Superior Manor of Festus, LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with orders for antipsychotic (medication used to treat psychosis) medications were informed about the medication before its use and failed to ensure the resident and/or the resident's representative signed a written informed consent authorizing the use of such medication for three residents (Residents #12, #28 and #30) out of three sampled. The facility's census was 46. Review of the facility's policy titled, Antipsychotic Medications, dated 02/23/23, showed: - The medication regimen helps promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representatives in collaboration with the attending physician and facility staff; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months from May 2024 through April 2025. The facility's census was 46. The facility did not provide a policy. Review of the residents' personal funds account for the last 12 consecutive months from May 2024 through April 2025 showed: - The facility's approved bond amount equaled $30,000.00; - The average monthly balance of the residents' personal funds equaled $39,701.26; - An average monthly balance of $39,701.26 rounded to the nearest thousand equaled $40,000.00, at one and one-half times would equal the required bond amount of at least $60,000.00. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 46. The facility did not provide a policy regarding the environment. Observation on 05/13/25 from 10:05 A.M. to 2:40 P.M. showed: - The 100 hall with a urine smell; - The vinyl plank floor cracking in an approximately three foot square area near the transition at the fire doors on the hall near the conference room; - room [ROOM NUMBER]'s vinyl plank floor buckled in an approximately four foot square area in the middle of the room; - room [ROOM NUMBER]'s vinyl plank floor buckled and taped at the buckled seams with black tape in a three foot wide area from the doorway to the opposite wall near Bed B; [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement a restorative nursing program to maintain or improve the highest level of function for one resident (Resident #2) out of 12 sampled residents and had the potential to affect all residents. The facility census was 46. The facility did not provide a policy. Review of Resident #2's medical record showed: - An admission date of 07/25/24; - Diagnoses of hemiplegia (paralysis of one side of the body) affecting left side, lack of coordination, explantation of shoulder joint prosthesis (surgical removal of a prosthetic shoulder joint implant), and need for assistance with personal care. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool used to assess the health status of residents) assessment, dated 10/15/24, showed: - Moderate cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, monitor, and modify interventions to maintain acceptable parameters of nutritional status for one resident (Resident #3) out of 12 sampled residents. The facility's census was 46. Review of the facility's Weight Loss Policy, dated 02/23/23, showed: - The facility will ensure that each resident maintains acceptable parameters of body weight unless the resident's condition demonstrates this is not possible; - The Charge Nurse will ensure each resident on the unit is weighed monthly or more frequently if ordered by the physician or deemed necessary for the resident's clinical condition; - The Charge Nurse will ensure all residents with unplanned weight loss are monitored by the physician and dietitian. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three Certified Nursing Assistants (CNAs) out of three sampled CNAs received annual performance reviews. The facility census was 46. The facility did not provide a policy regarding annual performance reviews. 1. Review of CNA E's employee file showed: - A hire date of 08/01/22; - No documented annual performance review. 2. Review of CNA F's employee file showed: - A hire date of 08/22/23; - No documented annual performance review. 3. Review of CNA D's employee file showed: - A hire date of 04/30/24; - No documented annual performance review. During an interview on 05/16/25 at 10:28 A.M., the Director of Nursing (DON) said she is aware that CNAs have not been getting annual reviews. They are monitored on the floor and educated or written up if there are any issues. [...]

