Every finding on record at Superior Manor of Festus, LLC

Based 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; - On 04/28/25, not notated per office. Observations of the facility from 05/13/25 through 05/15/25 showed: - On 05/13/25 at 12:37 P.M., a fly buzzed around the 400 hall; - On 05/13/25 at 12:32 P.M., a fly buzzed around Resident #36 while being interviewed. His/Her roommate had eyes closed, mouth open, and three flies buzzed around him/her; - On 05/13/25 at 12:40 P.M., Resident #19 had two flies on his/her bed; - On 05/13/25 at 3:10 P.M., two flies buzzed around room [ROOM NUMBER]; - On 05/14/25 at 1:45 P.M., a fly buzzed around room [ROOM NUMBER]; - On 05/14/25 at 1:48 P.M., a fly buzzed around Resident #7 while being interviewed; - On 05/14/25 at 1:50 P.M., a fly buzzed around the kitchen sink area; - On 05/14/25 at 1:55 P.M., a fly buzzed around the warmer in the kitchen; - On 05/15/25 at 12:00 P.M., flies buzzed around residents sitting at tables in the dining room waiting to eat; - On 05/15/25 at 12:15 P.M., a fly buzzed around the 400 hall. During an interview on 05/13/25 at 12:40 P.M., Resident #19 said the flies had been bad the past few days. During an interview on 05/14/25 at 1:48 P.M., Resident #7 said flies had been really bad and he/she hates them. The flies would land on tender skin areas, and he/she had to keep a fly swatter close at hand. During an interview on 05/16/25 at 1:58 P.M., the Administrator and Director of Nursing (DON) said they would expect the facility to be free from pests, such as flies. Pest control comes monthly. 46460

Based 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. During an interview on 05/16/25 at 9:38 A.M., the Administrator said she has been taking care of the funds and knows the bond isn't sufficient. She provided a form that she had completed in April that shows she figured it should be $58,500.00 and it's only $30,000.00. She has talked to the owner, and the owner is supposed to be working on it. During an interview on 05/16/25 at 1:58 P.M., the Administrator said she would expect the residents' funds bond to be at least 1.5 times the 12-month average in the resident funds account.

Based 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; - Each resident receives only those medications in doses and for the duration clinically indicated to treat the resident's assessed conditions; - Non-pharmacological interventions are considered and used when indicated, instead of, or in addition to, medication. 1. Review of Resident #12's current Physician Order Sheet (POS), dated, 05/16/25, showed: - admitted on [DATE]; - Diagnoses of paranoid schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly-characterized by persistent delusions and hallucinations, primarily paranoia), borderline intellectual functioning (categorization of intelligence where a person has below average cognitive ability), major depressive disorder, anxiety, and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms); - On 09/09/24, an order for evaluation and management with psychiatric services; - On 06/15/24, an order to monitor restlessness, agitation, increased complaints, foul language, delusions, aggressions, and refusal of care; - On 07/13/23, an order for aripiprazole (an antipsychotic medication) 15 milligrams (mg), once daily for schizophrenia; - On 10/09/24, an order for Invega Trinza (an antipsychotic medication) 546 mg/1.75 milliliters (ml) inject 1.5 ml intramuscularly (IM) every 90 days for behavior management related to schizophrenia. Review of Resident #12's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool that measures the health status of residents, filled out by facility staff), dated 03/25/25, showed: - Cognitively Intact, with a Brief Interview for Mental Status (BIMS) score of 15; - Receives an antipsychotic medication on routine basis. Review of the Resident #12's medical record, showed no documentation the resident or the representative was informed of risks and benefits prior to the initiating of aripiprazole or Invega Trinza. 2. Review of the Resident #28's current POS, dated 05/16/25, showed: - admitted on [DATE]; - Diagnoses of bipolar disorder (a disorder associated with episodes of mood swings, ranging from depressive lows to manic highs), schizophrenia, depression, anxiety, intellectual disabilities, schizoaffective disorder, and borderline personality disorder; - On 02/25/25, an order to monitor for itching, picking at skin, restlessness, agitation, hitting, increased complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, or refusal of care; - On 02/26/25, an order for olanzapine (an antipsychotic medication) 20 mg tablet once daily for bipolar disorder. Review of Resident 28#'s Quarterly MDS, dated [DATE], showed: - Moderately Impaired, with a BIMS score of 12; - Receives an antipsychotic medication on routine and as needled (PRN) basis. Review of Resident #28's medical record showed no documentation the resident or the representative was informed of risks and benefits prior to initiating olanzapine. 3. Review of the Resident #30's current POS, dated 05/16/25, showed: - admitted on [DATE]; - Diagnoses of anxiety disorder, mild intellectual disabilities, major depressive disorder, and disorder of psychological development (disorders of psychological development in adults refer to conditions that affect and individual's psychological well-being and behavior, often stemming from early childhood experiences or genetic factors); - On 01/06/25, an order to monitor itching, picking at skin, restlessness, agitation, hitting, increased complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression or refusal of care; - On 01/06/25, an order for psychiatric consult; - On 01/08/25, an order for quetiapine (an antipsychotic medication) 150 mg at bedtime for major depressive disorder. Review of Resident 30#'s Quarterly MDS, dated [DATE], showed: - Moderately Impaired, with a BIMS score of 10; - Receives an antipsychotic medication on routine basis. Review of Resident #30's medical record showed no documentation the resident or the representative was informed of risks and benefits prior to the initiating of quetiapine. During an interview on 05/16/25 at 8:40 A.M., the Administrator said she was not aware of any consent that would be signed prior to taking a psychotropic medication but she would look into it. During an interview on 05/16/25 at 1:58 P.M., the Administrator and Director of Nursing (DON) said they would expect residents and/or residents representatives to be informed in advance of the risks and benefits of proposed care, treatments, treatment alternatives, and be able to choose a different option if preferred.

