Every finding on record at Aspire Senior Living Excelsior Springs

Based on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to properly store and monitor food items for expiration dates, dispose of dented cans in a timely manner, and failed to maintain a three-day emergency food supply. This affected all residents in the facility. The facility census was 78.Request for facility Food Department Policies on food storage not provided;Observation in the Dry Storeroom on 1/5/25 at 9:00 A.M., showed:- Emergency Food Stock had only 12 cans of food and three bags of pasta for emergencies. - Two #10 sized cans of peans on the ground underneath the can storage rack. - Three rows of six #10 sized cans (18 total) in the can storage rack are dented and marked Do Not Use. - Three dented #10 sized cans on the ground labeled Do Not Use. Two are being used as door stops and one is just lying under a storage rack. One can is rusted and bulging on the side. - Large Plastic facility 5-gallon bin holding breadcrumbs dated 7/16/25 with no use by date.- Large Plastic facility 5-gallon bin holding gram cracker crumbs dated 10/18/25 with no use by date.- Large Plastic facility 5-gallon bin holding flour dated 10/14/25 with no use by date.- Large Plastic facility 5-gallon bin holding sugar dated 12/30/25 with no use by date.During an interview on 1/5/25 at 9:13 A.M., the Dietary Manager (DM) said:- There is not enough food in the emergency food supply to feed the residents for three days but she is working on restocking it through orders each week. - The dented cans have been here since the Thanksgiving and Christmas time frames. They are normally discarded with the food delivery driver once she feels the credit is large enough to make an impact. The food delivery driver will take them back anytime and regardless of quantity turned in and will give the facility credit for the dented cans. The food delivery driver comes to the facility weekly. Observation in the walk-refrigerator on 1/5/25 at 9:25 A.M., showed ground beef defrosting with a received date of 12/30/25 but no date for when defrosting started or a use by date.Interview on 1/5/25 at 9:27 A.M., the DM said that the hamburger was put in the refrigerator sometime during the weekend on 1/3/25 or 1/4/25. Observation in the Kitchen on 1/7/26 at 9:45 A.M., showed:- Dry storeroom had clear liquid shortening 5-gallon container, sitting on the ground;During an interview on 1/8/25 at 9:15 A.M., the DM said:- The budget is the main constraint on getting the three-day emergency food supply established quickly;- Food items should never be stored on the ground;- Bulk items such as sugar and flour are good for six months when they are not in their original storage packaging but should have a use by date;- There should be dating on food that is being defrosted as to when it started defrosting and when it should be used by;During an interview on 1/13/25 at 9:30 A.M., the Registered Dietician (RD) said:- Items that have been opened should be resealed and dated with a use by date and when they were originally opened;- Food items should not be stored on the ground;- Defrosted meat should have a date showing when it is to be used or at least when defrosting has started;- Dented cans should not be in the kitchen for four to six weeks, they should be turned in for credit at the next available opportunity;

Based on observation interview and record review the facility staff failed to complete inspection of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three of 18 sampled residents (Resident #51, #4 and #24). The facility census was set 78.1. Review of Resident #51's quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff dated 08/05/25 showed:-No cognitive impairment;-Dependent on staff for toileting and bed mobility;-Incontinent of bowel and bladder;-Two or more falls with injury since admission;-Diagnoses included Multiple Sclerosis (MS) a chronic autoimmune disease that can cause high cholesterol and depression.Review of the resident's care plan dated 01/04/26 showed:-Diagnosis of MS;-At risk for falls;-The resident had a non injury fall on 09/23/25;-The resident had a fall with injury on 01/01/26; -Used bilateral cane rails for bed mobility and positioning.Review of the resident's Physician's Order Sheet (POS) dated January 2026 showed:-Order for bilateral cane rails for bed mobility and positioning.Review of the resident's nurse's notes showed:-12/31/25 5:30 P.M., the resident was observed on the floor by the staff. The resident's right arm was caught behind him/her with his/her back to the dresser; -12/31/25 at 6:56 P.M., staff assisted the resident up in bed. The resident said he/she reached off the side of the bed to get something off the floor and his/her shoulder got caught in the bed rail.Review of the resident's medical record showed:-No documentation that an inspection of the bed frame and mattress had been done prior to the installation of bed rails;-No documentation that a regular and ongoing inspection of the bed frame, mattress, and bed rails, to identify areas of possible entrapment had been done. Observation on 1/6/26 at 3:11 P.M., showed:-The resident lying in bed and yelling for the staff;-Both bilateral cane rails in the up position at the head of the bed.Observation and interview on 1/7/26 at 10:48 A.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed;-The resident said the rails helped him/her get out of bed.2. Review of Resident #4's quarterly MDS dated [DATE] showed:-Severe cognitive impairment;-Dependent on staff for toileting and bed mobility;-One fall with injury since admission;-Diagnoses included heart failure, high blood pressure and anemia.Review of the resident's bed rail assessment dated [DATE] showed:-History of falls;-Bilateral assist bars used;-No height or weight of the resident was found on the assessment;-No documentation to confirm the bed rails installed were appropriate to the size and weight of the resident.Review of the resident's care plan dated 12/23/25 showed:-At risk for falls;-The resident had a non injury fall on 01/08/25;-The resident had a non injury fall on 04/18/25;-Used bilateral cane rails for bed mobility and positioning.Review of the resident's POS dated January 2026 showed:-Order for bilateral cane rails for bed mobility and positioning.Review of the resident's medical record showed:-No documentation that an inspection of the bed frame and mattress had been done prior to the installation of bed rails;-No documentation that a regular and ongoing inspection of the bed frame, mattress, and bed rails, to identify areas of possible entrapment had been done. Observation on 1/6/26 at 2:06 P.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed.Observation on 1/7/26 at 10:22 A.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed.3. Review of Resident #4's admission MDS dated [DATE], showed:-Severe cognitive impairment;-The resident had delusions;-The resident used side rails;-The resident required set up help with bed mobility;-History of falls prior to admission;-Diagnoses included atrial fibrillation (an irregular heartbeat), high blood pressure and Benign Prostatic Hyperplasia (BPH) enlargement of the prostate gland. Review of the resident's care plan dated 12/27/25, showed:-Impaired thought process related to dementia;-The care plan did not address the use of side rails.Review of the resident's bed rail assessment dated [DATE] showed:-Bilateral side rails used;-No height or weight of the resident was found on the assessment;-No documentation to confirm the bed rails installed were appropriate to the size and weight of the resident.Review of the resident's POS dated January 2026 showed:-Order for bilateral cane rails for bed mobility and positioning.Review of the resident's medical record showed:-No documentation that an inspection of the bed frame and mattress had been done prior to the installation of bed rails;-No documentation that a regular and ongoing inspection of the bed frame, mattress, and bed rails, to identify areas of possible entrapment had been done. Observation on 1/6/26 at 1:06 P.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed.Observation 1/7/26 at 09:22 A.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed. During an interview on 01/07/26 at 10:53 A.M., Certified Nurse Aid (CNA) A said:-Residents used the bed rails for positioning and bed mobility;-The nurses took care of completing any bed entrapment assessments;-The maintenance department took care of installing the bed rails;-He/She did not know anything about bed inspections.During an interview on 01/07/26 at 11:03 A.M., Licensed Practical Nurse (LPN) A said:-The Maintenance Director installed the bed rails after the evaluations were completed;-He/She did not know if bed inspections or were done or not.During an interview on 01/07/26 at 11:42 A.M., the MDS Coordinator said maintenance installs the rails. If there are bed inspections and measurements to take that would be maintenance department's responsibility.During an interview on 01/07/26 at 11:56 A.M., the Maintenance Director said:-He was responsible for the installation of bed rails;-He did not measure the resident beds before he/she installed the bed rails;-He did not do entrapment assessments;-He did not have ongoing inspection process for measuring the bed frame, mattress, and bed rails, to identify areas of possible entrapment;-Residents should be free from the risks of entrapment.During an interview on 1/07/16 at 12:02 P.M., the DON said:-The process for bed rails started at admission;-Maintenance was responsible for the installation of the bed rails;-He was not aware of entrapment assessments for residents with side rails; -He was not aware of an ongoing process for measuring the bed frame, mattress, and bed rails, to identify areas of possible entrapment;-Residents should be safe and free from the risk of entrapment.During an interview on 1/08/16 at 10:43 A.M., the Administrator said:-She was not aware the facility had to do entrapment assessments;-The facility did side rail assessments, but the height, weight and dimensions of the bed were not part of the assessment;-The facility did not have an ongoing process for measuring the bed frame, mattress, and bed rails, to identify areas of possible entrapment and she expected residents with side rails to be safe from possible entrapment.

