SKYLINE ASSISTED LIVING LLC.

PRINTED: 11/20/2024 . FORM APPROVED Missouri Department of Heaith and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2} MULTIPLE CONSTRUCTION A BUILDING: (%3) DATE SURVEY COMPLETED B. WING 41/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 100 HARD ROCK ROAD DRIVE VAN BUREN, MO 63965 SKYLINE ASSISTED LIVING LLC SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) 10 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 19 CSR 30-88.020(14) Resident Fund Bond Requirements The bond required by section 198.096, RSMo, for operators holding personal funds of residents shall be in a form approved by the department and shall provide that residents who allege that they have been wrongfully deprived of moneys held in trust may bring an action for recovery directly against the surety. The bond shall be in an amount equal to at least one and one-half (1 1/2) times the average monthly balance of the residents ' personal funds, including residents ' petty cash, or the average total of the monthiy belances for the preceding twelve (12) months. The average monthly baianca(s) or the average total of the monthly balance(s) shall be rounded to the neerest one thousand doltars ($1,000). One (1) bond may be used to cover the residents ' funds in more than one (1) facility operated by the same operator, if the facility is a multilicensed facility on the same premises. If not on the same premises, then one (1) bond may be used if the bond specifies the amount of coverage provided for each individual facility and the coverage for each facility is a minimum of one thousand dollars ($1,000). l/l This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents’ personal funds) amount for at least cne and one haif times the average monthly balance of the residents’ personal funds for the last 12 consecutive months trom November 2023 through October 2024. This | had the potential to affect all residents for whom the facility holds personal funds. The fecility's census was 21. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {X86} DATE fa ‘71 Ja - SAS H continuation aheot 1 of 2 STATE FORM 4MUM11 PRINTED: 11/20/2024 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 11/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 100 HARD ROCK ROAD DRIVE VAN BUREN, MO 63965 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SKYLINE ASSISTED LIVING LLC Continued From page 1 Review of the residents' personal funds account for the last 12 consecutive months from November, 2023 through October, 2024 showed: - The facility's approved bond amount equaled $25,000.00; - The average monthly balance for the residents’ personal funds equaled $16,678.82; - An average monthly balance of $16,678.82 rounded to the nearest thousand equaled $17,000.00, at one and one half times will equal the required bond amount of at least $25,500.00. : Raview of the facility's approved bond, dated March 15, 2021, showed the amount for $25,000.00. During a telephone interview on 11/18/2024 at 11:55 A.M., the Administrator said he/she was the one taking care of the Resident Funds and didn't realize the bond amount was not enough and would take care of this as soon as possible. Missouri Department of Health and Senior Services STATE FORM arse 4MUM11 H continuation sheet 2 of 2 PLAN OF CORRECTION Nomen “PPler | Skyline Assisted Living P.O. Box 780 / 100 Hard Rock Road, Van Buren, MO. 63965 Street Address, City, Zip: Date of Survey: 11-18-24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER po 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION : COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This facility will maintain the surety bond {a purchased bond for security of residents’ personal funds) amount for at least one- A9023 and one-half times the average monthly balance of the residents’ personal funds for the last 12 consecutive months for November 2023 through October 2024. We have requested that the bond be increased to $30,000.00 and on November 21st the request was granted. We are Pending paperwork on the request and then it will be sent over to DHSS for approval. All residents that were effected has been covered by the new bond. 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: 03/14/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {XT} PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 29947 B.WING 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 100 HARD ROCK ROAD DRIVE VAN BUREN, MO 63965 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} SKYLINE ASSISTED LIVING LLC A2249 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class Il Based on record review and interview, the facility failed to ensure the complete fire alarm system was tested annually and semi-annually in accordance with NFPA 72, 1999 edition. The facility census was twenty one (21). This deficiency affects twenty one (21) of twenty one (21) residents. Record review showed no current semi-annual fire alarm inspection on file for review. Record showed the last alarm inspection on file was dated 12/29/2023. During an interview the owner said he did not know why the inspection had not been performed. During a phone interview with the alarm company, it was confirmed the inspection had not been completed. During an interview on October 09, 2024 at 12:05 P.M. the owner said he was not sure why the alarm company had not come out for the inspection, and would make sure the inspection was completed. Missouri Department of Health arid Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 10/09/24 STATE FORM 6899 HEO711 if continuation sheet 1 of 1 UNABLE TO LOCATE PLAN OF CORRECTION