LODGE, THE.

PRINTED: 05/29/2025 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 BAWING 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 542 STATE ROUTE DD FAYETTE, MO 65248 (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) LODGE, THE A2256 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on 5/27/25, the facility failed to install and maintain self-closing smoke partition doors. The facility also failed to maintain one hour fire rated construction on all hazardous rooms. The facility census was fifty-four (54). This deficiency affected fifty-four (54) of fifty-four (54) residents Observation on building #1 (west building) revealed the kitchen and laundry room doors propped open with door stoppers, preventing self Missouri Department of Health and Senior Services PPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Aon sttat7l bf bofas If continuation sheet 1 of 3 STATE FORM PRINTED: 05/29/2025 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 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 542 STATE ROUTE DD FAYETTE, MO 65248 (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) LODGE, THE 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on 5/27/25, the facility failed to install and maintain self-closing smoke partition doors. The facility also failed to maintain one hour fire rated construction on all hazardous rooms. The facility census was fifty-four (54). This deficiency affected fifty-four (54) of fifty-four (54) residents Observation on building #1 (west building) revealed the kitchen and laundry room doors propped open with door stoppers, preventing self Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 DNWY11 If continuation sheet 1 of 3 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 LODGE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 closures from working properly. Observations found the roll window in the kitchen, with tea container blocking its ability to close properly. Observations on building #2 (east building) found the laundry room door propped open with a door stopper, preventing self closures from working properly. Observations also found the furnace room missing the attic cover, leaving the room open to the attic space. During the exit interview on 5/27/25 at 12:00 P.M. with the administrator, she shut the kitchen and laundry room doors during inspection, and stated she would locate the cover to the attic space. 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Protection from Hazards. (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class Il. Based on observation and interview on 5/27/25 the facility failed to ensure smoke partitions shall Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 DNWY 11 PRINTED: 05/29/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/27/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 542 STATE ROUTE DD FAYETTE, MO 65248 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 3 PRINTED: 05/29/2025 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 05/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 542 STATE ROUTE DD FAYETTE, MO 65248 (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) LODGE, THE Continued From page 2 be continuous from outside wall-to-outside wall, shall be self-closing, and shall not be held-open unless by an electromagnetic hold-open device connected to the fire alarm system. The census was fifty-four (54). This deficiency affects fifty-four (54) of fifty-four (54) residents. Observation on 5/27/25 found the fire rated door in resident rooms 101, 103, and 406 were being propped open with door stoppers. During an interview with the administrator on 5/27/25 at 12:00 P.M., she stated she would remove the stoppers from the rooms. Missouri Department of Health and Senior Services STATE FORM 6899 DNWY11 If continuation sheet 3 of 3 PLAN OF CORRECTION can | SUR OK DP, Fayette, MO ose PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION __ SHOULD BE CROSS-REFERENCED TO THE oo See ar ke ae _— cy A ddS¢ Ln building tnt. pel, db ln Lailhina pht.. tal A SANA ALL lhe FPF] “Zi dlie-st a LAA htt ban, SLAUAE ce a eee Fa back La pyast. Door styy Bare bec Az2GE ppaated Pegs tems pL lee # $4, iren all aPa_eaaal ten sere! ahaa tages Af aninistiaee type, fe | wahintigdnte 7 777 MET ITT? APE el We £2 [hahaa sng, Fiona atc all} Lj in the plan of correction being submitted on this form. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of

Could not obtain an administrator signature. PRINTED: 05/09/2024 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 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 542 STATE ROUTE DD FAYETTE, MO 65248 (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) LODGE, THE 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class Il. Based on observation and interview on 5/2/24, facility fails to ensure doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. Facility census is fifty-seven (57) This deficiency affects fifty-seven (57) of fifty-seven (57) residents. Observations showed laundry rooms in both buildings being held open by wedges. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 UEGM11 If continuation sheet 1 of 3 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 542 STATE ROUTE DD LODGE, THE FAYETTE, MO 65248 PRINTED: 05/09/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/02/2024 (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 Continued From page 1 Observations showed part of the ceiling drywall missing in the main buildings laundry room. Observations showed openings around pipes in sprinkler room. During interview with the administrator on 5/2/24 at 1:00 pm, she stated she would keep those doors shut and removed the wedges. Administrator stated the drywall missing was due to a leak in the ceiling and was scheduled to be fixed. Administrator stated that she would get the remaining pipes fire caulked. 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/IIl This regulation is not met as evidenced by: Class III Based on observation and interview on 5/2/24, the facility failed to insure that extension cords comply with electrical appliance approved standards. The facility census was fifty-seven (57). This deficiency potentially affected fifty-seven (57) of fifty-seven (57) residents. Missouri Department of Health and Senior Services STATE FORM 6899 UEGM11 DEFICIENCY) If continuation sheet 2 of 3 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 542 STATE ROUTE DD LODGE, THE FAYETTE, MO 65248 PRINTED: 05/09/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/02/2024 (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 Continued From page 2 Observations showed extension cords being used in resident rooms 105, 205, 303, and 505. Observations showed 3/6 way adapters being used in resident rooms 204,506,505,602,601, and 610. During the exit interview on 5/2/24 at 1:00 PM the administrator stated she would finish removing them from the rooms. Missouri Department of Health and Senior Services STATE FORM 6899 UEGM11 DEFICIENCY) If continuation sheet 3 of 3 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).