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance, of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for three Residents (Resident #9, Resident #44, and Resident #68) of the 18 sampled residents. The facility census was 78. Review of the facility's Protecting, Promoting and Ensuring Resident Rights- Facility Responsibility policy, dated 1/30/25, showed every Resident has the right to be fully informed, in advance, about the care and treatment and of any changes in the care or treatment that may affect the resident's well-being. 1. Review of Resident #44's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 11/21/25, showed: - Cognition was intact - The resident took antianxiety medications on a regular basis; - The resident took antipsychotic medications on a regular basis; - The resident had diagnosis of anxiety and depression. Review of the resident's care plan, revised 11/21/25, showed: - The resident wishes to be included in his/her treatment plan; - The resident had an activities of daily living self-care deficit; - The resident used psychotropic medications for dementia with psychosis. Review of the resident's Physician's Order Sheet, dated 1/8/26, showed: - The resident began taking diazepam 2 milligrams (mg) by mouth at bedtime, an anti-anxiety medication, on 6/1/25; - The resident began taking quetiapine fumarate 12.5mg by mouth at bedtime, an antipsychotic medication, on 1/2/26; Review of the resident's electronic medical record showed there were no consents signed by the resident or the resident's representative before or after beginning these medications. 2. Review of Resident #68's Quarterly MDS, dated [DATE], showed: - The resident was not cognitively intact; - The resident was taking antianxiety, antipsychotic, and antidepressant medication on a regular basis; - The resident had diagnosis of anxiety, depression, and psychotic disorder. Review of the resident's care plan, revised 11/6/25, showed: - The resident had an activities of daily living self-care deficit related to confusion and limited range of motion; - The resident used psychotropic medication related to psychosis. Review of the resident's electronic medical record showed there were no consents signed by the resident or the resident's representative before or after beginning these medications. During an Interview on 01/05/2026 at 3:11 P.M. the resident's Durable Power of Attorney said the facility did not have him/her sign any paperwork regarding new medications, medication side effects, or medication changes. During an Interview on 01/08/2026 at 11:15 A.M. Registered Nurse (RN) A said: - He/she had not obtained written consent from the resident or their representative before beginning psychotropic medications; - He/she was not sure who is responsible for obtaining written consent before starting psychotropic medications. 3. Review of Resident #9's Minimum Data Set (MDS) dated [DATE], showed:- Cognition was not intact;- The resident took anti-anxiety and anti-depressant medication;- Diagnosis of depression, anxiety, and Post Traumatic Stress Disorder (PTSD, mental health condition triggered by experiencing or witnessing a traumatic event). Review of the resident's care plan, revised on 12/22/25, showed:- The resident had pain related to disability and depression and relied on nursing staff to anticipate and meet needs;- The resident had a psychosocial well-being problem and relied on staff to encourage him/her to socialize and participate in activities. Review of the resident's Physician's Order Sheet, dated 1/6/26, showed:- The resident began taking the anti-depressant medication Trazodone 100 milligrams (mg) daily on 10/6/25; - The resident began taking the anti-depressant medication Venlafaxine 150 mg daily on 10/9/25;- The resident began taking the anti-depressant medication Bupropion 150 mg one time a day on 10/11/25. Review of the resident's electronic record showed no consents had been signed by the resident and/or resident's representatives before or after medication administration. During an interview on 1/8/2026 at 8:12 A.M., the Assistant Director of Nursing (ADON) said:- Residents and their representatives should know potential side effects and reasons for taking psychotropic medications before taking them;- There should be signed psychotropic consents. We do get signed consent for psychiatric doctor to treat but have learned that is not sufficient. During an interview on 1/8/2026 at 10:30 A.M., the Director of Nursing (DON) said:- Residents and their representatives should know potential side effects and reasons for taking psychotropic medications before taking them;- He had never had the expectation to require psychotropic consents, that was a new one for him as he was newer to long term care. During an interview on 1/8/2026 at 12:17 P.M., the Administrator said:- Residents and their representatives should know the potential side effects and reasons for taking psychotropic medications before taking them;- There should be signed psychotropic consents.

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for five residents (Resident #85, #86, #87, #88 and #89) and failed to notify by letter one resident (Resident #7) when they were within $200.00 of the Supplemental Security Income (SSI) resources limit. This affected six of 18 residents sampled. Facility census was 78. Review of facility policy Facility Resident Trust Fund, undated, showed:- The individuals trust account should be kept below the balance of $5700.00 as a best practice rule, however, the current limit for Medicaid recipients is $5909.25. Any individual Resident Trust Account that is nearing (within $200 dollars) the state specified maximum balance will require the following action: notification to resident or responsible party via letter, discussion on items resident might need for comfort.- Refund for discharged resident: Must be completed within 5 business days of the resident discharge.- Refund for expired resident: Facilities must submit the Personal Funds Account Balance Report (TPL Form) to MO HealthNet for expired resident that were MO Healthet participants.- Certified facilities must submit the TPL Form within 30 days of expiration.- DSS will respond to the TPL with determination for the remaining fund and instructions should be executed within 60 days of the response.- Funeral expenses are the only funds to be surrendered after expiration. 1. Resident #7's Quarterly Minimum Date Set (MDS-a federally required assessment tool completed by facility staff), dated [DATE], showed: - Moderate cognitive impairment;- Diagnoses: anemia, diabetes, hip fracture, seizure disorder, bipolar disorder, psychotic disorder and anxiety disorder.Review of the facility's Accounts Receivable Aging Report, dated [DATE], and Current Resident Trust Fund Balance Sheet, dated [DATE], showed Resident #7 had a balance of $8,072.15 in the Resident Trust Account that was owed to the resident.During an interview on [DATE] at 8:55 A.M., the Business Office (BO) said:- She had a conversation with the resident about spending down his/her balance a month or so ago. She did not know that a letter was required to inform the resident of the need to spend down the balance when it got within $200 of the State required limit which the resident was currently above.2. Review of the facility's Accounts Receivable Aging Report, dated [DATE], and Current Resident Trust Fund Balance Sheet, dated [DATE], showed:- Resident #85 discharged on [DATE] and had a balance of $3.51 in the Resident Trust Account;- Resident #86 expired on [DATE] and had a balance of $268.27 in the Resident Trust Account;- Resident #87 discharged on [DATE] and had a balance of $10.00 in the Resident Trust Account;- Resident #88 discharged on [DATE] and had a balance of $57.31 in the Resident Trust Account;- Resident #89 was not listed on the accounts receivable aging report and had a balance of $27.38 in the Resident Trust Account. During an interview on [DATE] at 12:40 P.M., the BO said:- Residents #85, #86, #88, and #89 should have been refunded or their money sent back to Medicaid. These were oversights which she is working on to fix. - Resident #87 was issued a $10.00 check but it was returned undelivered back to the facility.During an interview on [DATE] at 2:40 P.M., the Administrator said resident accounts should be reconciled and refunded as necessary within 5 days of discharge but no later than 30 days.

Based on observation and interview, the facility failed to provide privacy for two Residents (Resident #2 and #39) of 18 sampled residents during cares when staff failed to close the privacy curtain during peri-care for Resident #39 and failed to close the window blinds when performing a dressing change to Resident #2's buttock wound. The census was 78. Review of the facilities Perineal Care policy, dated April 2025, showed:- Staff were to provide privacy by pulling curtain or closing room door if a private room. Review of the facilities Resident Rights policy, dated April 2025, showed:- The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality;- The resident has the right to personal privacy;- When providing resident care, always provide privacy by knocking and announcing yourself, pulling the curtain around the bed, pulling the drapes to windows, closing the door, and draping the resident's body appropriately. 1. Review of Resident #39's Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 11/5/25, showed:- Cognition was not intact;- The resident was dependent on staff for showers, transfers, and dressing;- Diagnosis of Alzheimer's disease, respiratory failure, and heart failure. Review of the resident's care plan, revised on 1/5/26, showed:- The resident required anti-anxiety medication;- The resident had a self-care deficit and relied on nursing staff to anticipate and meet needs;- The resident was totally dependent on staff for cares. Observation on 1/5/2026 at 3:32 P.M., showed:- Certified Nursing Assistant (CNA) B and CNA C entered the resident's room to perform peri-care and closed the resident's door;- The curtain between the resident and the resident's roommate, who was lying in his/her bed and able to observe the procedure, remained open;- The resident was exposed and peri-care performed in full view of the roommate. During an interview on 1/5/26 at 3:32 P.M CNA B said he/she would normally provide proper privacy between the resident and the roommate but did not. During an interview on 1/6/2026 at 3:15 P.M., CNA D said staff should pull the curtain between residents to provide privacy and preserve their dignity. During an interview on 1/8/2026 at 8:12 A.M., the Assistant Director of Nursing (ADON) said:- Privacy should be provided when performing peri care on the residents, including pulling the curtains;- The facility provides training on privacy and proper cleaning with the aides. During an interview on 1/8/2026 at 10:30 A.M., the Director of Nursing said privacy should be provided for the residents when the staff are performing peri-care. During an interview on 1/8/2026 at 12:17 P.M., the Administrator said:-Nursing staff should provide privacy when performing peri-care on the residents;-Privacy provided would also include the curtains are pulled and window blinds closed. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], showed: The resident was cognitively intact; The resident was dependent on staff for toileting, bathing, and dressing; The resident had diagnosis of muscle weakness, stage three pressure ulcer of right buttock, and neuromuscular dysfunction of the bladder. Review of the resident's care plan, revised 11/26/25, showed: The resident had a colostomy; The resident was on hospice (care that focuses on comfort rather than curing the disease); The resident had an above the knee amputation to the right leg. Observation on 01/08/2026 at 10:16 A.M. showed: The Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) B provided wound care to the resident; The resident's perineal area and buttock were exposed to provide wound care; While the resident was exposed the blinds to the window next to the resident's bed were opened to the parking lot and a car drove into the parking lot and parked while care was being provided. During an Interview on 01/08/2026 at 11:19 A.M. Resident #2 said He/she just wanted staff to do what they needed to do, in regard to providing privacy during care. During an Interview on 01/08/2026 at 10:55 A.M. the ADON said blinds in the resident's room should be closed when providing care to the resident to maintain privacy. During an Interview on 01/08/2026 at 11:15 A.M. Registered Nurse (RN) A said privacy should be provided to resident's when providing care when the resident would be exposed. During an Interview on 01/08/2026 at 11:55 A.M. Certified Medication Technician (CMT) B said blinds in resident's rooms should be closed when providing care when the resident would be exposed. During an Interview on 01/08/2026 at 1:01 P.M. Certified Nursing Assistant (CNA) E said blinds should be closed, with the door shut and curtains pulled when providing care to a resident who would be exposed. During an Interview on 01/08/2026 at 12:55 P.M. The Director of Nursing (DON) said blinds should be closed and curtains should be pulled when performing any care where the resident would be exposed.