Inspectors wroteBased on observation and interview, the facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. This had the potential to affect all residents. The facility's census was 46. Review of the facility's Food Storage Policy, dated 2020, showed: - Food shall be stored on shelves in a clean, dry area free from contaminants; - All food will be labeled; - Label must include name of food, date by which it should be sold, consumed, or discarded; - Rotate products so oldest are used first; - Staff shall be instructed to use products with the earliest expiration date; - Discard food that has passed the expiration date; - Store deliveries as soon as they have been inspected; - Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure. Observation on 05/13/25 at 12:10 P.M. showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 46. Review of the facility's Quality Assurance and Performance Improvement Program policy, undated, showed: - This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's census was 46. Review of the facility's policy, Quality Assurance and Improvement Program (QAPI), undated, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; - The owner and/or governing body of our facility is ultimately responsible for the QAPI program; - The administrator is responsible for assuring that this facility's QAPI program complies with federal. state, and local regulatory agency requirements; - The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of over bed light fixtures for residents in five resident rooms. Storing items on the over bed light creates a hazard of the items falling on the resident below and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 46. The facility did not provide a policy for over bed lighting safety. Observation on 05/16/25 of resident rooms showed: - At 9:50 A.M., room [ROOM NUMBER] Bed A with two pictures on canvas and a wooden cutting board on the over bed light; - At 9:53 A.M., room [ROOM NUMBER] Bed A with a sock cap and a wooden note-shaped decoration and Bed B with a small speaker and three figurines on the over bed light; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program. This practice affected two residents (Resident #7 and #19) out of 12 sampled residents and one resident (Resident #36) outside of the sample. This practice had the potential to affect all residents and staff in the facility. The facility's census was 46. The facility did not provide a policy. Review of the Pest Control Invoices provided by the Administrator showed on 02/24/25, 03/24/25, and 04/28/25, Commercial General Pest Control services. Review of the Pest Control Service Log showed: - On 02/24/25, the location of provided service was the break room, medication room, dining room, activities room, and Rooms 406, 407, 403, and 400; - On 03/24/25, the location of provided service was the kitchen, common areas, restrooms, and Rooms 101, 103, 105, and 107; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual competency training for dementia care (care of a resident with impaired ability to remember, think, or make decision) and failed to have staff attend at least twelve hours of in-service education per year for three of three sampled Certified Nursing Assistants (CNAs). This deficient practice had the potential to affect all residents in the facility. The facility's census was 46. The facility did not provide a policy. 1. Review of CNA E's in-service record showed: - A hire date of 08/01/22; - A total of three hours annual in-service training for August 2023 through August 2024; - No documented annual dementia training. 2. Review of CNA F's in-service record showed: - A hire date of 08/22/23; - A total of three hours annual in-service training for August 2023 through August 2024; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff when staff had a verbal altercation with one resident (Resident #1) out of three sampled residents. The staff member cursed at the resident and physically jerked the resident around in their wheelchair. The facility census was 46. Review of the facility's policy titled, Abuse, dated 08/01/22, showed: - Physical abuse includes hitting, slapping, pinching, kicking, or controlling behavior; - Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents and their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; - The Human Resources department will ensure the facility does not employ individuals who: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Nurse Aide (NA) Registry was checked prior to hire to ensure the employee did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) for five employees (Dietary Staff A, Registered Nurse (RN) F, Activity Director G, Housekeeping Supervisor H, Maintenance Supervisor I) out of seven sampled employees. The facility's census was 46. Review of the facility's policy titled, Hiring, revised January 2008, showed: - The Human Resources (HR) Director will conduct any applicable investigations and determine whether the applicant is legally eligible to work in the United States and what appropriate background investigations may be conducted on persons making application of employment with the facility and on current employees; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 49. The facility did not provide a policy regarding the environment. Observation on 04/02/24 from 10:09 A.M. to 3:49 P.M., showed: - A musty and foul odor of urine and fecal material on the 100 and 200 Halls; - In room [ROOM NUMBER], the drywall behind both beds had scratches and holes. Two bottom drawers in the bathroom dresser were broken. The vent cover in the bathroom ceiling hung down 1.5 inches (in.) A small, clear medication cup with an unidentified yellow liquid sat on top of a dresser; - A strong urine smell in room [ROOM NUMBER]; - The floors in rooms [ROOM NUMBERS] were very sticky; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two Certified Nurse Assistants (CNAs) (CNA K and CNA R) out of two sampled CNAs received 12 hours of training annually. The facility census was 49. The facility failed to provide a policy regarding annual training. Review of the facility assessment, dated [DATE], showed: - Facility assessment not reviewed since 2022 when the facility opened and had a census of two residents; - Staff competencies and annual training requirements per regulatory authority and/or facility policy to include: [...]

