MAPLE TREE TERRACE ASSISTED LIVING.

PRINTED: 10/10/2025 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 G 17660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) 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) MAPLE TREE TERRACE ASSISTED LIVING 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: 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 test was administered timely for one of two sampled staff members (Level One Medication Aide (LIMA) A). The facility census was 16. General requirements for Tuberculosis Testing for | Employees in Long Term Care Facilities, 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 (1) subsequent annual test within the past two years. | Review showed the facility did not provide a policy for employee TB testing. 1. Review of LIMAA's personnel file showed the following: Missouri Department of H ORATORY DIRECTO Ith and Senior Services OR PR! ER/SUPPLIER REPRESENTATIVE'S SI x (X6) DATE 8WT011 If continuation sheet 1 of 11 PRINTED: 10/10/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 17660C E. WANG 09/23/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 NAME OF PROVIDER OR SUPPLIER MAPLE TREE TERRACE ASSISTED LIVING (X4) ID | PREFIX TAG A4724 | staff failed to ensure the required two step | tuberculosis (TB - a communicable disease that _ administered timely for one of two sampled staff SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 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 affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was members (Level One Medication Aide (LIMA) A). The facility census was 16. General requirements for Tuberculosis Testing for | Employees in Long Term Care Facilities, 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 (1) subsequent annual test within the past two years. Review showed the facility did not provide a policy for employee TB testing. 1. Review of LIMAA's personnel file showed the following: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6699 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) All employee files will be audited to ensure compliance with TB test requirements by November 7. DON will administer two step TB test for all new employees upon hire. DON will implement tracking tool to ensure all employee TB tests are in compliance with regulations no later than November 17. Regional support nurse will audit all employee TB tests monthly for one year to ensure compliance. TITLE (X6) DATE 8WT011 If continuation sheet 1 of 11 PRINTED: 10/10/2025 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 B. WING 09/23/2025 17660C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) MAPLE TREE TERRACE ASSISTED LIVING PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x4) ID PREFIX | TAG A4724 Continued From page 1 -Hire and start date of 01/20/25; -On 01/20/25, staff documented the first step of | the two-part TB screening test was administered | with a negative result noted on 01/23/25 (three days after start date): | -Staff did not document a second TB test was administered. During an interview on 09/23/25, at 2:25 P.M., the Director of Nursing (DON) said the following: -It was his/her responsibility to administer TB tests to new employees; | -He/She began working at the facility in ene | 2025 after LIMAA was hired; -He/She did not know LIMAA did not have the second TB test. During an interview on 09/23/25, at 4:33 P.M., the | | Administrator said the following: | -He/She had been the administrator for two | months; | -The DON was responsible for employee TB testing; -He/She just now became aware that LIMAAdid | not have the second TB test. 19 CSR 30-86.047(28)(G) Individual Service Plan | - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), | _ which means the planning document prepared by | an assisted living facility which outlines a resident | "'s needs and preferences, services to be provided, and goals expected by the resident or Missouri Department of Health and Senior Services STATE FORM 8WT011 DON received education on ISP development and regulations related to ISPs on 9/24/2025 from regional nurse consultant. DON will complete ISP for all residents within 24 hours of admission. DON will implement tracking tool recording the date of ISP and the next scheduled review for all residents no later than November 17. If continuation sheet 2 of 11 PRINTED: 10/10/2025 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 CG 17660C 2A ——————E—— 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (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) MAPLE TREE TERRACE ASSISTED LIVING A4754 Continued From page 2 Admin will review all ISPs as the resident ' s legal representative in partnership completed/updated with the facility; Il Admin will review tracking tool with This regulation is not met as evidenced by: | DON monthly to ensure ongoing Based on interviews and record review, the compliance facility staff failed to develop a complete individualized service plan (ISP - a document outlining a resident's needs and preferences, services to be provided, and goals expected by the resident or resident's legal representative in partnership with the facility) for one of three residents sampled (Resident #1). The facility census was 16. Review showed the facility did not provide a policy regarding ISP's. 1. Review of Resident #1's face sheet (basic medical information) showed the following | information: -Admission date of 01/02/25; -Diagnoses included high blood pressure and type two diabetes (a condition that affects the way | the body