Based on interview and record review, the facility failed to ensure an assessment of the Level I preadmission screening resident review (PASARR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities completed before admission to the nursing facility) was completed before admission for two Residents (Resident #68 and Resident #80). The affected two of 18 sampled residents. The facility census was 78. Review of the facility's Preadmission Screening for Individuals with a Mental Disorder/Intellectual Disability PASARR policy, dated 1/30/24, showed:- Ensure each resident in a nursing facility is screened for a mental disorder or intellectual disability prior to admission; - The initial screening is referred to as Level I identification of individuals with mental disorder or intellectual disability and is completed prior to admission to this facility;- PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. 1.Review of Resident #68's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 11/6/25, showed:- Cognition was not intact;- Was dependent on staff for completing activities of daily living;- Diagnoses of anxiety, depression, and psychotic disorder. Review of the resident's care plan, revised 11/6/25, showed:-He/She had the potential to be physically aggressive related to dementia;-He/She used psychotropic medications (medications that affect the mind, emotions, and behavior) related to psychosis;-He/She used anti-anxiety medication related to an anxiety disorder. Review of the resident's medical record showed that no documentation of a Level I PASARR had been completed. During an Interview on 01/08/2026 at 1:31 P.M. the Social Services Director (SSD) said:- The facility does not have documentation that a Level I PASARR had been completed; but they should have had one completed prior to admission;- The resident had admitted from a different facility and that facility did not provide documentation of a Level I PASARR;- She was not sure if the resident had a Level I PASARR completed. During an Interview on 01/08/2026 at 12:18 P.M. the Administrator said a Level I PASARR for each resident should be in the electronic medical record. When a resident is admitted from another facility, this facility will attempt to obtain the Level I PASARR from the other facility, but they do not always send it. During an Interview on 01/08/2026 at 12:55 P.M. the Director of Nursing (DON) said a Level I PASARR should be completed before a resident is admitted to the facility; and should have been done for this resident. He was not sure what the policy is on obtaining a PASARR for a resident if they were being admitted from another facility.

Based interview and record review the facility failed to provided care and treatment in of accordance with professional standards of practice when facility staff failed to follow physician's orders for three of 18 sampled residents (Resident #5, #24 and #68), when staff did not provide Mighty Shakes (a nutritional supplement used in individuals needing supplemental nutrition) and failed to notify the physician the shakes had not been given to Residents #5, #51 and #68 as ordered. The facility census was 78.The facility did not provide the requested policy regarding professional standards. 1.Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff dated 11/20/25 showed:-No cognitive impairment;-Partial assistance from staff with bed mobility and toileting; -Incontinent of bowel and bladder; -Diagnoses included dementia, low blood pressure and anxiety. Review of the resident's care plan dated 11/22/25 showed:-The resident had a potential nutritional problem related to dementia;-The resident was ordered a Mighty Shake in the morning to help promote weight gain. Review of the resident's Physician's Order Sheet (POS) dated January 2026, showed the order start date was 11/25/25, for a Mighty Shake three times a day. Review of the resident's Medication Administration Record (MAR) dated December 2025, showed no mighty shakes were given on the following days:-12/8/25 at 10:39 A.M.;-12/8/25 at 3:08 P.M.; -12/9/25 at 9:43 A.M.; -12/16/25 at 10:13 A.M.; -12/21/25 at 12:40 P.M.; -12/22/25 at 10:58 A.M.;-12/22/25 at 2:36 P.M.;-12/22/25 at 8:12 P.M.;-12/23/25 at 8:34 A.M.;-12/30/25 at 8:43 A.M. Review of the resident's MAR dated January 2026, showed no mighty shakes were given on the following days:-1/5/26 at 9:24 A.M.;-1/5/26 at 8:09 P.M.;-1/6/26 at 8:09 A.M. Review of the residents nurse's notes showed:-12/8/25 at 10:39 A.M., Mighty shake, out of supplement at this time;-12/8/25 at 3:08 P.M., Mighty shake, out of supplement at this time;-12/9/25 at 9:43 A.M., Mighty shake, out of supplement at this time;-12/16/25 at 10:13 A.M., Mighty shake, out of supplement at this time;-12/21/25 at 12:40 P.M., Mighty shake, out of supplement at this time;-12/22/25 at 10:58 A.M., Mighty shake, out of supplement at this time;-12/22/25 at 2:36 P.M., Mighty shake, out of supplement at this time;-12/22/25 at 8:12 P.M., Mighty shake, out of supplement at this time;-12/23/25 at 8:34 A.M., Mighty shake, out of supplement at this time;-12/30/25 at 8:43 A.M., Mighty shake, out of supplement at this time;-1/5/26 at 9:24 A.M., Mighty shake, out of supplement at this time;-1/5/26 at 8:09 P.M., Mighty shake, out of supplement at this time;-1/6/26 at 8:09 A.M., Mighty Shake, out of supplement at this time;-No documentation in the clinical record showed the Physician or Registered Dietitian (RD) had been notified. 2. Review of Resident #4's Quarterly MDS dated [DATE] showed:-Severe cognitive impairment;-Dependent on staff for toileting and bed mobility;-Diagnoses included heart failure, high blood pressure and anemia. Review of the resident's care plan dated 12/23/25 showed:-The care plan did not address the resident's use of health shakes. Review of the resident's POS dated January 2026 showed the order start date was 8/12/15, for Mighty Shake three times a day. Review of the resident's MAR dated December 2026, showed no there was no Mighty Shakes were given on the following days:-12/8/25 at 8:00 A.M.;-12/8/25 at 12:00 P.M.; -12/9/25 at 8:00 A.M.; -12/16/25 at 8:00 A.M.; -12/22/25 at 8:00 A.M.;-12/22/25 at 12:00 P.M.;-12/22/25 at 8:12 P.M.;-12/23/25 at 8:00 A.M.-12/30/25 at 8:43 A.M. Review of the resident's MAR dated January 2026, showed no mighty shakes were given on the following days:-1/5/26 at 8:00 A.M.;-1/5/26 at 12:00 P.M.;-1/6/26 at 8:00 A.M. Review of the residents nurse's notes showed:-12/8/25 at 10:40 A.M., Mighty shake, out of supplement at this time;-12/8/25 at 3:18 P.M., Mighty shake, out of supplement at this time;-12/9/25 at 9:42 A.M., Mighty shake, out of supplement at this time;-12/16/25 at 10:15 A.M., Mighty shake, out of supplement at this time;-12/21/25 at 12:50 P.M., Mighty shake, out of supplement at this time;-12/22/25 at 10:43 A.M., Mighty shake, out of supplement at this time;-12/22/25 at 2:38 P.M., Mighty shake, out of supplement at this time;-12/22/25 at 8:19 P.M., Mighty shake, out of supplement at this time;-12/23/25 at 8:40 A.M., Mighty shake, out of supplement at this time;-12/30/25 at 8:31 A.M., Mighty shake, out of supplement at this time;-1/5/26 at 9:43 A.M., Mighty shake, out of supplement at this time;-1/5/26 at 8:05 P.M., Mighty shake, out of supplement at this time;-1/6/26 at 8:10 A.M., Mighty Shake, out of supplement at this time;-No documentation showed the physician or RD had been notified. During an interview on 01/07/26 at 10:53 A.M., Certified Nurse Aid (CNA) A said:-The CNAs did not give out the health shakes;-The nurses and Certified Medication Technician (CMT)s gave the health shakes. During an interview on 01/07/26 at 11:03 A.M., Licensed Practical Nurse (LPN) A said:-Resident's who get a Mighty Shake have a physician's order for it;-The CMT's pass the Mighty Shakes out most of the time;-Physician's orders should be followed;-If a physician's order's cannot be followed the physician should be notified;-He/She did not know if the physician had been notified when the facility ran out of the Mighty Shakes and they were not given. During an interview on 01/07/26 at 11:18 A.M., CMT A said:-Sometimes the facility is out of Mighty Shakes;-When shakes supply is low he/she told the dietary manager;-He/She did not notify the nurse or the physician because the dietary department ordered the shakes;-He/She did not notify the nurse when the resident did not get the mighty shake;-The Mighty Shake is a physician's order and should be followed. During an interview on 01/08/26 at 10:00 A.M. the Dietary Manager (DM) said:-The facility can hold 5-6 cases of shake mix in the freezer indefinitely;-They take one case at a time out and defrost it in the refrigerator;-The CNAs will occasionally come up and tell her they are going through a lot of the shakes. During an interview on 01/08/2026 at 1:21 P.M., the Director of Nursing (DON) said: -If a physician's order is not being followed the physician should be notified;-The shake is ordered by the physician and the physician should be notified if it had not been given. During an interview on 1/8/26 at 1:43 P.M., the Administrator said:-She expected the nurse's to be notified by the CMT's when the shakes were not given;-She expected physician and the RD to be notified by the nurse when the shakes were not given;-She expected physician's orders to be followed. During an interview on 1/12/26 at 10:11 A.M., the RD said:-She issued a blanket order for nutritional supplements;-She expected staff should find a suitable substitute if they run out of the Mighty Shakes;-She had not been notified the facility had ran out of Mighty Shakes;-She had not been notified the residents had not received the shakes;-She would expect to be notified if the faculty was out of shakes and the residents had not received them. 3. Review of Resident #68's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by home staff, dated 11/6/25, showed: - The resident was dependent on staff for activities of daily living; - The resident was not cognitively intact; - The resident had diagnosis of Parkinson's Disease, muscle weakness, and Alzheimer's Disease. Review of the resident's care plan, revised 11/6/25, showed: - The resident had limited physical mobility; - The resident had potential for nutritional issues related to dementia; - The resident was on hospice (care that focuses on comfort rather than curing the disease) care. Review of the resident's Physician Order Sheet, dated 1/6/26, showed: The resident had an order for Mighty Shake three times a day for weight loss with meals that began on 12/16/25. Review of the resident's Medication Administration Record for the month of December 2025, showed: - No Mighty Shake as ordered at noon on 12/19/25 provided due to the shakes being frozen; - No Mighty Shake as ordered at 5:00 P.M. on 12/21/25 due to the shakes not being available; - No Mighty Shake as ordered at 8:00 A.M. and noon on 12/22/25 due to the shakes not being available; - No Mighty Shake as ordered at 8:00 A.M. on 12/23/25 due to no shakes available. Review of the resident's Medication Administration Record for the month of January 2026, showed: - No Mighty Shake as ordered at 8:00 A.M. and noon on 1/5/26 due to the shakes not being available; - No Mighty Shake as ordered at 8:00 A.M. on 1/6/25 due to the shakes not being available. During an Interview on 01/06/2026 at 3:20 P.M. Certified Medication Technician (CMT) C said: - Dietary staff was responsible for ordering Mighty Shakes; - The facility uses a case a day of the Mighty Shakes and will usually start to run short on mighty shakes on Mondays before the new shipment comes in on Tuesdays; - The home had not ran out of Mighty Shakes for more than a day at a time. During an Interview on 01/08/2026 at 11:55 A.M. CMT B said the facility runs out of Mighty Shakes. During an Interview on 01/08/2026 at 12:55 P.M. the Director of Nursing (DON) said If Mighty Shakes are not available the CMT should notify the nurse, the administrator, and the kitchen so more can be ordered.

