GARDEN VILLAS NORTH.

PRINTED: 10/28/2025 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: AZBURTBING COMPLETED Cc 28930 — 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, GITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFIGIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTIGN SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} GARDEN VILLAS NORTH 19 CSR 30-86.045(3)(A)(6 MA) Individual Evacuation Plan-Staff Requirements General Requirements. (A) If the facility admits or retains any individual needing more than minimal assislance due to | having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include the following components: A. The responsibilities of specific staff positions in an emergency specific to the individual: II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to provide the responsibilities of a single staff position who would be responsible for the resident in an emergency on the Individual Evacuation Plan (IEP), for two of four sampled residents (Residents #1 and #2). The census was 45, 1. Review of Resident #1's medical record, showed the facility admitted the resident on 6/6/24, with diagnoses which included diabetes and high blood pressure. Review of the resident's IEP dated 3/27/25, showed the following: -Mobility: the resident was unstable and required mechanical lift of two assists (private duty/Level One Medication Aide (LIMA) or two LIMAs with transfer to the wheelchair; -Need or additional staff: yes; -Staff member assigned: A assignment; -The JEP did not specify which staff member on the resident's hail would be assigned to the resident in the event of an emergency evacuation; Missour| Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE {6} DATE, <= NA wnunvetrol en Vile. STATE FORM sano 16N911 If coniinuation sheet 1 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDEN VILLAS NORTH (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued Fram page 1 -The IEP included the private duty person could assist in transfers. 2. Review of Resident #2’s medical record, showed the facility admitted the resident on 10/3/25, with diagnoses which include dementia, edema, anemia and asthma. Review of the resident's [EP dated 10/3/25, showed the following: -Mobility: the resident was unstable and required one person assist with transfer to the wheelchair; -Need for additional staff; no -Staff member assigned: B assignment; -The IEP did not specify which staff member on the resident's hall would be assigned to the resident in the event of an emergency evacuation. 3. During an interview on 10/14/25 at 2:49 P_MV., the Director of Nursing (DON) said there was a Caregiver assigned to assignment A and assignment B. There is a Medication Technician assigned to either assignment Aor B at any given time. The DON said she was responsible for the resident's IEPs, and she was not aware the IEP required specification on which staff member would be assigned to the resident during an emergency evacuation. 4. During an interview on 10/14/25 at 2:51 P.M., the Administrator said she was aware only one person was required to be assigned to the resident. The Administrator did not know the IEPs had more than one staff member listed. 19 CSR 30-86.047(41) Medication Storage/Accessibility Missouri Department of Health and Senior Services STATE FORM 899 16N914 PRINTED: 10/28/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 2 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDEN VILLAS NORTH (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. HAH This regulation is not met as evidenced by: Class I* Based on observation, interview and record review, the facility failed to properly store residents’ medications in a secure locked location, when medications were kept in an unlocked medication cart during the moming medication pass. The census was 45. Review of the facility's undated “Oral Medication Administration” policy, showed the staff were required to lock the medication cabinet. Review of the facility's undated “Eye Medication Administration” policy, showed the staff were required to lock the medication cabinet. 1. Observation on 10/14/25 between 7:43 A.M., and 7:46 A.M., showed Level One Medication Aide (LIMA) C left the medication cart unlocked in the hallway as he/she walked to the dining room to get a resident. The medication cart was out of sight and sound from LIMA C as he/she walked down the hallway into the dining room. Multiple residents were standing by and walking past the medication cart when LIMA C left it unlocked. The unlocked medication cart was parked with the drawers facing outward towards the hallway. 2. Observation on 10/14/25 between 7:34 A.M., and 7:37 A.M., showed LIMA C left the medication cart unlocked when he/she went into Missouri Department of Health and Senior Services STATE FORM 899 16N914 PRINTED: 10/28/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 3 of 14 PRINTED: 10/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GARDEN VILLAS NORTH Continued From page 3 resident room 151 to administer the resident's medication. The apartment door was completely closed, and the medication cart was out of sight and sound. The unlocked medication cart was parked with its drawers facing outward towards the hallway. 