Inspectors wroteBased on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. The facility failed to ensure that foods are maintained at a safe and appetizing temperature on the steam table according to current Food and Drug Administration (FDA) standards, food is kept covered while waiting to be served, and dietary staff sanitize their hands or change gloves during and after preparing food, wear the appropriate hair restraints while in the kitchen, and have policies and procedures in place for food brought in from outside the facility. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 49. Review of the FDA 2013 Code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, showed that: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies) was complete and reviewed annually. The facility census was 49. The facility did not provide a facility assessment policy. Review of the facility assessment, dated 08/30/22, showed: - The census of two residents; - The facility assessment not updated to reflect the current resident census and needs; - The facility assessment not reviewed annually; - No documentation the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.) The facility census was 49. Review showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview on 04/17/24 at 4:30 P.M., the Regional Nurse said he/she was unable to find any documentation that the facility had a QAPI Plan. He/She did not believe the facility had been doing anything related to QAPI. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 49. The facility did not provide a policy for a QAPI Plan or Performance Improvement Plans (PIPs). Review showed no documentation the facility maintained the minimum required documentation for a QAPI plan or PIPs. During an interview on 04/17/24 at 4:30 P.M., the Regional Nurse said he/she was unable to find any documentation that the facility had a QAPI Plan or PIPs in place. He/She did not believe the facility had been doing anything related to QAPI. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility census was 49. The facility did not provide a policy or any documentation related to QAPI. Review showed no documentation the facility maintained the minimum required quarterly QAA meetings with the required members. During an interview on 04/17/24 at 4:30 P.M., the Regional Nurse said he/she was unable to find any documentation that the facility had any QAPI meetings. He/She did not believe the facility had been doing anything related to QAPI. During an interview on 04/19/24 at 3:45 P.M., the Administrator said she would expect the facility to have QAPI meetings at least quarterly with the required members present.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when staff and a resident touched cups where residents put their mouth without performing hand hygiene. The facility failed to perform glove changes and hand hygiene and failed to clean the glucometer (a device to measure blood sugar) between resident use during blood sugar checks for two residents (Resident #30 and #252) outside the sample. The facility failed to perform glove changes and hand hygiene between residents when administering medications for one resident (Resident #18) out of 13 sampled residents and one resident (Resident #30) outside the sample. The facility failed to maintain proper infection control practices during wound care for one resident (Resident #1) out of one sampled resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure at least one person had completed specialized training in infection prevention and control for the Infection Preventionist (IP - a professional who assures healthcare workers and residents are doing everything possible to prevent infection) position. This had the potential to affect all residents in the facility. The facility census was 49. Review of the facility's policy titled, Infection Control Nurse, undated, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health training for nine out of nine sampled staff hired in the last year. The facility census was 49. The facility failed to provide a policy regarding behavioral health training. Review of the medical diagnoses (dx) of the 49 residents present during the on-site survey showed: - Twenty-two residents had dx of schizophrenia (disorder that affects a person's ability to think, feel and behave clearly); - Eleven residents had a dx of bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs); - Seventeen residents had a dx of anxiety (intense, excessive and persistent worry and fear about every day situations); - Twenty-two residents had a dx of depression (loss of pleasure or interest in activities for long periods of time); [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for six residents (Residents #15, #30, #41, #204, 307 and #311). The facility also failed to allow residents access to resident funds on an ongoing basis for one resident (Resident #252). This had the potential to affect all residents the facility managed funds for. The facility failed to keep resident funds over $50.00 for residents that receive Medicaid, in an interest bearing account for one resident (Resident #22). The facility census was 49. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility failed to maintain the accounting records of resident funds for each transaction and failed to provide resident trust statements quarterly. The facility also commingled resident petty cash with facility petty cash. The facility managed funds for 46 residents. The facility census was 49. 1. Record review of the facility maintained bank statements for the period 02/2023 through 03/2024 showed no documentation of reconciliations. During an interview on 04/09/24 at 2:09 P.M., the Owner said resident trust reconciliations were not completed. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource for one resident (Resident #22). The facility managed funds for 46 residents of 49 residents. 1. Record review of the facility maintained Trust Transaction History for the period 01/01/24 through 04/04/24, dated 04/04/24, showed Resident #22 had the following balances. Date Amount 02/15/24 $7,989.45 02/16/24 $6,592.05 02/23/24 $6,582.05 03/01/24 $8,420.05 03/05/24 $7,012.65 03/11/24 $6,974.65 04/03/24 $7,084.55 04/04/24 $6,884.55 2. Record review of the facility maintained Trust Transaction History for Resident #22 showed his/her account reached at least $200 less than the SSI resource limit of $5,726.00 for 02/15/24 through 04/04/24. 