Based on observations and interviews the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when facility staff did not provide proper incontinence care for two of 18 sampled residents (Resident #2 and #39). The facility census was 78. Review of the facilities Perineal Care policy, dated April 2025, showed:- It is the practice of this a facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown;- Staff were to provide privacy by pulling curtain or closing room door if a private room;- Cleanse buttocks and anus, front to back; vagina to anus in females and scrotum to anus in males, using a separate washcloth or wipes;- Separate the resident's genital folds with one hand and cleanse perineum with the other hand, repeat on opposite side using new disposable wipe with each stroke;- Clean urethral meatus or vaginal orifice using new disposable wipe with each stroke;- Clean and dry the anal area, starting at the posterior genital area and wiping from front to back. 1. Review of Resident #39's Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 11/5/25, showed:- Cognition was not intact;- The resident was dependent on staff for showers, transfers, and dressing;- Diagnoses of Alzheimer's disease, respiratory failure, and heart failure. Review of the resident's care plan, revised on 1/5/26, showed:- Use of anti-anxiety medication;- Required total assist of all activities of daily living (ADL); Observation on 1/5/2026 at 3:32 P.M., showed:- Certified Nursing Assistant (CNA) B and CNA C entered the resident's room to perform peri-care;- Both CNA's washed hands and applied gloves;- CNA B wiped down the resident's inner thigh and repeated with a new cleansing wipe down the other side of the inner thigh;- CNA B then took one cleansing wipe and twisted it into the front of genital opening but never spread the surrounding skin folds;- CNA B wiped down leg then up to anus but never spread folds or verified cleanliness; During an interview on 1/5/26 at 3:32 P.M. CNA B said he/she would normally wipe all areas that had been exposed to urine or feces and not just the middle of the genital opening but should have. During an interview on 1/6/2026 at 3:15 P.M., CNA D said:- Nursing should pull the curtain between residents to provide privacy and for their dignity;- Nursing should spread skin folds and clean everywhere that urine and stool could touch. On 1/7/2026 at 4:04 P.M. an anonymous employee interview said CNA B did not provide good peri-care to two residents who required toileting and changing. During an interview on 1/8/2026 at 8:12 A.M., the Assistant Director of Nursing (ADON) said nursing staff are to clean all areas where urine or feces touched when performing peri-cares on residents; nursing staff are trained on proper cleaning with peri care. During an interview on 1/8/2026 at 10:30 A.M., the Director of Nursing (DON) said:- Clean all areas where urine or feces could touch the skin when performing peri-cares on residents;- Improper peri-care on residents causes skin breakdown and odors;- Privacy should be provided when performing peri care. During an interview on 1/8/2026 at 12:17 P.M., the Administrator said nursing staff should clean all areas on a resident where urine or feces could have touched when performing peri- care and privacy should be provided. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], showed: - The resident was cognitively intact; - The resident was dependent on staff for personal hygiene; - The resident had diagnosis of irritant contact dermatitis due to friction or contact with body fluids, urinary tract infection, and neuromuscular dysfunction of bladder. Review of the resident's care plan, revised 11/26/25, showed: - The resident had a activities of daily living self-care deficit; - The resident had recurrent urinary tact infections related to suprapubic catheter (a tube inserted directly into the bladder through a small opening in the lower abdomen). Observation on 01/08/2026 at 10:16 A.M. showed: - The Assistant Director of Nursing (ADON) provided perineal care to the resident after completing the resident's wound treatment; - The ADON cleaned the resident's perineal area by wiping once down the middle of the perineal area, folded the wipe and used the same wipe to wipe down the middle of the perineal area. During an Interview on 01/08/2026 at 10:55 A.M. the ADON said: -The cleansing wipe can be folded and used again when provided perineal care; - A cleansing wipe should not be folded and used again more than three times when providing perineal care. During an Interview on 01/08/2026 at 1:01 P.M. Certified Nursing Assistant (CNA) E said a cleansing wipe should only be used once when providing perineal care. During an Interview on 01/08/2026 at 12:18 P.M. The Administrator said a cleansing wipe should only be used once when providing perineal care. During an Interview on 01/08/2026 at 12:55 P.M. the Director of Nursing said a cleansing wipe should not be folded and reused when providing perineal care. Intake 2711323