3. Observation on 10/14/25 between 7:41 A.M. and 7:42 A.M., showed LIMAC left the medication cart unlocked when he/she went into resident room 155 to look for the resident. The resident was not in the room. The apartment door was completely closed when LIMA C was inside of the resident's apartment looking for the resident. The unlocked medication cart was parked with its drawers facing outward towards the hallway. 4. Observation on 10/14/25 between 7:54 A.M. and 7:57 A.M., showed LIMA C left the medication cart unlocked when he/she went into resident room 154 to administer the resident's medication. The apartment door was completely closed, and LIMA C was inside the resident's bedroom. The medication cart was out of sight and sound from LIMA C. The unlocked medication cart was parked with its drawers facing outward towards the hallway. 5. During an interview on 10/14/25 at 1:05 P.M., LIMA C said he/she “probably” could have heard if someone got into the medication cart, but he/she should have locked the cart before leaving it. 6. During an interview on 10/14/25 at 2:46 P.M., the Director of Nursing said it was not okay to leave the medication cart unlocked in the hallway while in the resident's room. She said the drawers should be facing the doorway of the resident's Missouri Department of Health and Senior Services STATE FORM 6838 16N914 {f continuation sheet 4 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDEN VILLAS NORTH (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 room and not the hallway. 7. During an interview on 10/14/25 at 2:48 P.M., the Administrator said the medication cart should be locked at all times while not in active use and it should never be left unattended while unlocked. *The higher the classification merited due to the extent of the violation. 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ‘ instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident‘ s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquicl medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ‘s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if nota physician or a licensed nurse, shall be a certified medication technician or level | medication aide. iff Missouri Department of Health and Senior Services STATE FORM 899 16N914 PRINTED: 10/28/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet § of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDEN VILLAS NORTH (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 This regulation is not met as evidenced by: Class I Based on observation, interview and record review, the facility failed to ensure a safe and effective medication system when staff failed to administer medication appropriately when a Level One Medication Aide (LIMA) did not sanitize his/her hands or use gloves before administering eye drops. Also, the LIMA did not hold the inner canthus of a resident or instruct the resiclent to do so, after administering eye-drops, causing the medication to stream down the resident's cheek for one observed resident during the morning medication pass (Resident #5). Additionally, a LIMA pre-popped several resident's medications at one time which is against the facility’s policy for three of three observed residents in the morning medication pass (Residents #6, #7 and #8). Also, the LIMA picked up a medication without washing his/her hands or applying gloves beforehand for one resident's medication (Resident #10). Additionally, the LIMA did not watch a resident consume their medication before walking away for one observed resident during the morning medication pass (Resident #9). The census was 45. Review of the facility's undated "Eye Medication Administration” policy, showed the following: -Purpose: -To ensure all LIMAs use proper technique to administer eye medication; -Wash hands and apply gloves, hand sanitizer is NOT appropriate when administering ophthalmic (eyes) medications; -Hold the lower eyelid away from the eye to form a pouch; -For eye drops: Missouri Department of Health and Senior Services STATE FORM 899 16N914 PRINTED: 10/28/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 6 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDEN VILLAS NORTH (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 -Instill drop into the pouch, never directly onto the center of the eyeball: -With a gloved finger, apply pressure to the inside corner of the eye (inner canthus) for one minute. (Pressure does not need to be applied if the eye drop is a lubricate; artificial tears). If additional drop for the same medication is to be given, wait one minute before administering the second drop. If a different medication is io be given, wait five minutes before instilling the second medication. Review of the facility's undated “Oral Medication Administration” policy, showed the following: -Purpose: -To ensure all LIMAs use proper technique to administer oral medications; -Wash/clean hands and apply gloves if required. CAUTION: Medications may not come in direct contact with fingers/hands; -Note: Prepare only one resident's medication at a time; -Remain with the resident until the medication is swallowed. 