NORTHRIDGE PLACE ASSISTED LIVING.

PRINTED: 02/19/2026 ; 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 | Cc 20525D B.WING 02/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 (X4) 1D 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) NORTHRIDGE PLACE ASSISTED LIVING 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 shail, - 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 i 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; IVIII I i | ! This regulation is not met as evidenced by: Class II* Based on record review and interview, the facility | staff failed document completed employee disqualification list (EDL - a state list of individual | unable to work in a long-term care facility) checks : prior to resident contact for for three employees (Level One Medication Aide (LIMA) A, LIMA B, and LIMA D) out of four sampled employees. The : facility census was 27. Review showed the facility did not provide a policy regarding complete of EDL checks. | 4. Review of current employee LIMAA's | personnel record showed the following: | -Hire and start date of 01/07/26; -Staff did not document an EDL check completed prior to the LIMA's hire/start date; -The file contained an EDL check completed on 02/09/26. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR BRG0 BEwSe nels REPRESENTATIVE'S SIGNATURE TITLE {X6) DATE p ADAG if continuation sheet 1 of 4° _ FORM 4UW211 PRINTED: 02/19/2026 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 C 20525D B. WING 02/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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) NORTHRIDGE PLACE ASSISTED LIVING 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 record review and interview, the facility staff failed document completed employee disqualification list (EDL - a state list of individual unable to work in a long-term care facility) checks prior to resident contact for for three employees (Level One Medication Aide (LIMA) A, LIMAB, and LIMA D) out of four sampled employees. The facility census was 27. Review showed the facility did not provide a policy regarding complete of EDL checks. 1. Review of current employee LIMAA's personnel record showed the following: -Hire and start date of 01/07/26; -Staff did not document an EDL check completed prior to the LIMA's hire/start date; -The file contained an EDL check completed on 02/09/26. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4UWZ11 If continuation sheet 1 of 4 PRINTED: 02/19/2026 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 C 20525D B. WING 02/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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) NORTHRIDGE PLACE ASSISTED LIVING Continued From page 1 2. Review of current employee LIMA B's personnel record showed the following: -Hire and start date of 09/11/25; -Staff did not document an EDL check completed prior to the LIMA's hire/start date; -The file contained an EDL check completed on 02/09/26. 3. Review of current employee LIMA D's personnel record showed the following: -Hire and start date of 12/08/25; -Staff did not document an EDL check completed prior to the LIMA's hire/start date; -The file contained an EDL check completed on 02/09/26. 4. During an interview on 02/09/26, at 3:40 P.M., the Administrator said the following: -He/She was an interim administrator and had been at the facility about a week; -He/She was an employee of the company and knows that Administrators are responsible for personnel records; -EDL inquiries should be completed before an employee is hired; -He/She thought the previous Administrator completed the EDL inquiries, but he/she could not find documentation. *The higher classification merited due to the extent of the violation and when effect combined with other deficiencies. 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 Missouri Department of Health and Senior Services STATE FORM 6899 4UWZ11 If continuation sheet 2 of 4 PRINTED: 02/19/2026 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 C 20525D B. WING 02/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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) NORTHRIDGE PLACE ASSISTED LIVING Continued From page 2 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 first step of 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 in a timely manner for two staff members (Level One Medication Aide (LIMA) B and LIMA C) of four sampled staff members. The facility census was 27. 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; -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 subsequent annual test within the past two years; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; Review showed the facility did not provide a policy related to TB testing of employees. 1. Review of LIMA B's personnel file showed the following: -Hire and start date of 09/11/25; -On 01/20/26, staff documented the first step of the two-part TB screening test was administered Missouri Department of Health and Senior Services STATE FORM 6899 4UWZ11 If continuation sheet 3 of 4 PRINTED: 02/19/2026 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 C 20525D B. WING 02/09/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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) NORTHRIDGE PLACE ASSISTED LIVING Continued From page 3 with a negative result noted on 01/22/26 (over four months after hire/start date); -Staff failed to document the second TB step was administered. 2. Review of LIMA C's personnel file showed the following: -Hire date and start date pf 11/17/25; -On 01/20/26, staff documented the first step of the two-part TB screening test was administered with a negative result noted on 01/22/26 (two months after hire/start date); -Staff failed to document the second TB step was administered. 