 11:30 A.M., the Level One Medication Aide (LIMA) C said the following: -He/She was aware that containers should be properly labeled and dated; Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 11 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 11 -He/She was responsible for ensuring all food was covered and labeled; -He/She was in the process of organizing the kitchen items and labeling as needed. During an interview on 03/04/26, at 11:07 A.M., the Director of Care (DOC) B said the following: -He/She was aware that containers should be labeled and dated; -They have been trying to organize and keep up with everything. 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: Based on observation and interview, the facility failed to ensure all non-food contact surfaces were kept clean when the refrigerators, freezers, ovens, microwave, and cook tops was not kept clean. The facility census was 16. 1. Observations on 03/04/26, at 10:17 A.M., showed the following: -The microwave had a sticky residue on the outside and the inside had baked on food particles on the sides; -The top-mount refrigerator had sticky smearing on the outside and the inside had orange colored tape holding the bottom shelves together; -The glass cook top had caked on remnant of burnt on food that was built up; -The oven was covered in grease on outside as well as burnt on food. Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 12 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 12 During an interview on 03/04/26, at 11:07 A.M., the Director of Care (DOC) B said the following: -They have been trying to organize and keep up with everything; -They all work as a team and split duties when time allows; -They must complete all duties for residents including cooking/housekeeping as they don't have a budget to hire additional employees to assist so they can get behind on some things. During an interview on 03/04/26, at 11:30 P.M., the Level One Medication Aide (LIMA) C said the following: -He/She did not have a cleaning schedule. Staff clean what they have time for or anything urgent items; -They all work together to try to get the cleaning and maintenance completed as they don't have a designated housekeeper or maintenance person; -He/She was responsible for cleaning the kitchen after meals. 19 CSR 30-88.010(41) Resident Lives Not Regulated/Controlled Residents shall not have their personal lives regulated or controlled beyond reasonable adherence to meal schedules and other written policies which may be necessary for the orderly management of the facility and the personal safety of the residents. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the personal lives of residents were not controlled beyond reason when the facility failed to allow one resident (Resident #1) Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 13 of 14 PRINTED: 03/18/2026 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 C 20809C B. WING 03/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) AUTUMN COURT HEALTHCARE CENTER LLC Continued From page 13 to have coffee unless served with meals. The facility census was 16. 1. Review of Resident #'1's face sheet showed the following: -Admission date of 11/01/25. -Diagnoses included Type 2 diabetes, insomnia, spinal stenosis (the narrowing of spaces within the spine, causing pressure on the spinal cord or nerves), and depression; -Regular diet with no restrictions. During an interview on 03/04/26, at 12:10 P.M., the resident said he/she liked to have coffee to drink and was told he/she could only have it at meal times. During an interview on 03/04/26, at 11:07 A.M., the Director of Care (DOC) B said all residents can have beverages anytime with exception of coffee. Residents could burn themselves or break the coffee carafe if the residents were allowed to have hot coffee. During an interview on 03/04/26, at 1:32 P.M., the Manager said the resident could only have coffee at meal times. *The higher classification merited due to the extent of the violation and impact on the resident. Complaint MO00260556 & MO00260924 Missouri Department of Health and Senior Services STATE FORM 6899 ULCM11 If continuation sheet 14 of 14 PLAN OF CORRECTION Name: Provider/Supplier Autumn Court Healthcare Center LLC Street Address, City, Zip: 1421 South Landrum St. Mount Vernon MO 65712 Date of Survey: 03/04/2026 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A4703 Facility will ensure that a licensed nursing home administrator is designated as facility administrator. This will be the responsibility of the Regional Director of Operations, Human Resources and or designee 03.05.26 A4711 Facility will ensure that all employee background checks are completed through FCSR before the start of employment. This will be the responsibility of the Administrator, HR, and or designee 04.18.26 A4714 Facility will ensure that the EDL Inquiry is run with background check prior to the start of a new employee. The inquiry will be run through the DHSS website. This will be the responsibility of the Administrator, HR, and or designee 04.18.26 A4T24 Facility will ensure all employees complete a two step TB. The first step will be administered by the facility nurse and read 48- 72 hours after given. If negative then 24 step TB will be given 1 week after the first and read in 48-72 hours. This will be the responsibility of the facility nurse to complete, and the administrator and or designee to ensure it is completed. 04.18.26 A6011 Facility will ensure that any resident who has incontinence issues will be added to the hat room list which will ensure their roam is cleaned daily and free from offensive odor. This will be followed by our Angel Round Policy, This will be the responsibility of the Administrator and or Designee, Director of Care, Housekeeping, and Facility Staff. 