processes blood sugar). | Review of the resident's medical record showed staff did not have a documented ISP for the resident. During an interview on 09/23/25, at 4:06 P.M., the Director of Nursing (DON) said the following: -He/She was unaware that the resident did not have an ISP documented; -ISP's should be completed for each resident when they admit to the facility; -He/She was responsible for completing the ISP's. During an interview on 09/23/25, at 4:33 P.M. the Administrator said the following: | Missouri Department of Health and Senior Services STATE FORM 6899 8WT011 If continuation sheet 3 of 11 PRINTED: 10/10/2025 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 Cc 17660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) 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) MAPLE TREE TERRACE ASSISTED LIVING Continued From page 3 -He/She was unaware that the resident did not have an ISP documented; -The DON was responsible for completing ISP's; -An ISP was to be completed when a resident admits to the facility. 19 CSR 30-86.047(28)(H) Individual Service Plan | DON received education on ISP - Review Requirements _ completion and regulations related to ISPs on 9/24/2025 from the regional The facility may admit or retain an individual for nurse consultant. | residency in an assisted living facility only if the individual does not require hospitalization or DON will audit all current resident ISP skilled nursing placement as defined in this rule, and update as needed to ensure _and only if the facility: accuracy and compliance, including representative of the resident, at least annually or resident representatives no later than when there is a significant change in the resident November 17. s condition which may require a change in services; Il DON will update residents ISP on readmission, with any change of condition and every six months in accordance with policy and regulation effective immediately and ongoing. This regulation is not met as evidenced by: Based on interview and record review, the facility | staff failed to review the Individualized Service Plan (ISP- the planning document prepared by an | assisted living facility which outlines a resident's needs and preferences to be provided, and the goals expected by the resident or the resident's record the last ISP date and the next legal representative in partnership with the scheduled review date for all | facility) at least annually for two residents residents no later than November 17. (Resident #2 and #3). The facility census was 16. DON will implement tracking tool to Admin will review tracking tool with Review showed the facility did not provide a DON monthly to ensure ongoing policy regarding annual review of residents ISP's. | compliance. 4. Review of Resident #'2 face sheet (basic Regional nurse consultant will medical information) showed the following: monitor a sample of ISP quarterly to -Admission date of 08/06/19; ensure ongoing compliance. -Diagnoses included atrial fibrillation (abnormal and irregular heartbeat caused by chaotic Missouri Department of Health and Senior Services STATE FORM 6899 8WT011 If continuation sheet 4 of 11 PRINTED: 10/10/2025 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 C 17660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID 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) MAPLE TREE TERRACE ASSISTED LIVING Continued From page 4 electrical signals in the heart's upper chambers), post-polio syndrome (a progressive nerve and muscle disorder that affects some people who have had polio, usually decades after recovery), and coagulation defect (a condition where the blood's ability to form clots is impaired, leading to either excessive bleeding of abnormal blood clot formation). Review of the resident's medical record showed the following: -On 06/19/24, staff documented an ISP was completed; -Staff did not document a completed annual review for 2025. 2. Review of Resident #3's face sheet showed the | following: -Admission date of 05/16/23; -Diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down). Review of the resident's medical record showed the following: -On 02/22/24, staff documented an ISP was completed; -Staff did not document a completed annual review for 2025 3. During an interview on 09/23/25, at 4:06 P.M., the Director of Nursing (DON) said the following: -He/She was responsible for completing ISP's; -He/She knows the ISP's need to be updated at | least annually; -He/She did not know the residents’ ISP's were | not updated. Missouri Department of Health and Senior Services STATE FORM 6890 8WT011 If continuation sheet 5 of 11 PRINTED: 10/10/2025 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 C 17660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET MAPLE TREE TERRACE ASSISTED LIVING CARTHAGE, MO 64836 (X4) ID PREFIX | TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 | During an interview on 09/23/25, at 4:33 P.M. the Administrator said the following: -The DON was responsible for ISP's; -He/She did not know the residents' ISP's were not updated; -He/She knows the ISP's need to be updated at least annually. 