Based on observation, interview, and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned for four residents (Residents #2, #9, #29, and #39) and additionally failed to properly store oxygen accessories at the bedside for two residents (Resident #2 and #29). This affected four of 18 sampled residents. The facility census was 78.Review of the facility's Oxygen Administration policy, dated April 2006, showed:- There was no specific guidance on changing out prefilled disposable humidifiers by month or week;- Label humidifier with date and time opened. There was no guidance for when oxygen tubing should be changed;- Precaution - constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulceration;- There was no guidance on regular intervals to check and clean oxygen equipment, masks, tubing, or nasal cannulas;- There was no guidance on regular intervals to check liter flow contents of oxygen cylinder, fluid level in humidifier. 1. Review of Resident #9's Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 12/31/25, showed:- Cognition was not intact;- He/She was dependent on staff for showers and required setup assistance with all other Activities of Daily Living (ADL's);- Diagnoses included: respiratory failure, diabetes, and Post Traumatic Stress Disorder (PTSD, mental health condition triggered by experiencing or witnessing a traumatic event). Review of the resident's care plan, revised on 12/22/25, showed no staff direction related to oxygen use or care of equipment; Review of the Order Summary Report, dated 1/8/26, showed an order for staff to change oxygen tubing and humidifier every day shift on Sundays. Observation on 1/5/26 at 10:50 A.M., showed:- A humidifier bottle attached to the running concentrator dated 12/28;- An empty bag tied to the running concentrator dated 7/27;- Nebulizer tubing sat open on the nightstand dated 12/28;- The oxygen tubing, worn by the resident, had no date written on the attached tubing. Observation on 1/7/26 at 7:56 A.M., showed:- A humidifier bottle attached to the running concentrator dated 12/28;- A empty bag tied to the running concentrator dated 7/27;- Nebulizer tubing sat on the nightstand dated 12/28;- The oxygen tubing, being worn by the resident, with no date written on or attached to the tubing. Observation on 1/8/26 at 10:23 A.M., showed:- A humidifier bottle attached to the running concentrator dated 12/28;- An empty bag tied to the running concentrator dated 7/27;- Nebulizer tubing sat open on the nightstand dated 12/28;- The oxygen tubing, worn by the resident, with no date attached to the tubing. 2.Review of the resident's Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 11/24/25, showed:- Cognition was intact;- He/She required substantial assistance with showers, toileting, transfers and oxygen equipment;- Diagnoses included respiratory failure, diabetes, and heart failure. Review of Resident #29's care plan, revised on 11/13/25, showed:- He/She required oxygen therapy with oxygen ordered at two liters per minute via nasal cannula;- He/She relied on nursing staff to anticipate and meet all care needs. Review of the resident's Physician Order Summary Report, dated 1/8/26, showed an order for staff to change oxygen tubing and humidifier every night shift on Wednesdays. During an interview and observation on 1/5/2026 at 10:08 A.M., the Resident said:- He/She required oxygen all the time due to his/her diagnoses;- He/She got breathing treatments;- His/Her nose got dry and he/she had a bloody nose most of the time;- He/she had oxygen tubing on and was attached to the running concentrator without a date;- The oxygen tubing storage bag was dated 1-1;- No humidifier bottle was attached to the concentrator;- Oxygen tubing attached to the portable oxygen tank on the resident's wheelchair was not dated. Observation on 1/6/2026 at 12:51 P.M., showed: - Oxygen supply storage bag was dated 1/1;- Oxygen tubing attached to the concentrator was undated;- No humidifier bottle was attached to the concentrator. Observation on 1/8/2026 at 10:23 A.M., showed the resident's oxygen tubing had been replaced and dated on 1/7/26, but no humidifier bottle was attached to the concentrator per the physician's order. 3. Review of Resident #39's Minimum Data Set (MDS), dated [DATE], showed:- Cognition was not intact;- The resident was dependent on staff for showers, transfers, and dressing;- Diagnoses included Alzheimer's disease, respiratory failure, and heart failure. Review of the resident's care plan, revised on 1/5/26, showed:- He/She required oxygen therapy with oxygen settings at two liters via nasal cannula;- He/She relied on nursing staff to anticipate and meet all care needs. Review of the resident's Physician Order Summary Report, dated 1/8/26, showed an order for staff to change oxygen tubing and humidifier every day shift on Sundays. Observation on 1/5/2026 at 2:34 P.M., showed:- He/She had oxygen applied via nasal cannula;- The humidifier bottle was empty, connected to the oxygen concentrator, and undated;- The oxygen tubing was connected to the oxygen concentrator and was undated;- The supply storage bag attached to the concentrator was not dated. Observation on 1/6/26 at 3:15 P.M., showed:- Oxygen humidifier bottle attached to the concentrator had been changed and dated 1/6/26- The tubing attached to the portable oxygen cannister was not dated. During an interview on 1/6/2026 at 3:15 P.M., Certified Nursing Assistant (CNA) D said:- Night shift staff change and date the oxygen tubing and humidifier bottles;- Day shift staff change the oxygen bottles on days if they were empty;- Staff date the oxygen tubing when changed. During an interview on 1/8/2026 at 8:12 A.M., the Assistant Director of Nursing (ADON) said: -The resident's oxygen tubing should be changed and dated when changed;-Staff change out tubing and equipment on Saturday or Wednesday on the evening shift;-The supplies storage bag is to be changed and dated on the same days;-The humidifier bottle is to be changed and dated; - A humidifier bottle is provided, if ordered by the provider and care planned for the resident to have one. During an interview on 1/8/2026 at 10:30 A.M., the Director of Nursing (DON) said: - Oxygen tubing is to be changed and dated when changed. Normally by the evening shift staff;- The oxygen supply storage bag is to be changed and dated;- The humidifier bottle is to be changed and dated and in place if ordered by the provider or care planned for the resident. During an interview on 1/8/2026 at 12:17 P.M., the Administrator said:- Oxygen tubing and oxygen supplies storage bags should be changed and dated when changed by the staff;- Normally the evening shift staff change and date the respiratory equipment;- The humidifier bottle should be changed and dated when changed;- There should be a humidifier bottle attached to the concentrator if it was ordered by the provider or care planned for the resident. 4. Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE] showed: - He/She had trouble breathing at rest and with exertion and was prescribed Oxygen; - Diagnosis included chronic obstructive pulmonary disease (COPD) a progressive lung condition that blocks air flow, making it difficult to breathe. Review of the resident's care plan, revised 11/26/25, showed: -He/She required oxygen therapy as needed related to COPD; -He/She was on hospice (care that focuses on comfort rather than curing the disease). -He/She was dependent on nursing staff to meet oxygen equipment needs. Review of the resident's Physician Order Sheet, dated 1/8/26, showed: - An order for oxygen at one to three liters per nasal cannula as needed; - An order for oxygen tubing and humidifier to be changed every Sunday on night shift Observation on 01/05/2026 at 9:45 A.M. showed: - The nasal cannula tubing in use did not have a date indicating when the tubing was last changed; - No humidifier bottle attached to the resident's oxygen concentrator. During an Interview on 01/08/2026 at 11:09 A.M. the resident said he/she would like to have humidified oxygen since his/her nose does get dry while wearing oxygen and it bothers him/her. During an Interview on 01/08/2026 at 11:15 A.M. Registered Nurse (RN) A said: - Oxygen tubing was changed monthly; - Some resident's had orders for oxygen tubing to be changed on dayshift some had orders to be changed on nightshift; - Oxygen tubing should be dated when it was changed; - Residents who had an order for humidified oxygen should be provided with humidified oxygen. - Residents who wish to have humidified oxygen, staff can obtain a physician's order.

Based on observation, record review, and interviews, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation and when staff failed to ensure the bed's dimensions were appropriate for the resident's size and weight for three of 18 residents sampled (Residents #51, #4 and #24). The facility census was 78.Review of the facility's Bed Rails policy dated 1/30/2024 showed:-Ensure correct installation and maintenance of bed rails;-The facility will ensure correct installation and use maintenance of bed rails; -The facility will assess the resident's risk for entrapment from bed rails prior to installation and ensure the beds dimensions are appropriate for the residents size and weight;-The facility will follow the manufacturers recommendations and specifications for installing and maintaining bed rails; -The facility will inspect and regularly check the mattress and bed rails for areas of possible entrapment;-The facility must conduct routine preventive maintenance of bed rails and this should be evidenced in the residence record.1. Review of Resident #51's quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff dated 08/05/25 showed:-No cognitive impairment;-Dependent on staff for toileting and bed mobility;-Incontinent of bowel and bladder;-Two or more falls with injury since admission;-Diagnoses included Multiple Sclerosis (MS) a chronic autoimmune disease that can cause high cholesterol and depression.Review of the resident's care plan dated 01/04/26 showed:-Diagnosis of MS;-At risk for falls;-The resident had a non-injury fall on 09/23/25;-The resident had a fall with injury on 01/01/26; -Used bilateral cane rails for bed mobility and positioning.Review of the resident's Physician's Order Sheet (POS) dated January 2026 showed an order for bilateral cane rails for bed mobility and positioning.Review of the resident's nurse's notes showed:-12/31/25 5:30 P.M., the resident was observed on the floor by the staff. The resident's right arm was caught behind him/her with his/her back to the dresser; -12/31/25 at 6:56 P.M., staff assisted the resident up in bed. The resident said he/she reached off the side of the bed to get something off the floor and his/her shoulder got caught in the bed rail.Observation on 1/6/26 at 3:11 P.M., showed:-The resident lying in bed and yelling for the staff;-Both bilateral cane rails in the up position at the head of the bed.Observation and interview on 1/7/26 at 10:48 A.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed;-The resident said the rails helped him/her get out of bed.2. Review of Resident #4's quarterly MDS dated [DATE] showed:-Severe cognitive impairment;-Dependent on staff for toileting and bed mobility;-One fall with injury since admission;-Diagnoses included heart failure, high blood pressure and anemia.Review of the resident's bed rail assessment dated [DATE] showed:-History of falls;-Bilateral assist bars used;-No height or weight of the resident was found on the assessment;-No documentation to confirm the bed rails installed were appropriate to the size and weight of the resident.Review of the resident's care plan dated 12/23/25 showed:-At risk for falls;-The resident had a non injury fall on 01/08/25;-The resident had a non injury fall on 04/18/25;-Used bilateral cane rails for bed mobility and positioning.Review of the resident's POS dated January 2026 showed an order for bilateral cane rails for bed mobility and positioning.Observation on 1/6/26 at 2:06 P.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed.Observation on 1/7/26 at 10:22 A.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed.3. Review of Resident #4's admission MDS dated [DATE], showed:-Severe cognitive impairment;-The resident had delusions;-The resident used side rails;-The resident required set up help with bed mobility;-History of falls prior to admission;-Diagnoses included atrial fibrillation (an irregular heartbeat), high blood pressure and Benign Prostatic Hyperplasia (BPH) enlargement of the prostate gland. Review of the resident's care plan dated 12/27/25, showed:-Impaired thought process related to dementia;-The care plan did not address the use of side rails.Review of the resident's bed rail assessment dated [DATE] showed:-Bilateral side rails used;-No height or weight of the resident was found on the assessment;-No documentation to confirm the bed rails installed were appropriate to the size and weight of the resident.Review of the resident's POS dated January 2026 showed:-Order for bilateral cane rails for bed mobility and positioning.Observation on 1/6/26 at 1:06 P.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed.Observation 1/7/26 at 09:22 A.M., showed:-The resident lying in bed;-Both bilateral cane rails in the up position at the head of the bed. During an interview on 01/07/26 at 10:53 A.M., Certified Nurse Aid (CNA) A said:-Residents used the bed rails for positioning and bed mobility;-The nurses took care of completing any bed entrapment assessments.During an interview on 01/07/26 at 11:03 A.M., Licensed Practical Nurse (LPN) A said:-The residents used bed rails to get in and out of bed;-Side rail evaluations were completed by the MDS Coordinator or the Director of Nursing (DON);-The Maintenance Director installed the bed rails after the evaluations were completed.During an interview on 01/07/26 at 11:42 A.M., the MDS Coordinator said:-The admitting nurse notified the physician, and an order was obtained for a bed rail if the resident wanted one;-The nurses and therapy did the assessments for bed rails;-Maintenance installed the rails;-She had not heard of entrapment assessments.During an interview on 01/07/26 at 11:56 A.M., the Maintenance Director said:-He was responsible for the installation of bed rails;-He did not measure the resident beds before he/she installed the bed rails;-He did not do entrapment assessments.During an interview on 1/07/16 at 12:02 P.M., the DON said:-The process for bed rails started at admission;-If the resident wanted bed rails for bed mobility or therapy recommended the use of rails the resident would be evaluated by therapy and nursing;-Maintenance was responsible for the installation of the bed rails;-He was not aware of entrapment assessments for residents with side rails; -He expected residents with side rails to be safe from possible entrapment.During an interview 1/7/26 at 12:34 P.M., the supervisor of therapy said: -She did not know if the facility staff did bed entrapment assessments; -She expected residents with side rails to be safe from possible entrapment.During an interview on 1/08/16 at 10:43 A.M., the Administrator said:-She was not aware the facility policy included entrapment assessments;-The facility staff completed side rail assessments, but the height, weight and dimensions of the bed were not part of the assessment;-He expected residents with side rails to be safe from possible entrapment.

