LAKE PARKE SENIOR LIVING.

THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) PRINTED: 02/11/2026 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 03/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 (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) LAKE PARKE SENIOR LIVING 19 CSR 30-86.022(4)(C) Range Hood Certification Range Hood Extinguishing Systems. (C) The range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. II/III This regulation is not met as evidenced by: Class III Based on interview and record review during the fire safety inspection process on March 25, 2025, the facility failed to ensure that the range hood and its extinguishing system shall be certified at least twice annually in accordance with NFPA 96, 1998 edition. The facility census was 46. This deficiency potentially affects 46 of the 46 residents. Paper work review of the range hood extinguishing system inspections showed an annual inspection was performed in May 2024, however no paperwork could be located for any semi annual inspections of the hood system. During an interview at 4:00 P.M., the owner/manager stated she had searched for the paperwork and was not able to locate it. 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 II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 F4VW11 If continuation sheet 1 of 7 PRINTED: 02/11/2026 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 03/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 (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) LAKE PARKE SENIOR LIVING Continued From page 1 Based on record review and interview during the fire safety inspection process on March 25, 2025, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The facility census was 46. This deficiency affects 46 out of 46 residents. Record review at 1:45 P.M. showed no semi-annual inspection had been performed on the fire alarm system as required by the National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. No records available. During an interview at 4:00 P.M. the owner/manager stated she was not aware the previous manager in charge had not obtained the inspection and that she would make contact with the company to have one scheduled. 19 CSR 30-86.022(12)(C) Emergency Lighting -Battery Powered, 1.5 hrs Emergency Lighting. (C) If battery-powered lights are used, they shall be capable of operating the light for at least one and one-half (1 1/2) hours. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on March 25, 2025 the facility failed to maintain emergency lighting and exit lights in good repair. The facility census was 46 This deficiency affects 46 of 46 residents. Observation at 11:33 A.M. showed the emergency light outside room 411 would not Missouri Department of Health and Senior Services STATE FORM 6899 F4VW11 If continuation sheet 2 of 7 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 LAKE PARKE SENIOR LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: CAMDENTON, MO 65020 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 illuminate when the test button was pressed. During an interview at 4:00 P.M. the owner/ manager stated he would get the emergency lighting fixed as soon as possible. 19 CSR 30-86.022(13)(A) Interior Finish-Class AJB - on/after 11/13/80 Interior Finish and Furnishings. (A) In a facility licensed on or after November 13, 1980, for more than twelve (12) beds, wall and ceiling surfaces of all occupied rooms and all exitways shall be classified either Class A or B interior finish as defined in NFPA 101, 2000 edition. Il This regulation is not met as evidenced by: Class Il. Based on observation and interview during the fire safety inspection process on March 25, 2025, the facility failed to ensure wall and ceiling surfaces of all occupied rooms and all exit ways shall be classified either Class A or B interior finish as defined in NFPA 101, 2000 edition in facilities licensed on or after November 13, 1980, for more than twelve (12) beds. Facility census is 46. This deficiency affects 46 of 46 residents. Observation at 11:24 A.M. showed two drop ceiling panels in the new pantry room had holes cut in them that vented all the way to the roof. Interview at 4:00 P.M. with the owner/manager, he stated the room was a previous laundry room and the holes allowed the dryers to be properly vented. He stated the holes will be patched and the drop ceiling tiles replaced as soon as Missouri Department of Health and Senior Services STATE FORM 6899 F4VW11 PRINTED: 02/11/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 7 PRINTED: 02/11/2026 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 03/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 (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) LAKE PARKE SENIOR LIVING Continued From page 3 possible. 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. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on March 25, 2025 the facility failed to ensure only metal or UL- or FIM-fire-resistant rated wastebaskets were being used for trash. Facility census was 46. This deficiency affects 46 of 46 residents. Observation throughout the fire inspection showed twenty seven unapproved wastebaskets in use throughout the building. The following rooms were noted with one to three violations each during the inspection. 10:56 A.M.- 1- room 205 bathroom 10:58 A.M.- 1- room 203 bathroom 11:01 A.M.- 1- room 201 living room 11:02 A.M.- 1- under the front desk 11:07 A.M.- 1- room 102 bathroom 11:11 A.M.- 1- room 103 bathroom 11:19 A.M.- 1- room 300 near kitchenette 11:30 A.M.- 1- near the counter in the coffee bar 11:35 A.M.- 2- room 410 bathroom and living room 11:38 A.M.- 1- whirlpool bathroom 11:40 A.M.- 2- room 409 bathroom and bedroom 11:44 A.M.- 1- room 407 living room 11:44 A.M.- 2- room 406 living room and bathroom Missouri Department of Health and Senior Services STATE FORM 6899 F4VW11 If continuation sheet 4 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER LAKE PARKE SENIOR LIVING ee (X2) MULTIPLE CONSTRUCTION A. BUILDING: CAMDENTON, MO 65020 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 4 11:48 A.M.- 1- room 405 bathroom 11:49 A.M.- 3- room 403 living room, bathroom and bedroom 11:51 A.M.- 1- room 402 bathroom 11:54 A.M.- 2- room 400 bathroom and living room 11:56 A.M.- 3- room 500 bathroom, laundry room and kitchen 12:02 P.M.- 2- room 501 bathroom and kitchen During an interview at 4:00 P.M. the owner/ manager expressed his apologies and stated he had not been around to the rooms to check for trash because he thought his manager was taking care of the issue. He also stated he would get them on order as soon as possible and a written reminder would be sent to all residents families reminding them of the regulation and rules. 19 CSR 30-86.032(2) Substantially Constructed & A3201 Maintained The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: CLASS III Based on observation and interview during the fire safety inspection process on March 25, 2025 the facility failed to ensure the building was being maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. The facility census was 46. This deficiency affects 46 of the 46 residents. Missouri Department of Health and Senior Services STATE FORM 6899 F4VW11 PRINTED: 02/11/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER LAKE PARKE SENIOR LIVING (X2) MULTIPLE CONSTRUCTION A. BUILDING: CAMDENTON, MO 65020 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 Observation at 11:00 A.M. showed the electrical panel in hallway 200 had not been sealed between the panel and the drywall. Observation at 11:25 A.M. showed the electromagnetic holding device on the fire door near the kitchen and nurses station has a loose drywall mount and was pulling away from the wall when the fire door was being closed. During an interview at 4:00 P.M. the owner/manager stated he would see that the drywall gaps were properly sealed up and the electromagnetic holding device was properly mounted in place. 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/Ill This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process on March 25, 2025 the facility failed to properly maintain the building's electrical wiring to not cause a safety or Missouri Department of Health and Senior Services STATE FORM 6899 F4VW11 PRINTED: 02/11/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 7 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 145 4TH STREET LAKE PARKE SENIOR LIVING CAMDENTON, MO 65020 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 6 fire hazard. The facility census was 46. This deficiency affects 46 of 46 residents. Observation at 11:32 A.M. showed an electrical box with exposed wiring on the wall in the library. Observation at 11:40 A.M. showed an unapproved multi plug adaptor in use in the bedroom area of room 409. Observation at 11:40 A.M. showed an unapproved extension cord in use in the bedroom of room 409. Observation at 11:48 A.M. showed an unapproved extension cord in use in the living room of room 404. Observation at 11:57 A.M. showed a missing outlet cover in the kitchen of room 500. During an interview at 4:00 P.M. the owner/manager stated he was not aware of all the electrical issues and he would get them fixed as soon as possible. Missouri Department of Health and Senior Services STATE FORM 6899 F4VW11 (X2) MULTIPLE CONSTRUCTION PRINTED: 02/11/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/25/2025 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 7 of 7 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 PRINTED: 10/08/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED R 09/22/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 LAKE PARKE SENIOR LIVING SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG {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 shall be used for trash. Il This regulation is not met as evidenced