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 49. Review of the facility maintained Resident Trust Bank Statements for the period 04/2023 through 03/2024, showed an average monthly balance of $11,894.63. Review of the facility maintained Accounts Receivable (A/R) Aging Report, dated 04/08/24, showed the facility held a balance of resident funds in the amount of $9,577.14. Review on 04/25/24, of the Department of Health and Senior Services approved bond list showed the facility had a $1,000.00 approved bond, making the bond insufficient by $30,500.00. During an interview on 04/16/24 at 10:42 A.M., the Temporary Administrator/Business Office Manager said she thought the bond was determined by taking 30% of the total money managed but did not know for sure. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS - a federally mandated assessment completed by the facility) within the required time frames for 10 residents (Residents #1, #2, #6, #16, #26, #32, #33, #35, #36, and #38) out of 13 sampled residents and two residents (Residents #8 and #20) outside the sample. The facility census was 49. Review of the facility's policy titled, MDS Coordinator - Job Description, dated 02/23/23, showed: - Tracks and scheduled required resident assessments per state and federal requirements; - Completes all MDS assessments and Care Area Trigger Summaries; - Checks the facility's census daily and completes Discharge and Entry Tracking forms as needed; - Monitors documentation in the facility to ensure consistency and compliance with state and federal requirements; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility) within the required timeframe for seven residents (Residents #2, #18, #32, #33, #38, #40, and #42) out of 13 sampled residents. The facility's census was 49. Review of the facility's policy titled, MDS Coordinator - Job Description, dated 02/23/23, showed: - Tracks and schedules required resident assessments per state and federal requirements; - Completes all MDS assessments and Care Area Trigger Summaries; - Checks the facility's census daily and completes Discharge and Entry Tracking forms as needed; - Monitors documentation in the facility to ensure consistency and compliance with state and federal requirements; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments in a timely manner and in accordance with guidelines for ten residents (Residents #6, #16, #18, #32, #33, #35, #36, #38, #40, and #42) of 13 sampled residents. The facility's census was 49. Review of the facility's policy titled, MDS Coordinator - Job Description, dated 02/23/23, showed: - Tracks and scheduled required resident assessments per state and federal requirements; - Completes all MDS assessments and Care Area Trigger Summaries; - Checks the facility's census daily and completes Discharge and Entry Tracking forms as needed; - Monitors documentation in the facility to ensure consistency and compliance with state and federal requirements; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans with specific interventions to meet individual needs for three residents (Resident #1, #6, and #16) out of 13 sampled residents and one resident (Resident #29) outside the sample. The facility's census was 49. Review of the facility's policy titled, Care Planning - Interdisciplinary Team, reviewed 02/21, showed: - Every resident will be assessed using the Minimum Data Set (MDS - a federally mandated assessment completed by the facility) according to the guidelines set forth in the Resident Assessment Instrument (RAI) Manual; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a sufficient number of nursing personnel to provide care and respond to each resident's basic and individual needs required by the resident's diagnoses, medical condition, or plan of care. This had the potential to affect all residents in the facility. The facility census was 49. Review of the Facility Assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies), dated 08/30/22, showed: - Facility assessment not reviewed since 2022 when the facility opened and had a census of two residents; - Direct Care Staffing desired showed one Registered Nurse (RN), two Licensed Practical Nurses (LPN) and one Certified Nursing Assistant (CNA) for the two residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, not expired and reconciled for the facility's Emergency Medication Kit (E-Kit), which had the potential to affect all residents. The facility's census was 49. Review of the facility's policy titled, Medications-Pharmacy, dated 02/23/23, showed: - The facility will provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident; - Emergency Medications: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were securely stored in accordance with currently accepted practices and facility policy. The facility failed to ensure one resident (Resident #42) out of the 13 sampled residents had a physician's order to keep and self-administer medications at the bedside. The facility failed to ensure medication carts and medication rooms were free from expired medications, which had the potential to affect all residents. The facility failed to properly dispose of an expired medication for one resident (Resident #30) outside of the sample. The facility census was 49. Review of the facility policy titled, Medication Storage, dated 02/23/23, showed: - Medications must only be accessible to authorized staff and locked when not under the direct supervision of authorized staff; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document residents received or declined appropriate immunizations for five residents (Residents #1, #8, #26, #35 and #102) out of five sampled residents. The facility census was 49. Review of the facility's policy titled, Influenza (a highly contagious viral infection of the respiratory passages causing fever, severe aches and inflammation) Immunization, undated, showed: - Flu season is defined as October 1st through March 31st; - The Infection Control (IC) Nurse will inform charge nurse when influenza vaccine is available and when immunization process should begin; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a dining room large enough to accommodate the residents. This affected one resident (Resident #16) out of 13 sampled residents and two residents (Resident #27 and #252) outside the sample and had the potential to affect all residents. The facility census was 49. The facility did not provide a dining room policy. 