Based on observation, interview, and record review the home failed to store all drugs and biologicals under proper temperature controls, when the facility was unable to provide a record that the refrigerator temperature in the Certified Medication Technician (CMT) medication room had been monitored to ensure medication was being stored at the proper temperature. The facility census was 78. The facility did not provide a medication storage policy. Observation of the medication room labeled as the CMT medication room (Certified Medication Technicians) on 01/06/2026 at 3:20 P.M. showed:-No refrigerator temperature log sheet on refrigerator and no logbook available in medication room;-The freezer compartment of the refrigerator had ice buildup on it and extending past the edges of the compartment;-Contents of the refrigerator included: two Mighty Shakes (a nutritional supplement used in individuals needing supplemental nutrition) and Arformoterol (a medication used for long-term maintenance treatment of chronic obstructive pulmonary disease) for Resident #9. During an Interview on 01/06/2026 3:20 P.M. CMT C said:- He/she does not check the refrigerator temperature and was not sure where the log for the refrigerator temperatures was kept;- He/she was not sure how long ice had been built up in the freezer compartment of the medication refrigerator. During an Interview on 01/06/2026 at 3:30 P.M. the Administrator said:- The medication refrigerator temperature log was usually kept on the counter in the CMT medication room above the medication refrigerator;- The night shift CMT is responsible for checking the medication refrigerator temperature;- She is not sure how long the ice had been built up in the freezer compartment. During an Interview on 01/08/2026 at 11:15 A.M. Registered Nurse (RN) A said the medication refrigerator temperature should be checked every shift. During an Interview on 01/08/2026 at 11:55 A.M. CMT B said: - He/she does not check the medication refrigerator temperature and was not sure who was responsible for that task;- He/she was not aware of ice built up in the freezer compartment of the medication refrigerator. During an Interview on 01/08/2026 at 12:55 P.M. the Director of Nursing (DON) said the medication refrigerator temperature should be checked and recorded every night.

Based on interview and record review, the facility failed to maintain a qualified licensed administrator on duty from [DATE] to [DATE]. The facility census was 78. Review of an undated facility policy regarding the Administrator showed: -The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. A licensed administrator is responsible for the day-to-day functions of the facility. Review of the job description for the Administrator position showed: - Minimum Requirements, Abilities and Expectations include Current Administrator license or certification as required by state regulations. Review of the current Missouri Association of Nursing Home Administrators license registry web site showed Administrator A not listed as a current Missouri Licensed Administrator. During an interview on [DATE] at 11:45 A.M., Administrator A said she was not aware her license had expired and she would reach out to the Missouri Board of Nursing Home Administrators (BNHA) about the status of her license. Review of documentation provided by the BNHA shows the following: - [DATE] Administrator A was issued a license renewal reminder email; - [DATE] Administrator A was issued a second license renewal reminder email; - [DATE] Administrator A was issued a late license renewal reminder email. During an interview on [DATE] at 1:30 P.M., Administrator A said she had not received any emails from the BNHA regarding the need to renew her license. She notified the corporate office as soon as she became aware her license was expired. Administrator B was hired to serve as the licensed administrator for the facility until Administrator A can renew her license. Administrator A said it was an oversight on her part not to renew her license and she knows that she needs to maintain a valid license to serve as the administrator of a long-term care facility. During an interview on [DATE] at 3:30 P.M., Administrator B said: - She has stepped in to serve as the licensed administrator until the BNHA renews Administrator A's license; - When not serving as an Administrator at the facility, she works in a corporate role and her expectation is for administrators to maintain a valid administrator license; - The facility does not have a policy available regarding checking license status specific to administrators. We will implement one going forward. MO241880

Based on observation, interview, and facility policy review, the facility failed to remove expired medications from two of two medication storage rooms observed for medication storage. This failure had the potential to subject residents to unsafe or ineffective treatments. The facility census was 77. Review of the facility's undated policy titled, Storage of Medications revealed, . No discontinued, outdated, or deteriorated medications are to be used . All such medications are destroyed according to a facility policy . During an observation on 07/24/24 at 10:46 AM, Licensed Practical Nurse (LPN) 1 and the surveyor observed the medication room by nurse's station. Three tubes of expired Skintegrity Hydrogel, used in the treatment of some pressure ulcers, were noted on a shelf within a cabinet. Two of the tubes had an expiration date of May 2024. One had an expiration date of October 2023. LPN1 confirmed the hydrogel had expired and removed the tubes from the medication room. During an interview on 07/24/24 at 10:48 AM, LPN1 stated, The supply person goes through the med rooms daily. They check the expiration dates and stock for reordering. During an observation and interview on 07/24/24 at 11:04 AM, Certified Medication Aide (CMT) 1 and the surveyor observed the medication room on the 400 hall. Two bottles of cranberry (sometimes used to help prevent urinary tract infections) 450 milligrams (mg) tabs, 100 count in each, with the expiration date of May 2024 were found on a shelf within a cabinet. Three bottles of Thera-M multi-vitamins, 130 caplets in each, with expiration date of April 2024, were noted in another cabinet in the same medication storage room. CMT1 confirmed these medications were expired and removed them from medication room. CMT1 stated, I believe there is someone that checks expiration dates and destroys them. During an interview on 07/25/24 at 11:13 AM, the Infection Preventionist (ICP) nurse, who was also the wound care nurse, stated, I don't know who checks for expired meds. I know we have someone that destroys meds. During an interview on 07/25/24 at 12:16 PM, the Administrator stated, The nurses and CMTs do monthly audits on both med rooms and all the med carts. They also check when they are putting new stock medication away. The Administrator stated the process was for staff to pull older medication stock forward and put any new stock behind the older stock.

Based on observation, interview, and policy review, the facility failed to store food in accordance with professional standards of food service safety for 17 of 17 residents who received nutritional supplements. This had the potential to result in food born illnesses for residents who consumed nutritional supplements. The facility census was 77. Review of the facility's undated policy titled, Aspire Supplements, revealed the policy did not address thaw and use-by dates for any dietary supplement. During the initial tour of the kitchen on 07/22/24 at 8:40 AM, a box containing 59 four-ounce thawed Mighty Shakes (a nutritional supplement) was noted in the walk-in refrigerator in the main kitchen. The box was dated 08/22/24. Each four-ounce carton contained a warning label that recorded, . store frozen, thaw at below 40 degrees. Use thawed product within 14 days . It was recorded that Mighty Shake ingredients included skim milk. The nutritional supplements were not labeled with a thaw or use-by date. At 8:45 AM, seven Mighty Shakes were noted in the reach-in refrigerator in the main kitchen. The Mighty Shakes were not labeled with a thaw or use-by date. During an interview on 07/22/24 at 8:45 AM, the Dietary Manager (DM) revealed she was not aware of the thawing and use-by time frames on the Mighty Shake carton but did have a date on the box containing the Mighty Shakes. The DM verified she did not know who wrote the date on the Mighty Shake box or what the date meant.

