TEAL LAKE ASSISTED LIVING.

PRINTED: 11/05/2024 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 23534C B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1722 HUNTINGFIELD DRIVE MEXICO, MO 65265 10/22/2024 TEAL LAKE-ASSISTED LIVING BY AMERICARI (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES | 13} 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) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) : 19 CSR 30-86.032(3)(A) Additional ; Businesses-Requires DHSS Approval Only activities necessary to the administration of the facility shall be contained in any building used as a long-term care facility except as follows: ' (A) Related activities may be conducted in | buildings subject to prior written approval of these , activities by the Department of Health and Senior - Services (hereinafter-the department). Examples | Of these activities are Home Health Agencies, | physician ’ s office, pharmacy, ambulance service, child day care and food service for the : elderly in the community; liMH This regulation is not met as evidenced by: Class III Based on observation, interview, and record i | review, the facility failed to obtain approval from _ the Department of Health and Senior Services to | have a second business on the facility property i | when the facility kitchen provided off-site meals _ daily for residents in unlicensed independent | living apartments. The facility census was 20. "Review of the Department of Health and Senior | Services Second Log on 10/22/24 showed no | approval had been granted for a second . business, : 1,Observation on 10/22/24 at 10:00 A.M. of the | assisted living facility showed a meal delivery cart ; | for transporting meals prepared in the assisted | living kitchen to the independent living clubhouse for consumption by the independent apartment : residents. : _ 2.During interview on 10/22/24 at 10:00 A.M., the ; Dietary Manager said that the assisted living Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6} DATE KTUW11 if continuation sheet 1 of 2 PRINTED: 11/05/2024 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 23534C Be WING en 40/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1722 HUNTINGFIELD DRIVE MEXICO, MO 65265 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION i (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL i PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATICGN) | TAG CROSS-REFERENCED TO THE APPROPRIATE i DATE ! DEFICIENCY) : TEAL LAKE-ASSISTED LIVING BY AMERICARI Continued From page 1 dietary staff prepared meals in the assisted living | kitchen to be served off-site for residents of the unlicensed independent apartments. During interview on 10/22/24 at 4:40 P.M., the facility administrator said the following: -He had not been aware of the need for a second ; business license for the independent living meals; | -He would apply for a second business license as | it was his responsibility to do so; -It was his expectation that the facility be in compliance with ail regulatory requirements. Missouri Department of Health and Senior Services STATE FORM 6899 KTUW14 if continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Name: Teal Lake-Assisted Living by Americare Street Address, City, Zip: 1722 Huntingfield Dr. Mexico, MO 65265 Date of Survey: 40/22/2024 ID PREFIX TAG A3202 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 23534C COMPLETION DATE PROVIDER'S PLAN OF CORRECTION: The filing of this plan of correction does not constitute any admission by the facility regarding the alleged violation stated in the summary 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. The facility will ensure to obtain rea DHSS for the pur functions. uired approval from 10/29/2024 ose of additional (second) business No residents affected liance with the uirement, for all residents with the potential to be Measure taken to assure continued com cited rec affected: The Administrator and/or designee submitted additional business request to DHSS via E-mail dated 10/29/2024 2. The Administrator and/or designee will obtain new approval from DHSS for second business request every period as necessary to ensure continued compliance. | The above measure was accomplished as of 10/29/2024 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.