LAKE GEORGE ASSISTED LIVING.

PRINTED: 11/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41), PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE|GCONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 28997 8. WING 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5000 EAST RICHLAND ROAD LAKE GEORGE ASSISTED LIVING COLUMBIA, MO 68201 (41D | SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION XS) PREEIX | (EACH DEFICIENCY MUST BE PRECEODED 8Y FULL. PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG : CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2283: 19 CSR 30-86.022(14)(A) Smoking in | A2283 , Designated Areas & Supervised Smoking. {A) Smoking shall be permitted in designated : areas only. Areas where smoking is permitted ' shall be designated as such and shall be supervised either directly or by a resident informing an employee of the facility that the area is being used for smoking. II/Iil . This regulation is not met as evidenced by: Class If] Based on observation, interview, and record review, facility staff failed to provide non-combustible ashtrays and non-combustible receptacles to dispose cigarette butts in two areas used for smoking. The facility census was eight. 1. Review of the facility's Smoking policy, - undated, showed smoking is strictly prohibited inside the building and the residents who choose . to smoke can enjoy this outside or ina specifically designated place. 2. Observation on 10/31/25 at 11:25 A.M., : showed Resident #1 smoked in his/her bedroom . while he/she sat in his/her recliner. Observation showed Certified Medication Aid (CMA) A told the : resident he/she is not supposed to smoke inside . and asked the resident to go outside to his/her back patio to where he/she is supposed to smoke. During an interview on 10/31/25 at 1:20 P.M., the Dietary Manager said the resident is supposed to smoke on his/her back patio and staff are supposed to smoke by the big tree in between . the assisted living building and the independent Missouri Department of Health and Jenior Services LABORATOR QIRECTOR'S OB PROWSER/SUAPLIER REPRESENTATIVE’S SIGNATURE i | © HTL f co d TEV (ay OL Ue Sigal STATE FORM” 4 eBay " 7X38W11 {f continuabon gheel lof 6 ae (X6) fay . Ie ft} PRINTED: 11/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT GF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE |CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED 28997 B. WING 2 | ne a 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5000 EAST RICHLAND ROAD COLUMBIA, MO 65201 (X4) IO SUMMARY STATEMENT OF DEFICIENCIES 8) PROVIGER'S PLAN OF CORRECTION (XS) PREFIX. (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ! LAKE GEORGE ASSISTED LIVING A2283. Continued From page 1 A2283 : living building. He/She said the resident is supposed to get the cigarette butt wet and throw it in the trash and said staff puts their cigarette butts out and then throws them in the trash. , During an interview on 10/31/25 at 1:22 P.M., | CMA B said the resident usually smokes on : his/her back patio, but the resident gets confused _ Often. He/She said staff are supposed to smoke - by the big tree in between the assisted living : building and the independent living building. CMA : B said the resident and staff get their cigarette | butt wet and throws the butts into the trash. During an interview on 10/31/25 at 1:22 P.M., | . CMA B said the resident usually smokes on | his/her back patio, but the resident gets confused : Often. He/She said staff are supposed to smoke by the big tree in between the assisted living _ building and the independent living building. CMA ' B said the resident and staff get their cigarette ’ butt wet and throws the butts into the trash. Observation on 10/31/25 at 1:27 P.M., shawed a big tree in between the assisted living building and the independent living building. Observation : showed the area did not contain non-combustible ash trays and did not contain a non-combustible receptacle to dispose cigarette butts. Observation on 10/31/25 at 1:29 P.M., showed : the residents back patio did not contain a non-combustible ash tray and did not contain a ; non-combustible receptacte to dispose cigarette butts. During an interview on 10/31/25 at 1:41 P.M., the Executive Director said the resident is supposed to smoke on his/her back patio and staff are Missouri Department of Health and Senior Services STATE FORM 6899 7TXSW11 If continuation sheet 2 of 6 PRINTED: 11/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE|CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: _| COMPLETED A 40/34/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5000 EAST RICHLAND ROAD COLUMBIA, MO 65201 (X4) 10 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) LAKE GEORGE ASSISTED LIVING A2283. Continued From page 2 A2263 - Supposed to smoke by the big tree or in their car. : He/She said the resident and staff are supposed to get the butt wet and throw them into the trash. The Executive Director said he/she did not realize the smoking areas had to contain non-combustible ash trays and non-combustible receptacles and thought they just had to be away from the building. | A4776. 19 CSR 30-86.047(35) Protective Oversight AAT76 Protective oversight shall be provided twenty-four (24) haurs a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident's departure, of the resident ‘s estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II This regulation is not met as evidenced by: ' Class Il Based on observation, interview, and record | review, facility staff failed to assess one resident (Resident #1) to determine if the resident could | smoke cigarettes safely, independently and | : without staff supervision. The facility census was | eight, . 