Based on observation, interview, and record review, the facility failed to ensure that staff appropriately cleaned and disinfected patient equipment after using a wrist cuff and manual blood pressure cuff for one of three residents (Resident (R) 21) observed during the medication pass out of a total census of 77. This failure could promote the spread of multi drug resistant organisms (MDROs) throughout the facility. The facility census was 77. Review of the facility's undated policy titled, Medication Cart Clean/Disinfecting, revealed, . Clean all equipment (BP cuffs, pulse ox, etc.) that comes in contact with resident per packaging between each use . Review of R21's Admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses that included cerebral ischemia. During an observation on 07/24/24 at 8:55 AM, Certified Medication Aide (CMT) 1 took R21's blood pressure using a wrist cuff. CMT1 then placed the dirty wrist cuff on top of the medication cart and left. She returned five minutes later with a manual blood pressure cuff and rechecked R21's blood pressure. CMT1 placed the manual blood pressure cuff on top of the medication cart and wrapped her stethoscope around her neck. CMT1 wiped the wrist cuff with an alcohol prep pad and placed it back on the medication cart in the same area. She did not clean the top of the medication cart or use a barrier. She then cleaned the manual blood pressure cuff with an alcohol prep pad and placed it back in its' case. CMT1 removed her stethoscope, cleaned it with an alcohol prep pad, and placed it back around her neck. During an interview on 07/25/24 at 9:15 AM, CMT1 stated, We're supposed to wipe them [blood pressure cuffs] clean for each resident and at the end of my shift. She stated, I use alcohol pads to clean patient equipment. We use the [NAME] disposable germicidal surface wipes to clean the top of our med cart. CMT1 stated the medication carts were cleaned at the end of each shift. She stated, I'll have to look up the dry time for alcohol pads and germicidal surface wipes. During an interview on 07/25/24 at 9:35 AM, the Director of Nursing (DON) was asked what her expectation was related to cleaning patient care equipment, including blood pressure cuffs and stethoscopes. She stated, My expectation and the standard are to clean after every use. She stated, I clean mine when I get it out of my bag. I always wipe it down with cleanser or alcohol after each use and before next use. The DON stated she had just ordered new disinfecting wipes and was unsure of the dry time. During an interview on 07/25/24 at 9:41 AM, the Infection Preventionist (ICP) stated, I do infection control training and handwashing during onboarding, and we do it sporadically. She stated, We do training on cleaning patient care equipment several times, at least three to four times, throughout the year. 3-4 times a year. The ICP stated the dry time for the sanitizing wipes used by the facility was four minutes. During an interview on 07/25/24 at 10:07 AM, the Administrator stated, My expectation is to clean [patient care equipment] in between each resident and before and after use, just like they clean their carts. The Administrator stated the facility had sanitizing wipes and alcohol prep pads for cleaning and disinfecting. The Administrator stated, It's ok to use an alcohol swab to clean the pulse oximeters, but I expect a disinfectant wipe to be used on the blood pressure cuffs. It's not acceptable to use an alcohol swab on a blood pressure cuff.

Based on interview, record review, and review of Centers for Disease Control and Prevention (CDC) guidance and facility policy, the facility failed to maintain a functional Antibiotic Stewardship Program that ensured criteria was met for the use of antibiotics for one of two residents (Resident (R) 47) reviewed for antibiotics out of a total sample of 22. This had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary. The facility census was 77. Review of an undated, untitled CDC document located at https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html revealed, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated . Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority . Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use' . CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use . Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Below are examples of antibiotic use and outcome measures . Process measures: Tracking how and why antibiotics are prescribed . Antibiotic use measures . Tracking how often and how many antibiotics are prescribed . Antibiotic outcome measures . Tracking the adverse outcomes . Review of facility's policy titled Antibiotic Stewardship, dated 01/30/24, revealed, . Develop and implement protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic resistant organisms, from unnecessary or inappropriate antibiotic use . Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff . The antibiotic stewardship program protocols describe how the program will be implemented and antibiotic use will be monitored, consequently protocols must . Contain a system of reports related to monitoring antibiotic usage and resistance data . Review of R47's Admission Record, located under the Face Sheet tab of the electronic medical record (EMR), revealed R47 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 3 and urinary tract infection. Review of R47's Progress Notes, located under the Progress Notes tab of the EMR and dated 07/17/24 at 7:59 AM, revealed, .seems more confused and sad . res [resident] denies any urinary symptoms at this time . Review of R47's Physician Orders, located under the Orders tab of the EMR, revealed a physician's order, dated 07/17/24, for a urinalysis with culture due to increased confusion. Review of R47's Progress Notes, dated 07/17/24 through 07/19/24, revealed R47 was noted to have some confusion but was afebrile, had no urinary symptoms, and stated her mood was stable. Review of R47's Progress Notes, located under the Progress Notes tab of the EMR and dated 07/19/24 at 6:39 PM, revealed the results of the 07/17/24 urinalysis results were positive for gram negative bacilli in excess of 100,000 CFU/ml (colony forming unit per milliliter) and that the culture results were not available yet. Review of R47's Physician Orders, located under the Orders tab of the EMR and dated 07/20/24, revealed a physician's order for one tablet of Bactrim DS 800-160 milligram (mg) twice a day for a urinary tract infection. Review of R47's Progress Notes, dated 07/20/24 through 07/22/24, revealed no documentation R47 was having any signs or symptoms of a urinary tract infection. Review of R47's Progress Notes, located under the Progress Notes tab of the EMR and dated 07/22/24 at 11:21 AM, revealed, . denies any difficulty urinating . Review of R47's Progress Notes, located under the Progress Notes tab of the EMR and dated 07/23/24 at 9:44 AM, revealed R47's urine culture showed greater than 100,000 CFU/ml of Proteus mirabilis ESBL and Gram-Negative Bacilli. It was recorded, . Res [resident] has been on Bactrim DS but C&S [culture and sensitivity] report shows resistance. Review of R47's Revised McGeer Criteria for Infection Surveillance Checklist, dated 07/23/24 and completed three days after the physician first ordered Bactrim DS 800-160mg, revealed the urinary tract infection (UTI) criteria was not met. The Checklist recorded constitutional criteria of fever, leukocytosis, acute mental status change, and acute functional decline. R47 did not meet any of these criteria. Review of R47's Progress Notes, located under the Progress Notes tab of the EMR and dated 07/23/24 at 3:35 PM, revealed the physician had discontinued Bactrim DS and ordered for R47 to receive Gentamicin 60 mg intramuscularly (IM). Review of R47's Progress Notes, located under the Progress Notes tab of the EMR and dated 07/23/24 at 11:15 PM, revealed R47 remained asymptomatic of a UTI. It was recorded R47 denied urinary discomfort, remained afebrile, and had no signs or symptoms of distress. Review of R47's Physician Orders, located under the Orders tab of the EMR and dated 07/24/24, revealed R47 was to receive Gentamicin 60 mg IM every eight hours for three doses for a urinary tract infection. During an interview on 07/25/24 at 9:25 AM, the Infection Preventionist (ICP) stated that the facility used the McGeer Criteria for Infection Surveillance Checklist to determine antibiotic stewardship. She stated that the facility would contact the doctor to let them know what symptoms a resident had, the physician would order a urinalysis, and they might then start an order for antibiotics. The ICP stated that she would then complete a McGeer Checklist after the urinalysis was ordered. She stated that she would consider appropriate symptoms for a possible urinary infection and need for a urinalysis to include suprapubic pain, frequency, and foul urine odor. During an additional interview on 07/25/24 at 12:19 PM, the ICP stated that facility nurses would let her know when there was a new physician's order for a urinalysis or antibiotic. She stated that R47's family had a concern that the resident had increased confusion, so they had requested a urinalysis. The ICP confirmed that the staff was aware R47 did not meet the criteria for a urinalysis and that a physician's order for antibiotics was implemented prior to receiving the results of a sensitivity test. The ICP stated that when the sensitivity came back from the laboratory, it had indicated the resident was resistant to the prescribed antibiotic, the physician order for Bactrim DS was discontinued, and a new antibiotic was ordered. During an interview on 07/25/24 at 1:20 PM, the Director of Nursing (DON) confirmed that the facility should have followed the antibiotic stewardship protocol, including the use of the McGeer Criteria for Infection Surveillance Checklist. The DON stated that if a resident's symptoms did not meet the criteria, a urinalysis should not be completed. He confirmed that there had been a concern with antibiotic stewardship at the facility, and not all physicians were following the facility protocol. The DON stated that continuing education needed to take place to ensure there was better understanding for why the facility followed the McGeer Criteria tool. He confirmed that R47 did not meet the criteria for the use of antibiotics.