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. I/II This regulation is not met as evidenced by: Class Il Based on observation, interview, and record review, staff failed to ensure all residents received proper care per their individualized service plan (ISP - a required document used by staff that outlines the services needed to meet the life goals of the individual as well as their support needs), when staff failed to provide nail care per the resident's ISP, when staff had a non-nurse complete wound care, and when staff failed to complete wound care as ordered for one resident (Resident #2). The facility census was 16. Review showed the facility did not provide a policy regarding wound care, nail care, and compression wrapping. Review of the Level One Medication Aide (LIMA) Student Instruction Manual, revised 1993, and produced/printed by the University of | Missouri-Columbia, showed the manual does not | include training regarding compression wrapping, | Missouri Department of Health and Senior Services STATE FORM 6699 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DON received education on appropriate wound care protocols from regional nurse consultant on 9/24/2025. DON will ensure the completion of all wound care according to physician orders by appropriately licensed personnel, arranging for home health services as indicated. All nursing staff will receive education on compression garments no later than November 17. DON will complete nail care on all diabetic residents and all residents on blood thinners. DON will ensure nail care is appropriately documented in the resident's electronic medical record effective immediately and ongoing. 8WT011 If continuation sheet 6 of 11 PRINTED: 10/10/2025 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 CS 47660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (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 i | DEFICIENCY) MAPLE TREE TERRACE ASSISTED LIVING Continued From page 6 wound care, and nail care. 1. Review of Resident #2's face sheet (basic medical information sheet) showed the following: -Admission date of 08/06/19; -Diagnoses included atrial fibrillation (abnormal and irregular heartbeat caused by chaotic electrical signals in the heart's upper chambers), post-polio syndrome (a progressive nerve and muscle disorder that affects some people who have had polio, usually decades after recovery), | and coagulation defect (a condition where the | blood's ability to form clots is impaired, leading to | either excessive bleeding or abnormal blood clot formation). Review of the resident's ISP, dated 06/19/24, showed the following: -Staff assistance with nail care as needed. Podiatrist or beautician to trim toenails; -Follow doctor's orders with wound care and dressings; -Resident takes anticoagulation (slows blood clotting) medication and is to be monitored for bleeding and bruising. Review of the resident's Community Based | Assessment (CBA-determines an individual's | specific needs for care and support before admission and periodically after), dated 04/09/25, showed the resident was totally dependent on staff for toe/fingernail care. Review of the document titled "Physician Communication Order," dated 03/28/25, showed the resident to have compression wrappings on both legs daily, below the knee. Review of the document titled "Communication to Physician," from facility Director of Nursing Missouri Department of Health and Senior Services STATE FORM 6899 8WT011 If continuation sheet 7 of 11 PRINTED: 10/10/2025 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 Cc 17660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THEAPPROPRIATE | DATE DEFICIENCY) MAPLE TREE TERRACE ASSISTED LIVING Continued From page 7 (DON), dated 04/30/25, showed the following: -Resident was refusing daily wraps, but will allow weekly wraps after his/her shower; -Physician faxed back "ok." Review of the resident's Physian Order Statement (POS), dated 09/05/25, showed the following: -A current order for Eliquis (used for blood thinning) 5 milligrams (mg) two times daily; -An order, dated 05/29/25, to clean wound to left | outer ankle with wound cleanser, apply santyl (topical ointment used to remove dead tissue) to wound bed, cover with calcium alginate (used in wound dressings as a healing gel), and cover with border gauze weekly after shower: -An order, dated 09/18/25, to clean wound to left outer ankle with wound cleanser, apply santyl to wound bed, cover with calcium alginate, and | cover with border gauze daily -A current order to wrap legs daily in the morning | for compression, after performing wound care. | Review of the resident's July 2025 Medication Administration Record (MAR) showed wound care provided by LIMA B on 07/02/25, 07/09/25, 07/16/25, 07/23/25, and 07/30/25. There was no | documentation related compression wrappings. Review of the resident's August 2025 MAR showed the following: -Wound care provided by LIMAB on 08/06/25, 08/20/25, and 08/27/25; -Wound care provided by the Director of Nursing (DON) on 08/13/25; -There was no documentation related compression wrappings. Review of the resident's September 2025 MAR showed the following: -Wound care completed by the DON on 09/03/25; Missouri Department of Health and Senior Services STATE FORM ad 8WT011 If continuation sheet 8 of 11 PRINTED: 10/10/2025 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 c 17660C B WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) 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) MAPLE TREE TERRACE ASSISTED LIVING Continued From page 8 -Wound care completed by LIMA B on 09/10/25 and 09/17/25: -No wound care completed 09/18/25 to 09/23/25 (order changed to daily wound care on 09/18/25): -Leg wrappings completed by LIMA B 09/19/25, 09/20/25, 09/21/25, 09/22/25, and 09/23/25. | During an interview on 09/23/25, at 11:15 A.M., the resident said the following: -He/She was supposed to get his/her legs wrapped daily, beginning in March, but