1. Observation on 04/03/24 at 1:22 P.M., showed: - Several of the residents finished their meal and left the dining area before staff brought additional residents to the dining room to eat; - Nine round tables and four rectangle tables with twenty-seven chairs were available for residents. 2. Observation on 04/04/24 at 12:27 P.M., showed two residents (Resident #16 and #27) seated in the area where the vending machines were located due to no available seating for them in the dining room. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents (Residents #203 and #204) out of two sampled residents who were discharged from Medicare Part A services with benefit days remaining. The facility census was 49. The facility did not provide a policy for SNF ABN or NOMNC forms. 1. Review of Resident #203's medical record showed: - The resident discharged from Medicare Part A services on 11/23/23; - The resident remained in the facility; - The facility failed to issue a SNF ABN and NOMNC to the resident. 2. Review of Resident #204's medical record showed: - The resident discharged from Medicare Part A services on 10/04/23; - The resident remained in the facility; - The facility failed to issue a SNF ABN and NOMNC to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the use of a lap tray to determine if it was a restraint, failed to document the lap tray on the care plan, failed to identify a medical symptom that supported the use of the lap tray, failed to document the least restrictive use for the lap tray, and failed to document an ongoing re-evaluation for the use of the lap tray for one resident (Resident #16) out of one sampled resident with a restraint. The facility census was 49. Review of the facility's policy titled, Restraints - Definitions, dated 02/23/23, showed: - Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily, which restricts freedom of movement or normal access to one's body; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for five residents (Resident #6, #16, #18, #35, and #36) out of 13 sampled residents and one resident (Resident #43) outside the sample. The facility's census was 49. Review of the facility's policy titled, Discharges, undated, showed the Social Services department will notify the resident and family of the discharge in accordance with federal regulations. 1. Review of Resident #6's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or legal representative in writing of their bed hold policy at the time of transfer to the hospital for four residents (Residents #6, #16, #35, and #36) out of 13 sampled residents and one resident (Resident #43) outside the sample. The facility's census was 49. Review of the facility's policy titled, Discharges, undated, showed the Social Services department will provide the resident and family with the facility's bed hold and readmission policies. 1. Review of Resident #6's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident or resident representative was informed in writing of the facility bed hold policy at the time of transfer. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for five residents (Residents #6, #16, #18, #36, and #42) out of 13 sampled residents. The facility's census was 49. Review of the facility's policy titled, MDS Coordinator-Job Description, dated 02/23/23, showed: - Tracks and schedules required resident assessments per state and federal requirements; - Completes all MDS assessments and Care Area Trigger Summaries; - Checks the facility's census daily and completes Discharge and Entry Tracking forms as needed; - Monitors documentation in the facility to ensure consistency and compliance with state and federal requirements; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Level I Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for two residents (Resident #2 and #26) out of 13 sampled residents. The facility's census was 49. The facility did not provide a PASARR policy. 1. Review of Resident #2's medical record showed: - An admission date of 12/16/23; - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life), anxiety disorder (persistent worry and fear about everyday situations) and schizophrenia (a disorder that affects one's ability to think, feel and behave clearly); - No level I PASARR. 2. Review of Resident #26's medical record showed: - An admission date of 12/18/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for five residents (Resident #1, #2, #6, #18, and #32) out of 13 sampled residents. The facility census was 49. The facility failed to provide a policy related to baseline care plans. 1. Review of Resident #1's medical record showed: - An admission date of 12/16/23; - Diagnoses of diabetes mellitus (a condition that affects the way the body processes blood sugar), high blood pressure, and high cholesterol. Review of the resident's baseline care plan, dated 01/24/24, showed: - Not completed within 48 hours of admission; - No documentation the resident and/or the representative received a written summary of the baseline care plan. 2. Review of Resident #2's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan in seven days after completion of the comprehensive assessment and no more than 21 days after admission to properly care for six residents (Resident #18, #32, #33, #36, #40, and #42) out of 13 sampled residents. The facility census was 49. The facility did not provide a policy. 1. Record review of Resident #18's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/17/22, showed the following: - admitted to the facility on [DATE]; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to follow physician's orders for five residents (Residents #16, #18, #26, #33, and #40) out of 13 sampled residents and one resident (Resident #12) outside the sample. The facility census was 49. The facility did not provide a policy. 1. Review of Resident #12's medical record showed: - An admission date of 08/31/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #50) out of two discharged residents. The facility's census was 49. Review of the facility's policy titled, Discharge, undated, showed: [...]