by: This deficiency is uncorrected. For prior examples. refer to the Statements of Deficiencies dated March 25, 2025. Based on observation and interview, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were used for trash. The facility census was 52. This deficiency affects 52 of 52 residents. Observation on September 22, 2025 starting at 2:17 P.M. through 2:45 P.M., showed the following: -1 non-metal or UL-FM fire-resistant rated wastebasket in use in suite 400; -1 non-metal or UL-FM fire-resistant rated wastebasket in use in suite 405; -2 non-metal or UL-FM fire-resistant rated wastebaskets in use in suite 410; -3 non-metal or UL-FM fire-resistant rated wastebaskets in use in suite 501; -1 non-metal or UL-FM fire-resistant rated wastebasket in use in suite 500; -1 non-metal or UL-FM fire-resistant rated wastebasket in use in suite 300. During an interview on September 22, 2025 at 3:45 P.M., the owner/manager said all residents had been advised to purchase new cans. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE {A2286} TITLE (X6) DATE 6899 If continuation sheet 1 of 1 F4VW12

LARE PARKE SENIOR LIVING SUMMAHY STATIOMENT OF DEFICENGES oa merk (EAGH DEFIORNCY MUST BE PREGEDED BY FU i Sa. RCT Ere tas REGULATORY OF 1 80 IRENTIE YING INFORMATION) : Tho i GROSS-HEPERENCED TO Mais AAFTE 19-CSR 20-80.047(13 (A) Criminal Background i ei Prior to allowing arly parsdn who hes been hired. | iti 3 full-time, partdime, or fempomry position to | have contect with any resident, the facility shat, orn the case of temporary emplayoes hired #hrough or contiacted from an emptoyment agency, the employrent agency shal, prior to sending a temporary employee to a facility: {A} Request 8 criminal barkyround check for the | Persea, as provided m section 650.317, RSMo. | Each facility shall maintain documents vertying that the background chacks were raquesied, the date of each such request, and the nature of the response received for tach Buch requesi. it This regidation ts not met as evidenced by: Class 8 i Based on imeniews and record reviews, facitity gtaft tailed to complete a Criminal Background Check (CBC) prior to ultowing new staf members | | ig have contact wih residents for one staff i {program manager) out of four sampled staff members. The facility census was 29. i { +. The facility did nol provide a policy forCBC = | Paquest { 2 Review of the program manager's personnel Me showed.a hire date of 13/11/2024. Review i : showed staff requested the CBC on 04/26/24, | | t Eksring an interview on 06/25/2024 al 4:45 P.M., the owner sad he/she wes responsitie for i Soripleting CAC reviews and was hoping to train | sother employes te complete these items. | He/She aaid he/she had gotten behind schedule / | LABORATORY DIRECTOR'S OR PEL Te REPRERENTATIVE'S GICMAT LE Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION A. BUILDING: AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30084 B. WING PRINTED: 07/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE PARKE SENIOR LIVING 145 4TH STREET CAMDENTON, MO 65020 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 44711 19 CSR 30-86.047(13)(A) Criminal Background A4711 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. Il This regulation is not met as evidenced by: Class |i Based on interviews and record reviews, facility staff failed to complete a Criminal Background Check (CBC) prior to allowing new staff members to have contact with residents for one staff (program manager) out of four sampled staff members. The facility census was 39. 1. The facility did not provide a policy for CBC request. 2. Review of the program manager's personnel file showed a hire date of 03/11/2024. Review | showed staff requested the CBC on 04/26/24. During an interview on 06/25/2024 at 4:45 P.M., the owner said he/she was responsible for completing CBC reviews and was hoping to train another employee to complete these items. He/She said he/she had gotten behind schedule. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM oma KOD111 PROVIDER'S PLAN OF CORRECTION FORM APPROVED (X3} DATE SURVEY COMPLETED Cc 06/25/2024 (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (x6) DATE If continuation sheet 1 of 4 PRINTED: 07/09/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X%3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 30084 ee 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 (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) LAKE PARKE SENIOR LIVING A4724 Continued From page 1 A4724 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Class Il Based on interview and record review, 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 test was administered for three (Resident #1, Resident #2, and Resident #4) of seven sampled residents in accordance with 19 CSR 20-20.100. The facility census was 39. 1. Review of Missouri state regulations 19 CSR 20-20.100 (tuberculosis (TB) testing for residents and workers in long-term care facilities) showed: -Long-term care facilities shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test (TST). Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -lf the resident's or employee's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; Missouri Department of Health and Senior Services STATE FORM 6899 KOD111 lf continuation sheet 2 of 4 PRINTED: 07/09/2024 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 30084 B.WING 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 (x4) 1D 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) LAKE PARKE SENIOR LIVING A4724 Continued From page 2 -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. 2. The facility did not provide a policy for TB requirements. 3. Review of Resident #1's medical record showed an admit date of 06/12/2024. Review showed the resident's medical record did not contain documentation staff administered the first step TB skin test. 4. Review of Resident #2's medical record showed an admit date of 06/17/2024. Review showed the resident's medical record did not contain documentation staff administered the first step TB skin test. 5. Review of Resident #4’s medical record showed an admit date of 06/14/2024. Review showed the resident's medical record did not contain documentation staff administered the first step TB skin test. 6. During an interview on 06/25/2024 at 5:50 P.M., the owner said the Director of Nursing (DON) is responsible for TB testing and screening. During an interview on 06/25/2024 at 5:45 P.M., the DON said he/she had been on vacation. He/She did not have another person designated to administer TB tests. Missouri Department of Health and Senior Services STATE FORM sana KOD111 {f continuation sheet 3 of 4 PRINTED: 07/09/2024 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 30084 BR VYING (ona 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 (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) LAKE PARKE SENIOR LIVING Missouri Department of Health and Senior Services STATE FORM 8899 KOD111 If continuation sheet 4 of 4 “PLAN OF CORRECTION r sh hema mea LAKE PARKE SENIOR LIVING Provider/Suppiier | Name: PROVIDER/SUPPLIER/CLIA IDENTIFICATION RUMBER 1O PREFIX TAG | PROVIDER'S PLAN OF CORRECTION: [EACH CORRECTIVEACTION | COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} | Aart | The ctiminal background check (CBC) must be performed j before any potential staff member is hired or allowed any ; teraction with the residents of Lake Parke Senior, minsnene sn | We wil perform the Criminal Background check (CBC) when we | make the decision to hire a new Staff mamber by contacting FCSR to perform the background check. in orderto be hired, = | | the potential staff member must have “No finding reported in | the background screening” on the background screening tesults document we receive from Family Care Safety Registry. ene tmnt We wii motitor this by having the hiring director perform tus 1 j background check prior to the completion of the hiring of the i new employee. Ths “Background Screening Result’ will be { i i Printed and put in the employee file i “This policy is in place on this date 7/15/2024 PLAN OF CORRECTION | Provider/Suppiter | aos atseiin b= ane Name: LAKE PARKE SENIOR LIVING | Street Address, Sine’ 145 41 ST CAMDENTON, MO 68020 a thet tir ati Acme hoe AP i Date of Survey: 06/2572024 Se Ce mea ADS PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 1D PREFIX TAG PROVIDER'S PLAN OF CORRECTION: [EACH CORRECTIVE ACTION | COMPLETION L | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIQENCY) | _ UATE. i T Recording to Missouri state regulations, lang term care faciities | are to screen residents and staff for tuberculosis using the | Mantoux method. This test must be completed within one ; | Month prior to or one week after admission, All residents new to i ; fong term care are required to have the initial test of a two-step AS724 | TB test, | if the resident’s or employee's initiat test is negative, the second | test should be given one to three weeks later These tests need | | to be read 48 to 72 hours after administration. ; { Our corrective action is as follows. = ae i ae “. i ? | 7 | We performed TB tests on all current residents and staff that | i | were identified as missing the 2-step testing. All residents and { } employees are current and updated on their TB screening in i ,_their fies FH 5I2024 a “| Moving forward we will test each new resident or employes prior | } to admission (or hiring) utliizing the 2 step TB testing process as 75/2024 | required by Missouri State regulations. This will be documented | } i ___ _,.n_ the file maintained for that resident or employee. i | Our director of nursing will moniter this process and ensure thai |---| the documentation is present in the resident or employee files. _ SEER — vesaapen: FASI2026