1. Review of Resident #5's medical record, showed the facility admitted the resident on 4/15/21, with diagnoses which included Parkinson's disease and dementia. Review of the resident's Physician's orders sheet, showed an order for refresh eye drops. Instill one drop into each eye one time daily. Observation on 10/14/25 at 3:05 A.M., showed LIMA C, without sanitizingAwvashing his/her hands or putting on gloves, administered the eye drops to the resident just outside the dining room. LIMA C told the resident to tilt his/her head back and the resident did so. With an ungloved hand, LIMA Missouri Department of Health and Senior Services STATE FORM 899 16N914 PRINTED: 10/28/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 7 of 14 PRINTED: 10/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GARDEN VILLAS NORTH Continued From page 7 C pulled the resident's eye lid down and administered one drop into each eye. The lubricant rolled out of the resident's eyes and down his/her cheeks. LIMA C did not hold the inner canthus of either eye or instruct the resident to do so. LIMA C handed the resident a tissue and the resident wiped his/her cheeks and eyes with the tissue. 2. Observation on 10/14/25 at 7:55 A.M., showed LIMA C prepared a resident's medication without sanitizing or washing his/her hands beforehand. LIMA © dropped Isosorbide (used to prevent chest pain), 50 milligrams (mg) onto the medication cart and picked the pill up with his/her bare hand and put if in the medication cup. 3. Observation on 10/14/25 at 7:54 AM., LIMA C entered Resident #0's apartment and went into the resident's bedroom. The resident walked out of the bathroom and greeted LIMA C. LIMAC set the resident's medication on the nightstand near the resident's bed. The resident stood in the doorway of the bathroom as LIMA C exited the apartment. The resident did not take the medication in front of LIMA C and he/she did not ask the resident to take the medication in front of him/her. 4. Observation on 10/14/25 at 7:30 A.M., showed LIMA C had several resident's medications pre-popped in the medication cart. In the medication cart's drawer, were the following: -Resident #6's medication below was pre-popped in the medication drawer, -Vitamin C, 500 mg; -Vitamin D3; -Colace (used as a stool softener), 100 mg; -Daily vitamin; -Furosemide (used to treat fluid retention), 20 Missouri Department of Health and Senior Services STATE FORM 6838 16N914 {f continuation sheet § of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDEN VILLAS NORTH (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 mg; -Loratadine (used to treat allergies), 10 mg; -Metformin (used to treat diabetes), 500 mg; -Pravastatin (used to lower cholesterol), 20 mg; -Omeprazole (used to treat acid reflux), 20 mg; -Resident #7’s medication below was pre-popped in the medication drawer; -Align (used to treat digestive issues), 10 milliliters; -Calcium, 10 mg; -Carvedilo! (used treat high blood pressure), 6.25 mg; -Vitamin B12; -Entresto (used to treat heart failure), 24-26 mg; -Lexapro (used to treat anxiety), 10 mg; -Furosemide, 40 mg; -Giucosamine (used to maintain cartilage), 250-200 mg; -Meloxicam (used to treat osteoarthritis), 25 mg, -Omega 3, 1000 mg; -Spironolactone (used to treat heart failure), 25 mg; -Vitamin D3; -Resident #8's medication below was pre-popped in the medication drawer; -Aspirin (used as a blood thinner), 81 mg; -Potassium (used to treat heart failure), 25 mg; -Metoprolol (used to treat high blood pressure), 25 mg; -Omeprazole, 40 mg; -Torsemide (used to treat high blood pressure and water retention), 20 mg; -Vitamin D3; -Resident #9’s meclication below was pre-popped in the medication drawer; Missouri Department of Health and Senior Services STATE FORM 899 16N914 PRINTED: 10/28/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 9 of 14 PRINTED: 10/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GARDEN VILLAS NORTH Continued From page 9 -Aspirin 81 mg; -Potassium, 25 mg; -Metoprolol, 25 mg; -Omeprazole, 40 mg; -Torsemide, 20 mg; -Vitamin D3; -Ail of the medication cups were together in the top drawer. Each medication cup had the resident's room number written in Sharpie on the side of the cup. 5. During an interview on 10/14/25 at 1:00 P_M., LIMA © said he/she did not know to hold the inner canthus after administering eye drops. LIMA C said no one in management told him/her to do so and they should have. LIMA C said he/she sanitized his/her hands several times during the merning medication pass which is why he/she did not wear gloves when administering eye drops. LIMA C said he/she did net remember picking a medication up with his/her bare hand. LIMA C said Resident #9 usually took their medication without issue. LIMA C said he/she would not have known if the resident dropped a pill and could not take the medication. LIMAC said he/she should have watched the resident take the medication. LIMA C did not know pre-popping medication was against the facility's medication policy. He/she said the management "probably” went over the medication policy with him/her, but he/she did not remember. 6. During an interview on 10/14/25 at 2:44 P.M., the Director of Nursing (DON) said it was not okay to pre-pop medication, and it was against the facility's policy to do so. She said after a staff member administers eye drops to a resident, the staff needs to hold the inner canthus for a while so the eyeball can absorb the medication. The DON said the staff member should not have Missouri Department of Health and Senior Services STATE FORM 6838 16N914 If continuation sheet 10 of 14 PRINTED: 10/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GARDEN VILLAS NORTH Continued From page 10 touched the medication with an unwashed hand and should not have administered the eye drops without gloves on. She said the staff member should have watched the resident take the medication before leaving the apartment. 