Inspectors wroteBased on observation, interview and record review the facility facility to provide needed care and services in accordance with professional standards of practice for one resident (Resident #42) out of one sampled resident receiving chemotherapy services. The facility census was 49. Review of the facility policy, Intravenous Therapy, dated 02/23/23, showed: - A physician's order is required for intravenous (IV) therapy and must state route, type of solutions and additives, flow, rate, and time of administration, type and frequency of flushes, start date, and stop date; - Registered Nurses (RNs) who have had IV training or certification are the only staff members authorized to change IV dressings, maintain IV sites, set up or change any settings on transfusion pumps, and remove an IV; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Registered Dietician's (RD) recommendations for weight loss were provided to the physician which affected one resident (Resident #16) out of 13 sampled residents. The facility census was 49. Review of the facility policy titled, Weight Loss, dated 02/23/23, showed: - The facility will ensure that each resident maintains acceptable parameters of body weight, unless the resident's clinical condition demonstrates that this is not possible; - The charge nurse will ensure that each resident is weighed monthly or more frequently if ordered by the physician or deemed necessary for the resident's clinical condition; - Ensure that all residents with unplanned weight loss are monitored by the physician and dietician; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure services to promote the resident's highest level of functioning and psychosocial needs for three residents (Residents #20, #29 and #45) outside the sample with dementia. The facility census was 49. The facility did not provide a dementia policy. 1. Review of Resident #20's medical record showed: - An admission date of 01/09/23; - Diagnosis of dementia with behavioral disturbance (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning). [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for two residents (Residents #29 and #43) outside of the sample. This failure had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage of medication due to not monitoring if a medication is treating the target symptom. The facility census was 49. The facility did not provide a policy. 1. Review of Resident #29's medical record showed: - An admission date of 12/16/23; - Diagnoses of dementia with behavioral disturbance and altered mental status; - An order for paroxetine (antidepressant medication) oral tablet 10 milligrams (mg), give one tablet by mouth one time a day related to altered mental status (change in mental function that stems from illnesses, disorders and injuries), dated 12/17/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were six errors out of 42 opportunities for error, resulting in an error rate of 14.29%. This practice affected one resident (Resident #36) out of 13 sampled residents and one resident (Resident #12) outside the sample. The facility census was 49. Review of the facility policy titled, Medication Administration, undated, showed: - The facility will provide pharmaceutical services, including procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident; - Scan the resident's other medication orders to make sure there are no contraindications between the medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appealing alternative options of similar nutritive value to residents who choose not to eat food that was initially served. The facility census was 49. 1. Observations of the white dry erase board hung next to the serving window in the dining room showed: - On 04/03/24 at 6:00 P.M., the menu for dinner as flatbread pizza, salad, and a bread stick, with no alternative option; - On 04/04/24 at 12:37 P.M., the menu for lunch as chicken parmesan with pasta, asparagus, and garlic bread, with no alternative option. Observation on 04/03/24 at 1:14 P.M., showed Resident #27 told staff he/she did not like the meal being served. Staff brought the resident a bowl of cereal with milk in place of the lunch option because there were no other alternatives available. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pests out and to keep the garbage contained in the dumpster. The facility census was 49. The facility did not provide a garbage policy. Observations of two dumpsters, both with two lids, on the back left side of the facility showed: - On 04/04/24 at 10:01 A.M., the dumpster on the left with the left lid opened; - On 04/09/24 at 9:31 A.M., and 04/19/24 at 9:34 A.M., all of the dumpster lids opened with visible cardboard boxes and other miscellaneous items; - On 04/16/24 at 11:00 A.M., only one dumpster present with the lid up on the right side of the dumpster. During an interview on 04/09/24 at 4:04 P.M., the Dietary Manager (DM) said the trash dumpster lids should be closed after staff discard trash and other miscellaneous items. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Covid-19 (an infectious disease caused by a virus that could cause some people to become seriously ill and require medical attention) vaccination was offered, administered, or refused by the resident and/or resident's representative for three residents (Residents #1, #26 and #102) out of five sampled residents. The facility's census was 49. The facility did not provide a Covid-19 vaccination policy. 1. Review of Resident #1's medical record showed: - admission date of 12/16/23; - Diagnoses of diabetes mellitus (a disease which the body's ability produce or respond to insulin is impaired resulting in elevated levels of glucose in the blood), bradycardia (heart beats slower than normal) and high blood pressure; - No documentation of the education for the COVID-19 vaccination was provided; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 49. The facility did not provide a policy for overbed lighting safety. 1. Observation on 04/02/24 at 1:52 P.M. of room [ROOM NUMBER] showed: - A bottle containing artificial flowers lay sideways on top of the light fixture above the bed by the door; - A bottle of shampoo and a book sat on top of the light fixture above the bed by the window. 2. Observation on 04/05/24 at 3:10 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an effective training program for all new and existing staff was in place. The facility failed to implement a plan regarding the training needs listed in the facility assessment, and did not have a schedule of how or when required training would be completed. The facility census was 49. Review of the facility assessment, dated [DATE], showed: - Facility assessment not reviewed since 2022, when the facility opened and had a census of two residents; - Staff competencies and annual training requirements per regulatory authority and/or facility policy to include: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide abuse/neglect training for five Certified Nursing Assistants (CNAs) and one Certified Medication Technician (CMT) of eight sampled staff hired in the last year. The facility census was 49. Review of the facility's policy titled, Abuse, dated 08/01/22, showed: - This policy and procedure and the facility's abuse in service will be read to all newly hired employees during the facility orientation; - All employees are required to attend the yearly facility in-service on abuse. 1. Review of CMT F's employee file showed: - A hire date of 08/20/23; - No documentation of abuse/neglect training. 2. Review of CNA I's employee file showed: - A hire date of 08/28/23; - No documentation of abuse/neglect training. 3. Review of CNA S's employee file showed: - A hire date of 10/04/23; - No documentation of abuse/neglect training. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of abuse prevention and dementia care for two out of two Certified Nursing Assistants (CNAs) sampled. The facility census was 49. Review of the facility's policy titled, Abuse, dated 08/01/22, showed: - This policy and procedure and the facility's abuse in-service will be read to all newly hired employees during the facility orientation; - All employees are required to attend the yearly facility in-service on abuse. The facility did not provide a policy regarding dementia care. 1. Review of CNA K's employee file showed: - A hire date of 03/17/23; - CNA K attended a total of 30 minutes of in-services, lacking an additional 11 hours and 30 minutes; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure staff interacted with one resident (Resident #1) in a respectful manner, which recognized the resident's physical limitations and communication needs when Certified Medication Tech (CMT) A sat on the resident's lap to coerce medication administration. This practice has the potential affect all residents of the facility. The facility census was 51. Review of the facility's policy titled Medication Administration, undated, showed: - Oral medications may be administered to the resident in the dining room if the resident is agreeable, but medication by any other route (ie. injection, tube feeding, topical, eye drops, nebulizer, etc), must not be given in the dining room; - Resident privacy and dignity must be maintained when giving medications. Review of Resident #1's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence for a facility- initiated discharge for one resident (Resident #1) who was issued an immediate discharge notice and transferred to an acute care facility. The facility also failed to follow appropriate discharge practices when they discharged Resident #1 to the hospital and refused to allow the resident to return to the facility. The facility census was 50. Review of the facility policy titled, Discharges, undated, showed: -A physician's order is required for all discharges; -Nurse notifies Director of Nursing, the Minimum Data Set (MDS) Coordinator, social services, Activities, Dietary and the Therapy Department of pending discharges; -Social Services will notify the resident and family of the discharge in accordance with federal regulations. [...]