this did not happen until August; -LIMA B was usually the one that wrapped his/her legs; | -LIMA B and other staff (other than the DON) were cutting his/her toenails. He/She complained to the DON and the DON cut them the last time a few weeks ago; -LIMA B was doing wound care on his/her ankle about once a week. He/She thinks this is supposed to be done daily now. Observation on 09/23/25, at 3:50 P.M., of the resident's left outer ankle showed a circular wound about one inch in diameter, with a purplish | color, covered with a bandage. During an interview on 09/23/25, at 1:08 P.M., LIMA B said the following: -He/She had been clipping the resident's toenails | as the DON asked him/her to do this; -The resident is on a blood thinner and he/she feels the DON should be clipping the toenails; -He/She has been completing compression wrapping for the resident's legs for several months; -The resident was having leg wraps weekly for several months, then daily for the past month or so; -He/She does the wrappings when he/she is Missouri Department of Health and Senior Services STATE FORM 6899 8WT011 If continuation sheet 9 of 11 PRINTED: 10/10/2025 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 C 17660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) 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) MAPLE TREE TERRACE ASSISTED LIVING Continued From page 9 working, and thinks other LIMA's may be doing this when he/she is off work; -He/She has been doing the wound care for the resident for four months. This is done weekly after his/her shower. He/She did not know about | a daily order for wound care. During an interview on 09/23/25, at 1:26 P.M., Lifestyle Coordinator (LSC)/LIMA C said the following: -The DON tells LIMA's, including him/her, to clip the resident's toenails; -He/She feels with the resident's conditions the DON should be clipping his/her toenails; -The resident has gone a long time in the past without his/her toe nails clipped; -The resident was supposed to have his/her legs | wrapped daily, but this was not being done till recently; -LIMA B was doing the resident's wound care and has been for a long time; -He/She also did the resident's wound care at times. During an interview on 09/23/25, at 2:25 P.M., the | DON said the following: -LIMA's are doing toenail clipping for non diabetic | residents and residents that are not taking blood thinners; -He/She clips the toenails of diabetics and residents taking blood thinners and clipped the resident's toenails a few weeks ago; -The resident did have an order for daily leg wrapping, but often refused and the physician discontinued this a while back; -The resident had been having daily leg wrappings since August. If LIMAB was working he/she did this, if LIMAB is off another LIMA | takes care of this area; -The resident was having wound care once a Missouri Department of Health and Senior Services STATE FORM Seep 8WT011 if continuation sheet 10 of 11 PRINTED: 10/10/2025 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 Cc 17660C B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) MAPLE TREE TERRACE ASSISTED LIVING Continued From page 10 week, but this order changed to once daily on 09/18/25; -They have not begun the daily wound care yet; -LIMA B generally does the wound care; -He/She did not know wound care was outside the scope of practice for LIMA's. During an interview on 09/23/25, at 4:06 P.M., the Administrator said the following: -He/She thinks the DON clips the toe nails of diabetics and residents on blood thinners; -He/She knew that the resident was not having his/her toenails clipped regularly and he/she told the DON to take care of this; -He/She did not know that wound care was outside the scope of practice for LIMA's. MO00258006 Missouri Department of Health and Senior Services STATE FORM 6899 8WT011 If continuation sheet 11 of 11

PRINTED: 12/19/2023 FORM APPROVED STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 17660C 6. WING 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1 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) MAPLE TREE TERRACE-ASSISTED LIVING BY A4714| 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 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) for four (Director of Nursing (DON) A, Dietary B, Certified Medication Aide (CMA) C and CMAD) of five sampled newly hired staff members prior to the staff member beginning employment with resident contaci. The facility census was 12. Review showed the facility did not provide a policy regarding completion of EDL checks. 1. Review of DON A's personnel record showed the following: -Hire and start date of 05/15/23; -The file did not contain an EDL check before start date; Missouri Department of Health and Senior Services BORAT Oe TORS OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE z we-raispote— (2/19/23 TATE FORM 6899 QGswi1 lf continuation sheet 1 of 3 PRINTED: 12/19/2023 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 17660C B. WING 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 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) MAPLE TREE TERRACE-ASSISTED LIVING BY Continued From page 1 -Staff documented an EDL check completed on 10/17/23. 2. Review of Dietary B's personnel record showed the following: -Hire and start date of 02/17/23; -The file did not contain an EDL check before start date; -Staff documented an EDL check completed on 10/17/23. 3. Review of CMA C's personnel record showed the following: -Hire and start date of 08/10/23; -The file did not contain an EDL check before start date; -Staff documented an EDL check completed on 10/17/23. 