7. During an interview on 10/14/25 at 2:47 P_M., the Administrator said the staff should not have pre-popped the medication and he/she should have watched the resident take the medication. The Administrator said the staff should have held the resident's inner canthus after administering eye drops. She said the staff should have washed his/her hands or worn gloves before picking up a medication. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary fo keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. HI/III This regulation is not met as evidenced by: Class t* Based on observation and interview, the facility failed to ensure all staff washed their hands and/or wore gloves when plating and serving food in the kitchen. The census was 45. 1. Observation on 10/14/25 between 7:52 A.M. and 8:10 A.M., of the breakfast plating and service, showed the following: -At 7:52 A.M., Cook Adonned a set of gloves, Missouri Department of Health and Senior Services STATE FORM 6838 16N914 if continuation sheet 11 of 14 PRINTED: 10/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GARDEN VILLAS NORTH Continued From page 11 and with his/her left hand, closed the microwave door. With his/her right hand, he/she grabbed a pair of tongs and flipped the bacon. With both gloved hands, he/she moved slices of bread to the skillet top. With right hand, he/she grabbed the spatula to lift bread off the stove top, and used his/her left gloved hand on top of the bread to balance the bread on the spatula, to the plate. He/she walked to the toaster, opened the bread bag, and with both gloved hands, rernoved four slices of bread and placed them in the toaster. With his/her gloved right hand, he/she grabbed a spatula, and with his/her left hand, picked up a carton of liquid eggs and poured them on to the skillet top. With his/her right hand, he/she grabbed a set of fongs and moved a sausage patty from the warming tray onto a plate and placed the plate in the window for service. With his/her right hand, he/she used the tongs to remove two slices of french toast from the warming tray and placed them on a plate. With both gloved hands, he/she moved toast from the toaster to the skillet top, grabbed the tongs with his/her right hand, and removed more bread from the package. With both gloved hands, he/she placed bread into the toaster. With his/her right hand, he/she opened the microwave, removed the plate from the microwave, and placed it in the window. With his her right hand, he/she grabbed a spatula, and with his/her left hand, grabbed a carton of liquid eggs and poured them on the skillet top. With his/her right hand, he/she used the spatula to transfer the eggs to the plate, used tongs to place french toast on the plate, and with his/her left hand, grabbed a cinnamon roll, placed it on the plate, and placed the plate up in the window. With his/her right hand, he/she moved the toast from the toaster on to the skillet top, buttered the top of the toast, and used the spatula to move the toast from the skillet top fo a Missouri Department of Health and Senior Services STATE FORM 6838 16N914 If continuation sheet 12 of 14 PRINTED: 10/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) GARDEN VILLAS NORTH Continued From page 12 warming plate with his/her left hand on top of the toast. He/she placed the plate in the window for service. With his/her right hand, he/she grabbed tongs and moved a sausage patty to a plate, french toast to a plate, pancakes to a plate, and placed the plate in the window. With his/her right hand, he/she grabbed a spatula, lifted the toast with his/her left hand on top of toast to the plate. With his/her right hand, he/she grabbed a rag and wiped down the service top, walked to the sink, rinsed out the rag, and set it down. With his/her right hand, he/she opened the under counter refrigerator, and with his/her right hand, grabbed a hard boiled egg. With his/her right hand he/she grabbed tongs to move french toast to a plate. With both hands, he/she moved toast from the toaster to the skillet top, buttered the top of the toast, and used his/her right hand to grab a spatula to move the toast from the skillet top to the plate, with his/her left hand on top of the toast to balance on the spatula. With his/her right hand, he/she cracked four eggs onto the skillet top, removed the gloves, and washed his/her hands; -At 8:10 A.M., Cook A donned a new pair of gloves, grabbed tongs, and moved pancakes and sausage to a plate. With his/her right hand, he/she used a spatula to move eggs fo the plate and placed the plate in the window. With his/her right hand, he/she grabbed a pair of tongs and removed four slices of bread from the package. With both hands, he/she took the bread and placed them into a bowl. During an interview on 10/14/25 at 2:54 P.M., the Administrator said the cooks should be removing their gloves and washing their hands between any contaminants. She said Cook A should have absolutely have been changing gloves between tasks. Missouri Department of Health and Senior Services STATE FORM 6838 16N914 If continuation sheet 13 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER GARDEN VILLAS NORTH (X2) MULTIPLE CONSTRUCTION A. BUILDING: BLACK JACK, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 *The higher classification merited due to the extent of the violation. 