Based on observation, interview and record review, the facility failed to keep the residents' medical record accessible to staff for 14 residents (Resident #51,#7, #36, #12, #26, #153, #11, #34, #9, #49, #30, #4, #45 and #3) out of 14 sampled resident's. The facility census was 54. 1. Record review of the resident's sampled on survey, Resident #51,#7, #36, #12, #26, #153, #11, #34, #9, #49, #30, #4, #45 and #3), showed the following records were not accessible: - Nurses Notes prior to 12/1/17; - Care Plans; - Physicians orders prior to 1/1/17; - Admission and Quarterly risk assessments prior to 12/1/17; - Physician notes prior to 12/1/17; - Pharmacy Recommendations. - Immunization Records Observation on 6/20/22 at 11:00 A.M., showed the care plans were not readily available to staff and staff did not have access to the previous electronic health record. During an interview on 6/20/22 at 11:13 A.M., the Minimum Data Set (MDS) coordinator said the care plans were not in one place, some were in the old electronic health record, some were in the new health record. During an interview on 6/23/22 at 3:00 P.M., the administrator (ADM) said: - The facility changed electronic medical record companies after the purchase of the facility in June 2022. - She was aware that the change of ownership occurred and was given four days notice of the change. - The new company was told by the old company that they would leave the electronic medical records for the integration of the medical record into the new companies electronic medical record, but the next day at midnight, the prior company removed all access to the medical records. - They can get into some records and some they cannot. - The new company is working quickly to integrate the electronic medical record, but some information is not accessable to the staff. - The staff are documenting on paper and do not have access to the old electronic medical record.

Based on record review and interview, the facility failed to develop quality assessemnt and assurance (QAA) activities and a quality assurance/performance improvement (QAPI) plan which drives the facility's ability to address any areas of concern and to correct any quality deficiencies identified by the QAPI process. The facility census was 54. The facility did not provide a policy for their QAA/QAPI committee and process. The facility was unable to provide record of their QAA/QAPI committee and process. During an interview on 6/23/22 at 10:40 A.M, the Administrator said: -The QAA committee met on 2/8/22, with the Administrator, Director of Nursing and Medical Director in attendance. - There is no record or minutes from this meeting as the records were kept on the Administrator's computer, which was erased when the facility changed ownership on 6/1/22.

Based on record review and interview, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. The facility census was 54. The facility did not provide a policy in regards to their QAA process or committee. The facility was unable to provide record of the QAA and QAPI program. During an interview on 6/23/22 at 10:40 A.M., the Administrator said: - The facility has had one QAA Committee meeting on 2/8/22. The Administrator, Director of Nursing and Medical Director were present. - There are no minutes or record of this meeting as the records were kept on the Administrator's computer, and previous ownership erased the computer when the facility changed ownership on 6/1/22.

Based on record review and interview, the facility failed to review and update their facility-wide assessment to determine what resources are necessary to care for their residents competently during day to day operations and emergencies. The facility census was 54. The facility did not provide a policy regarding maintaining a facility assessment. Review of the facility assessment, provided by the facility, showed: -The assessment was last updated on 12/3/2021. - The information provided did not include any updates or evidence of review for the first six months of 2022. During an interview on 6/23/2022 at 3:00 P.M., the Administrator said: - The facility assessment has not been updated to reflect recent changes at the facility, including change of ownership. - It is the Administrator's responsibity to ensure the facility assessment is reviewed regularly and updated as needed.

Based on interview and record review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) requirements and Centers for Disease Control Prevention (CDC) recommendations to prevent the exposure and transmission of COVID-19 (infectious disease) in the facility. The facility failed to provide a safe environment after being notified of COVID-19 positive test results for 2 staff members and not prohibiting those staff from working and providing care and services to residents in the facility who were COVID-19 negative. The census was 45. The facility reported 56 residents and 34 staff members had tested positive for COVID-19 and six deaths related to COVID-19. The noncompliance placed all residents at risk for COVID-19 and resulted in Immediate Jeopardy (IJ). As a result of the identified noncompliance, the Administrator was notified on 11/23/20 at 9:16am of the Immediate Jeopardy (IJ), which began on 09/11/20. Review of the facilities COVID-19 Outbreak Management policy, revised 9/29/20, revealed that staff who tested positive for COVID-19 should be excluded from work for the appropriate amount of time based on the Criteria for Return to Work for Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection (Interim Guidance) or during crisis staffing shortages such that resident care may become severely compromised, refer to the CDC Strategies to Mitigate Healthcare Staffing Shortages. Review of the Centers for Disease Control and Prevention (CDC) Coronavirus 2019 (COVID-19), Criteria for Return to Work for Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection (Interim Guidance) revealed: Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: -At least 10 days have passed since symptoms first appeared and -At least 24 hours have passed since last fever without the use of fever-reducing medications and -Symptoms (e.g., cough, shortness of breath) have improved. Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [CONDITION(S)] diagnostic test. HCP with severe to critical illness or who are severely immunocompromised: -At least 10 days and up to 20 days have passed since symptoms first appeared; -At least 24 hours have passed since last fever without the use of fever-reducing medications and; -Symptoms (e.g., cough, shortness of breath) have improved; -Consider consultation with infection control experts. Review of the facility's COVID-19 data reported to the CDC revealed no residents were suspected or confirmed of having COVID-19 for the week of 8/31/20, with a facility census of 66. During an interview on 11/10/20 at 8:30am, the Administrator stated the facility conducted COVID-19 testing on staff and residents and would then send the testing samples to a laboratory in Alabama. She stated the laboratory posted the test results into a web based portal that the facility had access to view at any time. She stated results were usually posted to the portal within 48 hours of sending the sample. She stated she was checking the portal frequently to obtain the COVID-19 results for staff and residents. 1. Review of a laboratory COVID-19 test report document for Registered Nurse (RN1) revealed a nasopharyngeal sample was collected on 9/9/20 at 10:35am. The sample was received at the laboratory on 9/10/20 and the lab reported a positive COVID-19 result on 9/10/20 at 5:23pm. Review of time clock records for RN1 revealed he/she worked and provided care to residents on 9/11/20 from 5:45am until 8am. The facility was notified RN1's positive COVID-19 result on 9/10/23 at 5:23pm. The facility allowed RN1 to work and care for residents after testing positive for COVID-19. During an interview on 11/10/20 at 7:50pm, RN1 stated she was tested for COVID-19 on 9/9/20. She stated she came to work on 9/11/20, clocked in for her shift and then proceeded to see her assigned residents, administer medications and conduct assessments. She stated she was called to the administrator's office around 8am and was told that she had tested positive for COVID-19. She stated that after being informed of testing positive for COVID-19 on 9/9/20, she was asked to complete a count of narcotics and then leave the facility. During an interview on 11/16/20 at 2:15pm, the Administrator stated RN1's COVID-19 positive test result may not have been seen until she came to work on 9/11/20. Review of the facility's COVID-19 data reported to the CDC revealed one resident with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 65. Review of the facility's COVID-19 line listing report showed one resident tested positive for COVID-19 on 09/23/2020. 2. Review of a laboratory COVID-19 test report document for Laundry Staff (LS1) revealed a nasopharyngeal sample was collected on 9/29/20 at 6:30pm, received at the laboratory on 10/1/20 and the lab reported a positive COVID-19 result on 10/1/20 at 2:21pm. Review of time clock records for LS1 revealed he/she worked and provided services to residents in the facility from: -5:03am until 1:05pm, on 10/2/20. -2:14pm until 10:22pm, on 10/3/20. -2:03pm until 10:27pm, on 10/4/20. During an interview on 11/19/20 at 7:45am, LS1 stated he/she worked in the laundry department and normally worked the 2pm to 10pm shift. She stated her job responsibilities included picking up the dirty laundry that was located in the soiled laundry bins that were located in the utility room on each hall of the facility. She stated that once the resident's personal items had been washed and dried, she delivered the clothing items to the resident room closets once per day. She stated that she also stocked the linen closets on the 300 and 400 hallways. LS1 stated she was test for COVID-19 on 9/29/20 during the facility's routine testing. She stated she was never informed of the results from that test. She stated she was tested again on the 10/4/20 during the facility's routine testing and was told that she tested negative for COVID-19. She stated on 10/5/20 the local health department contacted her to let her know that she and others in her household would need to be quarantined due to her testing positive for COVID-19 on 9/29/20. LS1 stated she never ran a fever but remembered taking some cold medication the last weekend in September or the first weekend in October due to thinking she had a [MEDICATION(S)] infection. LS1 stated the facility never informed her that she had tested positive for COVID-19 on 9/29/20. During an interview on 11/16/20 at 2:15pm, the Administrator stated she did not see LS1's positive COVID-19 test result that was reported on 10/1/20 at 2:21pm. Review of the facility's COVID-19 data reported to the CDC on 10/25/20 revealed 17 residents with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 59. Review of the facility's COVID-19 line listing report revealed 54 residents tested positive for COVID-19 from October 7, 2020 until November 7, 2020. Review of the facility's COVID-19 data reported to the CDC, revealed 35 residents with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted an acceptable abatement plan on 11/23/20. The IJ was removed on 11/26/20 after onsite verification of implementation of the abatement plan. The deficient practice was corrected as of 11/26/20. There was no remaining deficient practice.