4. During an interview on 02/09/26, at 3:40 P.M., the Director of Nursing (DON) said the following: -He/She was responsible for employee TB testing; -He/She was aware of TB requirements and tested both LIMAB and LIMA C for TB when they were hired; -The recent TB tests were screenings, as he/she screens all employees in January of every year; -He/She provided the TB documentation to the prior Administrator, but now cannot find the documentation. Missouri Department of Health and Senior Services STATE FORM 6899 4UWZ11 If continuation sheet 4 of 4 PLAN OF CORRECTION | Provider/Supplier Northridge Place Assisted Living Name: Street Address, City, Zip: 1500 Lynn St., Lebanon, MO 65536 Date of Survey: 2/9/2026 a 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 The filling of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the summary Statement of Deficiencies date 2/19/2026 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. Administrator and/or designee will verify that any individual is not listed on the Employee Disqualification List/(Abuse Registry F ani prior to being hired for any type of position at the facility. This Cngaing verification will be printed and placed in the employee's file. | An audit was completed of all current employee files to ensure the EDL is documented. Any that weren't documented were 2/9/2026 checked immediately to verify that they were not on the Employee Disqualification List/Abuse Registry. Administrator and/or designee will review the list of quarterly additions to the Employee Disqualification List to verify that none of our current employees have been added to this list after being Ongoing hired. After reviewing, this document will be signed and placed in file/binder. Both L1MA B and L1MA C will have the complete 2 Step TB test administered per regulations, properly document the results and file in the proper location. AA724 4/1/2026 Administrator and/or designee to review all employee files and resident charts to ensure TB screenings are up to date and complete. Administrator and/or designee will ensure ongoing TB screenings are completed in accordance with both state regulation and company policy for all future hires Ongoing -2567/State Form is indicating their approval of The Administrator signing and dating the first page of the CMS the plan of correction being submitted on this form.

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION PRINTED: 09/26/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED A. BUILDING: B. WING 20525D 09/23/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 NAME OF PROVIDER OR SUPPLIER NORTHRIDGE PLACE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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. |! | This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process, the sprinklered facility, licensed for more than twelve (12) beds on or after November 13, 1980, failed to provide _ separation from a hazardous area with | self-closing, smoke-resistant partitions or doors. The facility census was 22. This deficiency affects 13 of 22 residents. Observation revealed that the Northridge has a range/oven for resident use. The range/oven is in a common area and not enclosed within a 1-hour Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER ie SIGNATURE TITLE 1 le DATE ; STATE FORM 6899 M12711 If continuation sheet 1 of 4 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 20525D PRINTED: 09/26/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING: B. WING 1500 LYNN STREET NORTHRIDGE PLACE ASSISTED LIVING (X4) ID PREFIX TAG A2256 STATE FORM LEBANON, MO 65536 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 fire rated room. Power was secured to the range/oven. The facility does not have an exception for the range/oven. During the exit interview on September 23, 2025 at 4:30 PM, the administrator stated she would begin the paperwork for an exception from DHSS. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing _ Sprinkler Systems. | (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, | maintain, and test these systems in accordance with the requirements that were in effect for such | facilities on August 27, 2007. I/II | This regulation is not met as evidenced by: | Class Il | Based on record review and interview during the fire safety inspection process, the facility failed to maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. The facility census was 22. This deficiency affects 13 of 22 residents. Record review revealed a deficiency on Northridge's annual fire sprinkler inspection. The sprinkler system requires a 5 year inspection. | During the exit interview on September 23, 2025 _ at 4:35 PM, the maintenance man stated he | would call the sprinkler company and schedule the testing. Missouri Department of Health and Senior Services COMPLETED 09/23/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 2 of 4 PRINTED: 09/26/2025 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 20525D B. WING 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs) 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) NORTHRIDGE PLACE ASSISTED LIVING A3214 Continued From page 2 A3214 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in | effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not | present a safety hazard. All facilities shall have | wiring inspected every two (2) years by a qualified electrician. II/Ill | This regulation is not met as evidenced by: Class III | Based on record review and interview during the | fire safety inspection process, the facility failed to ensure the facility's electric wiring was properly | maintained. The facility census was 22. This deficiency affects 22 of 22 residents. Record review revealed the facility's electrical wiring certificate had expired in March 2025 During the exit interview on September 23, 2025 at 4:40 PM, the maintenance man stated he Missouri Department of Health and Senior Services STATE FORM 6809 M1Z711 If continuation sheet 3 of 4 PRINTED: 09/26/2025 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 20525D TN 