19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. Ill This regulation is not met as evidenced by: Based on observation and interview, the facility failed fo ensure all non-food contact surfaces were clean. The census was 45. Observation on 10/14/25 between 7:35 A.M. and 2:10 P.M. of the kitchen, showed the following: -The freestanding stainless steel fryer covered with built up grease and food debris on the interior shelf under the fry baskets, on the side panels of the interior of the fryer, and going down the outside of the fryer walls; -The cooking range covered with built up black grease going half way up the back splash behind the right rear bummer; -The servery station covered with a grease build up and food debris, streaking down the front of the drawers. During an interview on 10/14/25 at 2:54 P.M, the Administrator said she was not sure what the kitchen cleaning schedule was but was aware they had one. She said she expected the surfaces in the kitchen to be free of grease and debris and was not sure why they were not. Missouri Department of Health and Senior Services STATE FORM 899 16N914 PRINTED: 10/28/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 10/14/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 44 of 14 Agency Name STREET ADDRESS, CITY, ZIP: Provider Number STATE PLAN OF CORRECTION Garden Villas North Assisted Living Community 4505 Parker Road, Black Jack, MO 63031 om 28930 Exit Date > 10/14/2025 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS - REFERRENCED TO THE APPROPRIATE DEFICIENCY) The Administrator signing and dating the first page of the STATE FORM (X5) is indicating their approval of the plan of correction being submitted COMPLETION on this form. DATE The Plan of Correction is submitted as required under State and Federal law. The submission of this Plan does not constitute an admission on the part of Garden Villas Assisted Living (the Community) as to the accuracy of the surveyors’ findings or the conclusions drawn there from. The Plan of Correction does not constitute an admission on the part of the Community that the findings cited are accurate and/or that the findings constitute a deficiency. Any changes to Community policies and procedures should be considered to be subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible by any third party in any civil or criminal actions against the community or any employee, agent, officer, director or shareholder of the Facility. The Community takes pride in ensuring that our residents are safe in the event of an 10/14/2025 emergency where a full or partial evacuation is necessary. The Individualized Evacuation Plans (IEPs) for Resident’s #1 and #2 were updated by the Administrator and Community Nurse to include the staff member’s assignment to assist in the event of an emergency. An audit was done on all IEP’s in the community and updated as needed. The Administrator and Community Nurse re-inserviced all direct care staff to ensure they understand the IEP process to include resident’s IEP assignments. The Administrator will review the IEP’s monthly and/or with resident change in condition to ensure no revisions are needed and staff are properly assigned. The community has a detailed policy and procedure regarding safe storage of 11/10/2025 medications to include being kept in a secured location behind at least one (1) locked cabinet. All LIMAs to include L1MA C were re-inserviced on the medication storage policy and procedure to include but not limited to the need to ensure the medication cart is locked when not in use or being supervised. Page 1 of 3 All new staff who administer medications will continue to be trained on proper medication storage to include locking of med carts. The Administrator and Community Nurse will check med carts at least weekly for the next (4) weeks and one (1) time monthly for following two (2) months to ensure compliance. The Community Nurse Manager (DON) will bring findings to monthly QAPI meeting for (3) months to ensure compliance. The Community has a safe and effective system of medication control although the 11/8/2025 policy read that pressure does not need to be applied if the eye drop is a lubricant such as artificial tears which is what was applied. The Community has revised the eye drop policy to read ALL eyedrops. All Medication Technicians/LIMAs to include LIMA C have been inserviced on the | 11/10/2025 new policy by the Community Nurse Manager (DON). The inservice included holding the inner canthus for one (1) minute after applying any eye drop. All Medication Technicians/L1MAs to include LIMA C also completed or will complete an Eye Drop competency with a return demonstration in the presence of the | 11/14/2025 Community Nurse Manager (DON). All Medication Technicians/L1MAs to include LIMA C were re-imserviced by the 11/10/2025 Community Nurse Manager (DON) on the Oral Medication Policy to mclude washing and applying gloves if required, preparing only one resident's medication at time and remaining with the resident until the medication is swallowed. This will be monitored by the Community Nurse by observing (1) LIMA per week for four (4) weeks and sharing the findings with the Administrator. Staff members are expected to thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as 1s necessary to keep them clean and after smoking, eating, drinking or using the toilet. All Cooks to include Cook A was re-in-serviced and completed a handwashing 