1. Review of the facility's Smoking policy, ‘ undated, showed the following: _ -The facility's nursing staff will complete a smoking assessment; -A physician order for approval to smoke will be obtained: -Smoking is strictly prohibited inside the building; -The residents who choose to smoke can enjoy Missouri Department of Health and Senior Services STATE FORM 5899 7XAW11 If continuation sheet 3 of 6 PRINTED: 11/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT GF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLEICONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 28997 B. WING ___| = 10/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5000 EAST RICHLAND ROAD COLUMBIA, MO 65201 (%4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION {XS) PREFIX (EACH DEFICIENCY MUST 812 PRECLIDED BY FULL i PREFIX (EACH CORRECTIVE ACTICN SHOULD BE COMPLETE! TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS-REFERENCED TO THE APPROPRIATE DATE: DEFICIENCY) LAKE GEORGE ASSISTED LIVING A47768. Continued From page 3 ' this outside or in a specifically designated place. 2. Review of Resident #1's Community Based Assessment, dated 05/04/24, showed staffed assessed the resident as having some memory lapse regarding memory/recall, judgement and _ Orientation to date, day, and place. . Review of the resident's medica! record on 10/31/25, showed the medical record did not contain a smoking assessment. _ Review of the resident's Physician Order Sheet (POS), dated 10/13/25, showed: ' -Diagnosis of memory loss: : -An order for oxygen 2 liters as needed: -Did not contain an approval order for smoking. : Review of the resident's nurses notes dated showed: ~On 05/22/25 the resident smoked in his/her bathroom and ashes found in the residents sink: -On 07/20/25 the resident was caught smoking in his/her recliner at noon and he/she was asked to . go outside to smoke; . -On 09/10/25 the resident was caught smoking in ‘ his/her room. Staff reminded him/her it was not ' safe or a smart thing to do; _-On 09/11/25 the resident was in his/her room : smoking again and staff kindly told him/her that it : was not allowed and he/she needed to stay outside. Observation on 10/31/25 at 9:46 A.M., showed the residents room with a smell of cigarette smoke and a pack of cigarettes on the residents table. Observation showed an oxygen Missouri Department of Health and Senior Services STATE FORM 6399 7X3W11 IF continuation sheet 4 of 6 PRINTED: 11/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT QF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLEICONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING COMPLETED NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 6000 EAST RICHLAND ROAD COLUMBIA, MO 65201 {X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (KACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ' TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) LAKE GEORGE ASSISTED LIVING A4776 Continued From page 4 concentrator not on and nat in use by the _ residents bed and showed a portable oxygen tank in the corner of the residents room not on and not in use. : Observation on 10/31/25 at 11:15 A.M., showed _ the resident's door had a sign that said "Danger oxygen in use. No smoking or open flames." Observation on 10/31/25 at 11:25 A.M., showed the CMAA entered the resident's room to give him/her medications, when the resident was ; Observed in his/her recliner with a lit cigarette in ' his/her hand. Observation showed there was an - oxygen concentrator and an empty portable oxygen cylinder in the resident's room. Observation on 10/31/24 at 11:30 A.M., showed signs hung on the resident's closet door, refrigerator, back patio door, and bathroom door _ that read "No smoking. Must be 50 feet from building." During an interview on 10/31/25 at 11:27 A.M., _CMAA said the resident was caught smoking in ‘his/her room approximately six months ago and : the resident is supposed to smoke outside on his/her back patio. During an interview on 10/31/25 at 1:22 P.M., CMA B said the resident usually smokes on his/her back patio and was not sure if the resident smoking in his/her room has been an : issue or not. CMA B said the resident will wet his/her cigarette butt and throw it away in the trash after smoking. He/She said the resident is often confused. - During an interview on 10/31/25 at 1:41 P.M., the Missouri Department of Health and Senior Services STATE FORM BBa9 FXO If continuation sheet 5 af 6 PRINTED: 11/17/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLEICONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5000 EAST RICHLAND ROAD L AKE GEORGE ASSISTED LIVING COLUMBIA, MO 65201 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL, | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG GROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4776 Continued From page 5 Executive Director said the resident has not been assessed for smoking and did not realize the facility's smoking policy required residents to be - assessed for smoking. He/She said the resident has had a couple prior incidents of smoking in _ his/her bedroom and said after the incidents, the : resident was reminded not to smoke in his/her bedroom. The Executive Director said he/she would expect the resident to not smoke in his/her room and to smoke on his/her back patio. , He/She said the resident is expected to wet : his/her cigarette butt and throw them in the trash. He/She said the resident gets confused at times and just depends on the day. Missouri Department of Health and Senior Services STATE FORM egg 7K3W11 If continuation sheet 6 of 6 Name; | Provider/Supplier ~ PLAN OF CORRECTION — Lake George Assisted Living City, Zip: Street Address, 5000 E Richland, Rd, Columbia, MO 65201 Date of Survey: 10/31/2025 ID PREFIX TAG | ___| SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION This plan of correction (POC) is submitted a$ required under State and Federal law. This submission of POC does not constitute an admission on the part of Lake George Senior Living (the facility), as to the accuracy of the|surveyor findings, nor the conclusion drawn therefrom. The facility's submission of the POC does not constitute an admission oh the part of the facility that the findings cited are accurate, or that the scope and severity regarding their deficiencies cited ar@ correctly applied. The POC is intended to constitute the