09/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 (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) NORTHRIDGE PLACE ASSISTED LIVING A3214 Continued From page 3 _ would get an electrician in right away. Missouri Department of Health and Senior Services STATE FORM 6899 M1Z711 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Northridge Place — Assisted Living by Americare Name: Street Address, City, Zip: 1500 Lynn St., Lebanon, MO 65563 Date of Survey: 9/23/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 20525D COMPLETION PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION DATE SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Paper work submitted to DHSS for exception. Carmen, from DHSS, state they will meet in October for this approval. Will send in letter upon approval. Will have in binder and check quarterly that this will remain up to date. 10.31.2025 Sprinkler company notified. Will do inspection on 10.6.2025. Will A2269 send in inspection once completed. Will have in binder and 10.06.2025 quarterly that this will remain up to date. __eee | Electrical company notified. Inspection completed on 9.30.2025. A3214 Will send in inspection. Will have in binder and check quarterly 10.10.2025 to ensure this remains up to date. The filing of this plan of correction does not constitute any admission by the facility regarding the alleged violations stated in the summary Statement of Deficiencies date 09/23/2025 by the Missouri State Fire Marshall. This plan of correction is filed as evidence of our continuing commitment to provide care in pliance with applicable law. 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 COULD NOT BE OBTAINED. PRINTED: 12/13/2024 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 20525D — 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 (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) NORTHRIDGE PLACE-ASSISTED LIVING BY AMERIC, 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, the facility failed to maintain self closing smoke partition doors that separate the kitchen area from the dining area. The facility census was nineteen. This deficiency affects nineteen of nineteen residents. Observation revealed the kitchen smoke partition door's self-closure device failed to close the door. During the exit interview on December 4, 2024 at 1045 the maintenance man said he would have Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 XQ5V11 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: 20525D NAME OF PROVIDER OR SUPPLIER NORTHRIDGE PLACE-ASSISTED LIVING BY AMERIC, (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 the door repaired. 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 III Based on observation and interview during the fire safety inspection process, the facility failed to ensure all emergency lighting was operational. The facility census was nineteen. This deficiency affects nineteen of nineteen residents. Observation revealed an emergency light failed to illuminate, while depressing the test button, in the Arbors dining room. During the exit interview on December 4, 2024 at 1050, the administrator stated she would have the light repaired. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 XQ5V11 PRINTED: 12/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/04/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 20525D NAME OF PROVIDER OR SUPPLIER 1500 LYNN STREET LEBANON, MO 65536 NORTHRIDGE PLACE-ASSISTED LIVING BY AMERIC, SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 2 amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on observation and interview during the fire safety inspection process, the facility failed to ensure the facility's electric wiring was properly maintained. The facility census was nineteen. This deficiency affects nineteen of nineteen residents. Observation revealed a missing cover plate for a junction box in the kitchen of the Arbors. During the exit interview on December 4, 2024 at 1100, the maintenance man stated stated he would place a cover on it. Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: XQ5V11 PRINTED: 12/13/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/04/2024 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 3 of 3 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 07/08/2024 FORM APPROVED Missourt 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 20525D BoWUING acerca 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 (X4) ID | SUMMARY STATEMENT OF DEFICIENCIES i 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) NORTHRIDGE PLACE-ASSISTED LIVING BY Al 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 i administered timely for two staff members | (Licensed Practical Nurse (LPN) Aand Cook B) of five sampled staff members. The facility i census was 20. | General requirements for Tuberculosis testing for : employees in Long Term Care Facilities, 19 CSR | 20-20.100, reads as follows: -Long-ierm 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 subsequent annual test within the past two years. Review of the facility policy titled "Americare Senior Living Handbook,” dated September 2020, showed employees may be required to obtain a Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S 0 -PROVIDER/SUPPLIER REPRESE ITATIVE'S SIGNATURE TITLE (X6) DATE STANT: UUStRatIDKR orto /z024 STATE FORM ease B33211 {f continuation sheet 1 of 5 PRINTED: 07/08/2024 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 20525D B. WING 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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) NORTHRIDGE PLACE-ASSISTED LIVING BY Al Continued From page 1 tuberculin skin test post job offer. 1. Review of LPN A's personnel file showed the following: -Hire date of 05/06/24: -Start date of 05/28/24: -On 05/22/24, staff documented the first step of the two-part TB screening test was administered with negative results on 05/24/24: -Staff did not document the second step of the two-part TB screening test was administered. 