11/14/2025 competency with the Director of Dining Services (DDS) to ensure a complete understanding of when handwashing must be done and proper techniques to ensure infection control and prevention. All Dining staff were re-in-serviced by the Director of Dining Services (DDS) on proper handwashing techniques. The DDS will observe 3 staff members per week for one month and monthly for (2) additional months to ensure all are dining services staff are properly following infection control procedures to include proper hand-washing techniques. The DDS will bring any findings to the monthly QAPI meeting for (3) months. Page 2 of 3 Nonfood contact surfaces of equipment will be cleaned a s often as necessary to keep | 11/10/2025 equipment free of accumulation of dust, food particles and other debris. The freestanding stainless steel fryer, interior shelf under the fry basket, the side panels of the interior fryer, outside of fryer walls, the cooking range back splash behind the right rear burner and the servery station surface and outside drawers have been thoroughly cleaned and placed on the departments cleaning schedule. The DDS will spot check the areas weekly for one (1) month and monthly for the following two (2) months for compliance. The DDS will bring findings to the QAPI meetings monthly for three (3) months. Page 3 of 3

PRINTED: 01/22/2025 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 28930 iid 01/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 (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} GARDEN VILLAS NORTH 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. Ill This regulation is not met as evidenced by: Class [i Based on record review and interview on January 08, 2025, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition. The facility census on January 08, 2025 was 37. This deficiency potentially affects 37 of 37 residents. Record review on January 08, 2025, at 2:55 P.M. showed no semi-annual inspection had been conducted of the fire alarm system as required by (NFPA) 72, 1999 edition. Table 7-3.1. During an interview on January 08, 2025, at 4:35 P.M. the facility Administrator said he/she would have the semi-annual fire alarm system inspection scheduled for six (6) months after the annual fire alarm system inspection is completed. 19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications Complete Fire Alarm Systems. (D) All facilities shall have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with NFPA 72, Missouri Department of Health and Senior Services LABORATORY PIRECEORS Sees ESENTATIVE'S SIGNATURE STATE FORM lf continuation shest 7 of 2 — wv2N11 PRINTED: 01/22/2025 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 BWING 01/08/2025 NAME OF PROVIDER OR SUPPLIER STREET AODRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 (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} GARDEN VILLAS NORTH | A2250) Continued From page 1 1989 edition, at least annually, I/Il This regulation is not met as evidenced by: Class 1) Based on record review and interview on January 08, 2025, the facility faited to have inspectians and written certifications of the complete fire alarm system completed by an approved qualified service representative in accordance with National Fire Protection Association (NFPA) 72, 1999 edition, at least annually. The facility census on January 08, 2025 was 37. This deficiency potentially affects 37 of 37 residents. Record review on January 08, 2025, at 2:55 P.M. showed no annual fire alarm system inspection had been conducted. Records show the last inspection and written certification of the complete fire alarm system was completed on January 09, 2023, During an interview on January 08, 2025, at 4:35 P.M. the facility Administrator said he/she contacted the facilities fire alarm system company and scheduled the annual fire alarm system inspection to be conducted on Fébruary 10th & 11th, 2025. Missouri Department of Health and Senior Services STATE FORM asa WV2N11 lf continuation shaet 2 of 2 PLAN OF CORRECTION Provider/Supplier Garden Villas North Name: — Street Address, 4505 Parker Road City, Zip: Date of Survey: January 8", 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE Garden Villas North does contract for a semi-annual inspection for our fire alarm system.in accordance with the National Fire 8/11/2025 Protection Association (“NFPA). The annual inspection will be performed on 2/10 and 2/11/2025, The Semi-annual will be due in six months from this date and will be scheduled as soon as the annual inspection is completed A2249 and will be performed no later than 8/11/2025. This will be done by the Maintenance supervisor and monitored for compliance by the Administrator. Garden Villas North does contract for an Annual Fire Alarm inspection in accordance with the National Fire Protection AZ250 Association (NFPA). The Annual inspection is set up for 2/10- Sn 2/11/2025. Upon completion the results will be forwarded to DFS. This will be done by the Administrator. Upon the completion of each inspection going forward a new inspection date will be set up for the next inspection- Annual and Semi Annual. This is will be done by the Maintenance Director and monitored by the Administrator for compliance, ongoing.; The Administrator signing and dating the first page of the CMS-2567/State Form is indicating thelr approval of the plan of correction being submitted on this form.