4. Review of CMA D's personnel record showed the following: -Hire and start date of 10/11/23; -The file did not contain an EDL check before start date; -Staff documented an EDL check completed on 10/17/23. 5. During an interview on 12/05/23, at 3:40 P.M., the Administrator said the following: -The corporate office is responsible for EDL checks; -The EDL checks should be in the file, but are also kept electronically; -Quarterly EDL checks were completed 10/17/23; -He/She cannot locate the missing EDL checks. Missouri Department of Health and Senior Services STATE FORM Sa99 QG5W11 If continuation sheet 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 17660C B. WING NAME OF PROVIDER OR SUPPLIER 2510 CLINTON STREET MAPLE TREE TERRACE-ASSISTED LIVING BY CARTHAGE, MO 64836 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 *The higher class merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 QG5W11 (X2) MULTIPLE CONSTRUCTION CROSS-REFERENCED TO THE APPROPRIATE PRINTED: 12/19/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/05/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 3 of 3 PLAN OF CORRECTION Seas Supplier Maple Tree Terrace Assisted Living by Americare Street Address, City, Zip: 2510 Clinton Carthage, MO 64836 12/05/2023 Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 17660C ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The filing of this correction does not constitute any admissions by the facility regarding the alleged violation stated in the Summary Statement of Deficiencies dated December 05, 2023 by the Missouri Department of Health and Senior Services. This plan of correction is filed as evidence of our continuing Commitment to provide care in compliance with applicable law. Immediate Action: Prior to allowing any employee contact with 1/4/2024 any resident, regardless of employment status, full, part or prn the facility will check the State EDL by making inquiry through DHSS website. Confirmation of the verification will be printed and placed in the employee confidential file. In addition, all active employees will be checked against the EDL quarterly. The Administrator will be responsible for compliance ongoing. ON A, Dietary B, CMA C, CMA D EDL’s will be printed out. 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.

An administrator signature on the 2567 & approved POC could not be found in file. PRINTED: 06/16/2025 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 17660C B. WING 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 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) MAPLE TREE TERRACE-ASSISTED LIVING BY 19 CSR 30-86.022(9)(B)(1)(B) Alarm/Detectors- Correct Faults Complete Fire Alarm Systems. (B) Facilities that are required to install a sprinkler system in accordance with section (11) of this rule shall comply with the following requirements: 1. Until the required sprinkler system is installed, each resident room or any room designated for sleeping shall be equipped with at least one (1) battery-powered smoke alarm installed, tested, and maintained in accordance with manufacturer "'s specifications. In addition, the facility shall be equipped with interconnected heat detectors installed, tested, and maintained in accordance with NFPA 72, 1999 edition, with detectors in all areas subject to nuisance alarms, including, but not limited to, kitchens, laundries, bathrooms, mechanical air handling rooms, and attic spaces. Il B. Upon discovery of a fault with any detector or alarm, the facility shall correct the fault. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on September 26, 2023, the facility failed to correct a fault in fire alarm system. The facility census on September 26, 2023 was thirteen (13). This deficiency potentially affected thirteen (13) of thirteen (13) residents. Observation on September 26, 2023 at 10:20 A.M., Showed the fire alarm system show a trouble light. Atest was performed at 10:32 A.M. and the system still call 911. Facility started a fire at that time and said it will perform it until the fire alarm is fixed. During an interview on September 26, 2023 at Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 X64011 If continuation sheet 1 of 2 PRINTED: 06/16/2025 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 17660C B. WING 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2510 CLINTON STREET CARTHAGE, MO 64836 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) MAPLE TREE TERRACE-ASSISTED LIVING BY Continued From page 1 1:39 P.M., the administrator said they would get the fire alarm system fixed and was calling the company right now. The administrator also said they would notify by email as soon as it was fixed. 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 Based on record review and interview on September 26, 2023, the facility failed to test and maintain the complete fire alarm system in accordance with the National Fire Protection Association (NFPA) 72, 1999 edition. The facility census on September 26, 2023 was thirteen (13). This deficiency potentially affected thirteen (13) of thirteen (13) residents. Record review on September 26, 2023 at 12:51 P.M. showed the last the semi-annual fire alarm inspection was done on October 13, 2021. The Maintenance personal done one in June of 2023. During an interview on September 26, 2023 at 1:39 P.M., the administrator said they would look into this. Missouri Department of Health and Senior Services STATE FORM 6899 Xx64011 If continuation sheet 2 of 2