2. Record review of Cook B's personnel file showed the following: -Hire date of 04/18/24: -Start date of 04/19/24; -On 04/17/24, staff documented the first step of the two-part TB screening test was administered; -Staff did not document the results of the first step of the two-part TB screening test; -Staff did not document the second step of the two-part TB screening test was administered. 3. During an interview on 06/26/24, at 2:30 A.M., the Administrator said the following: -The Director of Nursing (DON) started work at the facility on 05/28/24: -The DON is aware she is responsible for completing the staff TB tests; -The facility had a turnover of administrators and Directors of Nursing and the TB's fell to the wayside the past couple of months. 19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ Missouri Department of Health and Senior Services STATE FORM 6899 B33211 If continuation sheet 2 of 5 PRINTED: 07/08/2024 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 20525D B. WING 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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) NORTHRIDGE PLACE-ASSISTED LIVING BY Al Continued From page 2 The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (I) Written statement signed by a licensed physician or physician 's designee indicating the person can work in a long-term care facility and indicating any limitations; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure a written statement by a licensed physician or physician's designee indicating each staff member could work in a long-term care facility and indicating any limitations was on file for four staff members (Licensed Practical Nurse (LPN) A, Cook B, Dietary Aide (DA) C, and Activity Director (AD) D) for five sampled staff members. The facility census was 20. Review of the facility policy titled "Americare Senior Living Handbook," dated September 2020, showed the following: -The company/facility may require physical examinations, which may include a substance-abuse screening, and compliance with immunization standards for positions where mandated by state law or licensing agencies; -This is to ensure that staff are placed in a job that can be performed without endangering the health and safety of staff, our residents, or coworkers; -Any required physical exams will take place after an offer of employment is made (per state and local regulations). 1. Review of LPN A's personnel file showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 B33211 If continuation sheet 3 of 5 PRINTED: 07/08/2024 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 20525D B. WING 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 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) NORTHRIDGE PLACE-ASSISTED LIVING BY Al Continued From page 3 -Hire date of 05/06/24: -Start date of 05/28/24; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the LPN could work ina long-term care facility and indicating any limitations. 2. Review of Cook B's personnel file showed the following: -Hire date of 04/18/24; -Start date of 04/19/24; -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the cook could work in a long-term care facility and indicating any limitations. 3. Record review of DA C's personnel file showed the following: -Hire date of 01/29/24: -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the DA could work in a long-term care facility and indicating any limitations. 4. Record review of AD D's personnel file showed the following: -Hire date of 05/02/24: -The personnel file did not contain a written statement by a licensed physician or physician's designee indicating the AD could work in a long-term care facility and indicating any limitations. 5. During an interview on 06/26/24, at 11:00 A.M., Missouri Department of Health and Senior Services STATE FORM 6899 B33211 If continuation sheet 4 of 5 PRINTED: 07/08/2024 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 20525D B. WING 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1500 LYNN STREET LEBANON, MO 65536 (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) NORTHRIDGE PLACE-ASSISTED LIVING BY Al Continued From page 4 the Administrator said the following: -In December 2023, there were quite a few turnovers of Administrators and Directors of Nursing; -The Director of Nursing at the facility's memory care gave health exam forms to new staff to give to their physician and expected them back at the end of the month; -She doesn't believe the heath exams were getting done. Missouri Department of Health and Senior Services STATE FORM 6899 B33211 If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier NorthRidge Place Assisted Living Name: Street Address, City, Zip: ee Date of Survey: 06/26/2024 | PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 20525D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 1500 Lynn St, Lebanon, MO 65536 Administrator and/or designee to review all employee files and resident charts to ensure TB screenings are up to date and A4724 complete. Administrator will ensure ongoing TB screenings are completed in accordance with both state regulation and company policy for all future hires Administrator and/or designee compieted an audit of all emplayee’s personnel files to ensure that all have an employee health examination signed by a licensed physician/physician designee indicating the employee can work in a long-term care facility and indicating any limitations and a copy is in employee’s A4733 personnel file. Employees that didn’t have the physician 8/10/2024 statement in their personnel record were given statement and asked to return statement no later than 8/10/2024 Administrator will ensure ongoing compliance with employee physician statements in accordance with both state regulation and company policy for all future hires. 8/10/2024 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.