PRINTED: 09/27/2024 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 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 GARDEN VILLAS NORTH (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 GR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4749) 19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or F Raa C orre cH cy) be skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: A. Within five (5) calendar days of admission; I This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ansure the community based assessments (CBA) were completed fully and within five days of admission to the facility, for three of four sampled residents (Residents #4, #2 and #3). The census was 41. 1. Review of Resident #4's medical record, showed the following: -Admit date 8/5/16: -Diagnoses included high blood pressure, blindness, heart disease and anemia. Review of the resident's CBA dated 7/20/24, showed the following: -The prescription medication section had "refer to pos (physician's order sheet) in chart" documented but no physician orders for that time | were attached; -Prescription medication section left blank; -No doctor information listed; -No home health agency name listed; -No other health care providers listed. Missouri Department of Health and Senior Services LABORA’ Y DIRECTOR'S OR PROVI DER/SUPPLIER-REPRESENTATIVE'S SIGNATURE S TITLE a wished STATE FORM a cv2D11 Ifecontinuation sheet 1 of PRINTED: 09/27/2024 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 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4505 PARKER ROAD BLACK JACK, MO 63033 (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) GARDEN VILLAS NORTH Continued From page 1 2. Review of Resident #2's medical record, showed the following: -Admit date 4/15/21; -Diagnosis which included Alzheimer's disease, kidney disease, diabetes and high blood pressure. Review of the resident's CBA dated 4/5/24, showed the following: -No prescription medications listed; -No doctor information listed; -No home health agency name listed; -No other health care providers listed. 3. Review of Resident #3's medical record, showed the following: -Admit date: 9/24/22 -Diagnosis which included gait instability, history of stroke, osteoarthritis, and osteoporosis Review of the resident's CBA dated 9/6/24, showed the following: -The prescription medication section had "refer to pos in chart" documented but no physician orders for that time were attached; -No doctor information listed; -No home health agency name listed; -No other health care providers listed. 4. During an interview on 9/13/24 at 12:26 P.M., the Director of Nursing said she is responsible for completing the CBAs. She said she usually will write "see POS" on the form but she must have over looked attaching it to the form. She was not aware she was not completing the forms in full. 5. During an interview on 9/13/24 at 12:23 P.M., the Administrator said the Director of Nursing is responsible for completing the CBAs. She said the CBAs should be filled out completely and she Missouri Department of Health and Senior Services STATE FORM 6899 CV2D11 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 4505 PARKER ROAD GARDEN VILLAS NORTH BLACK JACK, MO 63033 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PRINTED: 09/27/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/13/2024 (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 A4749 Continued From page 2 expected the physician's orders pages to be attached. She was not aware they were not completed. Missouri Department of Health and Senior Services STATE FORM 6899 cv2D11 If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Nanie: Garden Villas North Street Address, — 4505 Parker Road, Black Jack MO 63033S City, Zip: Date of Survey: September 13, 2024 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 Staff at Garden Villas take great pride in the care and services provided to our residents. Residents #2, #3 and #4 CBAs (Community Based Assessment) A4749 have been completed to include Physician Order Sheet which 9/13/2024 includes Medications and Doctor information, home care agency and other health care providers. All residents CBA's (Community Based Assessment) have been reviewed and updated as needed to include the Physician Order sheet which includes medications, doctor information and home 10/4/2024 care agency or any other health care providers as requested/needed/preferred. Each resident upon admission, hospitalization or change in condition will have a CBA (Community Based Assessment) completed in full within 5 days to include the Physician order Sheet which includes Medications, doctor information and home care provider(s) (if applicable). This will be done by the community nurse. It will be monitored by the administrator, ongoing. 9/18/2024 A calendar was developed to identify when a CBA (Community Based Assessment) is due. The community nurse will complete the assessments in full within § days and include all required/pertinent information as listed above. The nurse will write "See Attached POS” and the Physician Order Sheet will be attached to the CBA to complete the document. This will be monitored by the Administrator to ensure full completion of the CBA, ongoing. The Administrator will check the CBA for all new admissions and re-admissions within 5 days to ensure nurse compliance with 10/4/2024 completion, ongoing