PRINTED: 11/08/2024 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 30084 B. WING 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 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) LAKE PARKE SENIOR LIVING 19 CSR 30-86.022(7)(A) Exits-2 per Floor-Remote/Unobstructed Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. Il This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on February 26, 2024, the facility failed to have at least two (2) Unobstructed exits remote from each other in the basement resident area. The facility census was 33. This deficiency potentially affected 33 of 33 residents. Observation at 3:25 P.M. showed two seperate, occupied, resident apartments as well as the resident storage rooms in the basement with both exit hallways in them blocked by numerous pieces of furniture and various objects. During an interview, at time of discovery, the new Director advised he would see that a 36 inch walk way would be cleared throughout all the basement exit hallways. 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 II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 YMMZ11 If continuation sheet 1 of 4 PRINTED: 11/08/2024 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 30084 B. WING 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 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) LAKE PARKE SENIOR LIVING Continued From page 1 Based on record review and interview during a fire safety inspection on February 26, 2024, the facility failed to insure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The faciliy census was 33. This deficiency affects 33 out of 33 residents. Record review at 3:30 P.M. showed no semi-annual inspection paperwork had been obtained to show the fire alarm system had been tested as required by the National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. During an interview at the time of discovery, the Director stated she believed the inspection had been performed and she would work to obtain the correct paperwork as soon as possible. 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, 1999 edition, at least annually. 1/II This regulation is not met as evidenced by: Class II Based on record review and interview during a fire safety inspection on February 26, 2024, the facility failed to insure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 ed. The faciliy census was 33. This deficiency affects 33 out of 33 residents. Missouri Department of Health and Senior Services STATE FORM 6899 YMMZ11 If continuation sheet 2 of 4 PRINTED: 11/08/2024 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 30084 B. WING 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 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) LAKE PARKE SENIOR LIVING Continued From page 2 Record review at 3:30 P.M. showed no annual inspection paperwork had been obtained to show the fire alarm system had been tested as required by the National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. During an interview at the time of discovery, the Director stated she believed the inspection had been performed and she would work to obtain the correct paperwork as soon as possible. 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. II This regulation is not met as evidenced by: Class Il Based on observation and interview during the fire safety inspection process on February 26, 2024 the facility failed to ensure only all metal or UL or FM fire-resistant rated wastebaskets were being used for trash. Facility census was 33. This deficiency affects 33 of 33 residents. Observation at 2:55 P.M. showed an unapproved metal trash can with a built in plastic liner in use in the bathroom in room 411. Observation at 3:00 P.M. showed an unapproved metal trash can with a built in plastic liner in use in room 408. Observation at 3:01 P.M. showed an unapproved metal trash can with a built in plastic liner in use Missouri Department of Health and Senior Services STATE FORM 6899 YMMZ11 If continuation sheet 3 of 4 PRINTED: 11/08/2024 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 30084 B. WING 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 145 4TH STREET CAMDENTON, MO 65020 (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) LAKE PARKE SENIOR LIVING Continued From page 3 in room 407. Observation at 3:05 P.M. showed an unapproved plastic trash can in use in room 405. Observation at 3:11 P.M. showed an unapproved metal trash can with a built in plastic liner in use in the bathroom of room 401. Observation at 3:15 P.M. showed an unapproved metal trash can with a built in plastic liner in use in the Sun room bathroom. Observation at 3:18 P.M. showed an unapproved metal trash can with a built in plastic liner in use in the basement resident room. During an interview at 3:55 P.M. the Director stated he will remove them and replace them with approved trash cans. Missouri Department of Health and Senior Services STATE FORM 6899 YMMZ11 If continuation sheet 4 of 4 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).