facility's credible letter alleging compliance. A2283 The facility has established a designated smoking area. The designated smoking area contains a non-combustible ash tray and a non-combustible receptacle to dispose of cigarette butts. The administrator is in-serviced by owner about the designated smoking area requirements. The facility staff are in-serviced by the administrator about the facility's smoking policy and availability of designated smoking area. Staff are also in-serviced on ensuring residents smoke only at designated smoking area. If any residents find smoking in a non-designated staff are instructed to natify administrator immediately. Resident # 1 is educated on smoking at the designated smoking area only. The administrator/ designee will check designated smoking area during the weekly check for 4 weeks to ensure there is a non- combustible ash tray and a non-combustible receptacle available to dispose of cigarette butts. Anything found out of compliance corrected immediately. 12/08/2025 | Asmoking assessment was done on Residént#1. 2 8 | J A physician order is obtained for Resident #/1 to smoke. Resident # 1 is educated on smoking at the designated smoking \ area only. DON is in-serviced by the owner about doing smoking assessments on residents who smoke. . The facility staff are in-serviced by the administrator about the facility's smoking policy and availability of désignated smoking area. Staff are also in-serviced on ensuring tesidents smoke only at designated smoking area. If any residents find smoking | in a non-designated staff are instructed to notify administrator immediately. | The DON/ designee will do facility wide audit to ensure if any other resident needs a smoking assessment. Then the DON will audit weekly for 4 weeks, ensuring smoking assessments are up to date. Anything found out of compliance cadrrected immediately. the plan of correction being submitted on this form.

PRINTED: 11/06/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (x2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 11/04/2024 28997 STREET ADDRESS, CITY, STATE, ZIP CODE 5000 EAST RICHLAND ROAD COLUMBIA, MO 65201 NAME OF PROVIDER OR SUPPLIER LAKE GEORGE ASSISTED LIVING PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x5) COMPLETE DATE (X4) ID PREFIX TAG 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 II Based on record review and interview during a fire safety inspection on November 4, 202, 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 facility census on November 4, 2024, was 9. This deficiency affects 9 out of 9 residents. Record review On November 4, 2024 at 2:45 P.M. showed no semi-annual inspection had been performed on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1. No records were available for a previous semi annual fire alarm inspection. During an interview on November 4, 2024 at 3:55 P.M. administrator stated she had contacted the owner and he had requested a copy of the inspection from the testing company, who she knew to have been at the location in April 2024. She also stated she would email me a copy of the inspection as soon as she recived it. * During a phone call from the owner on November 5, 2024 at 10:33 A.M. he stated he had discovered the testing company was on location on April 2, 2024, but had failed to perform a semi annual inspection on the Fire Alarm Missouri Department of Health and Senior Services TITLE (X6) DATE x ar If continuation sheet 1 of 2 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5000 EAST RICHLAND ROAD LAKE GEORGE ASSISTED LIVING COLUMBIA, MO 65201 PRINTED: 11/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 11/04/2024 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE A2249_ Continued From page 1 system. He stated they had only inspected the kitchen hood system when they were on location. Missouri Department of Health and Senior Services DEFICIENCY) If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: Lake George Assisted Living Street Address, City, Zip: Date of Survey: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This plan of correction (POC) is submitted as required under State and Federal law. This submission of POC does not constitute an admission on the part of Lake George Senior Living (the facility), as to the accuracy of the surveyor findings, nor the conclusion drawn therefrom. The facility's submission of the POC does not constitute an admission on the part of the facility that the findings cited are accurate, or that the scope and severity regarding their deficiencies cited are correctly applied. The POC is intended to constitute the facility's credible letter alleging compliance. Corrections will include: 5000 E Richland, Rd, Columbia, MO 65201 09/04/2024 The following was accomplished for the areas that have been affected by the alleged deficient practice: 1. The facility has done a complete fire alarm system inspection on September 13, 2024. The facility will conduct the next semi-annual fire alarm system inspection in March 2025. The facility will identify other areas having the potential to be affected by the same alleged deficient practice as follows: 12/18/2024 1. The facility has done a complete fire system inspection on September 13, 2024. The facility will conduct the next semi-annual fire alarm system inspection in March 2025. The facility will put measures in place and/ or make systematic changes to ensure that alleged deficient practice does not occur as follows: 1. The facility has requested the fire alarm testing Korsmeyer) to schedule both annual and semi-annual inspections at the facility in September and March accordingly. The facility will monitor the corrective actions to ensure the solutions are sustained as follows: 1. The Quality Assurance committee will monitor continued compliance with these corrective measures during quarterly meetings. Follow-up will occur as indicated. The Administrator signing and dating the first page of the CMS-2557/State Form is indicating their approval of the plan of correction being submitted on this form.