05.03.26 A6012 Facility will ensure that all floors shall be cleaned and maintained in good repair. Kitchen staff will ensure that the kitchen floor is cleaned daily in between meal times and as needed. Facility will ensure all floors are in good repair by ensuring the sunroom floor to be repaired by 4/30/26, the carpeted areas repaired by 5/30/26 and the kitchen and laundry room floors repaired by 6/02/26. This will be the responsibility of the dietary staff to ensure floors are cleaned, Maintenance to ensure ail floors are repaired by the following dates, and the 06.02.26 Administrator and or designee to ensure all tasks are completed. Facility will ensure that all waste containers used in food preparation and utensil washing areas will be kept covered when not in use. This will be the responsibility of the Dietary Manager and Dietary Staff and or Designee A6031 05.03.26 Facility will ensure that all food is stored and identified with name, date of open, and date of expiration. Facility will make A7019 sure waterproof labels are used in the event they are needed. 05.03.26 This will be the responsibility of the Dietary Manager, Dietary Staff, and or designee Facility will ensure all nonfood contact surfaces are cleaned daily each shift and as needed to make sure all equipment is A?067 free from the accumulation of dust, dirt, food particles, and other 05.03.26 debris. This will be the responsibility of the Dietary Manager, Dietary Staff, and or designee Facility will ensure that coffee is provided outside of meal times via facility setting up a Keurig machine with coffee pods, and educating the residents on how to use, and staff helping A8042 residents as needed. Facility will ensure coffee pods are stocked 04.02.26 and restocked at the request of the residents. This will be the responsibility of the Dietary Manager, Facility Staff, Administrator and or designee 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: 04/02/2024 FORM APPROVED Missouri Department of Kealth and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA {X2} MULTIPLE CONSTRUCTION (X3) OATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20809C 8, WING ___ 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65742 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X65) 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 OATE DEFICIENCY) COMMUNITY OF AUTUMN COURT AT MT VERI A4724} 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20,100. This regulation is not met as evidenced by: Based on interview and record review, the facility staff failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening fests were administered timely for two of three sampled staff members (Personal Care Aide (PCA) A and Level One Medication Aide (LIMA) B). The facility census was 13. | General requirements for Tuberculosis testing for employees in Long Term Care Facilittes, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their employees for tuberculosis using the Mantoux method purified protein derivative (PPD - a skin test to determine if you have tuberculosis) two-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. Review of the facility policy titled "Infection Prevention and Control Manual TB Conirol Plan," datéd 2019, showed the following: © ~~~ Missourl Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE JC5M1414 if continuation sheel 1 of 2 PRINTED: 04/02/2024 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 20809C B. WING 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1421 SOUTH LANDRUM MOUNT VERNON, MO 65712 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) COMMUNITY OF AUTUMN COURT AT MT VERI Continued From page 1 -New employees will not be allowed to work until the Tuberculin Skin test or chest x-rays results are known; -Employees who will be receiving the two-step Tuberculin Skin test may begin work after the first step results are negative. 1. Review of PCAA's personnel file showed the following: -A hire and start date of 11/08/23; -Staff documented the first step of the TB test was administered on 03/08/24, with a negative reading on 03/11/24 (four months after start date); -Staff documented the second step of the TB test was administered on 03/19/24 with a negative reading on 03/21/24. 2. Review of LIMA B's personnel file showed the following: -A hire and start date of 05/10/23; -Staff documented the first step of the TB test was administered on 11/30/23, with a negative reading on 12/02/23 (six months after staff start date); -Staff did not document the second step of the TB test was administered. 3. During an interview on 03/28/24, at 2:30 P.M., the Manager said the following: -Staff TB tests are completed by the Licensed Practical Nurse (LPN); -The LPN is responsible for other facilities and is not in this facility on a daily basis. Missouri Department of Health and Senior Services STATE FORM 6899 JC5M11 If continuation sheet 2 of 2 ee PLAN OF CORRECTION | Provider/Supplier | 4s tumn Court Name: Street Address, City, Zip: 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 law. The submission of the plan of correction does not constitute an AAT24 | 1421 S. Landrum St, Mt Vernon MO 65712 COMPLETION DATE admission on the part of Seneca Home Place’to the findings nor the conclusions drawn there from. The facility's submission of the POC does not constitute an admission on the part of the facility that the findings constitute a deficiency. The facillty does screen all employees, as required for long term —_ ; The manager has audited ail ampioyee health flies for compliance with TB testing, Any employee out of compliance 5-41-24 has received their TB testing. The manager will be responsible for auditing employee files for compliance with TB testing requirements, monthly X6. Any imegularities Identified wil be comected immediaiely. The Regional Nurse will audit all employee TB testing P monthlyX6 and discuss audit with manager. fF All residents would be at nsk if ampioyees were not screened for TB as required. PGA A. and LIMA B’s TS skin testing is up to date. the pian of correction being submitted on this form.