Based 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; - room [ROOM NUMBER]'s vinyl plank floor buckled and some of the buckled seams taped from the doorway to the middle of the room and the room smelled of urine with no residents in it at the time; - room [ROOM NUMBER]'s vinyl plank floor beginning to pull away and buckle at three seams near the doorway; - Area in front of the 100/200 hall nurses station with vinyl plank floor with six planks buckled and cracked, one plank missing an approximately two inch long by one inch wide piece, one tile missing a six inch long by half inch wide area; - Area connecting 100 to 200 hall vinyl plank floor with two buckled planks with an approximate area of 12 inch long section by a quarter inch wide, and an approximate area 16 inches long by a half inch wide. Observation on 05/15/25 at 8:26 A.M. showed room [ROOM NUMBER] with a urine smell. Observation on 05/16/25 at 11:25 A.M. showed room [ROOM NUMBER] Bed A with an approximate five inch by four inch hole in the light fixture cover above the bed. During an interview on 05/16/25 at 12:13 P.M., Resident #29 said his/her floor is a big mess and staff have a hard time pushing his/her chair over the buckled floor. During an interview on 05/16/25 at 1:58 P.M., the Administrator said she would expect floors to be in good repair without cracks or buckling and light covers not to have holes in them.

Based 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 admitted [DATE]; - 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; - Impairment on both upper extremities; - Wheelchair for mobility; - Supervision for oral hygiene; - Substantial/maximum assist for toileting; - Substantial/maximum assist for showering; - Substantial/maximum assist for lower body dressing. Review of the resident's quarterly MDS assessment, dated 01/08/25, showed: - Moderate cognitive impairment; - Impairment on one upper extremity; - Wheelchair for mobility; - Partial/moderate assist with oral hygiene; - Dependent on staff for toileting; - Substantial/maximum assist for showering; - Dependent on staff for lower body dressing. Review of the resident's quarterly MDS assessment, dated 04/01/25, showed: - Severe cognitive impairment; - Impairment on one upper extremity; - Wheelchair for mobility; - Partial/moderate assist with oral hygiene; - Substantial/maximum assist for toileting; - Dependent on staff for showering; - Substantial/maximum assist for lower body dressing. Review of the resident's Physician's Order Sheet (POS), dated 05/16/25, showed: - Per orthopedic follow up visit on 10/29/24: Resident may use left extremity as tolerated with weekly range of motion (ROM) for stretching for eight weeks, one time a day every seven day(s) for post surgical. Provide gentle ROM to left extremity. Document tolerance, dated 10/29/24; - Physical Therapy (PT)/Occupational Therapy (OT) evaluate and treat, dated 11/06/24; - Skilled PT for evaluation and treatment, three times per week for 30 days for therapeutic exercise (therex), therapeutic activity (theract), neuromuscular re-education (NMRE-ed), bed mobility, transfer, balance training, dated 11/06/24; - Skilled OT to evaluate and treat patient for 12 visits in two months for functional deficits related to aftercare following explantation of shoulder joint prosthesis. Treatments may include the following: therapeutic exercise, therapeutic activity, self-care management, wheelchair management, neuromuscular reeducation, manual and group therapy as indicated, dated 11/06/24; - Discontinue skilled PT, dated 12/04/24. Review of the Physical Therapy Discharge Summary, dated 12/04/24, showed: - Resident discharged due to highest practical level achieved; - Discharge Recommendations: Patient will remain in this skilled nursing facility (SNF) with staff assist for transfers. Patient encouraged to perform lower extremity home exercise program (HEP) daily to maintain strength and ROM; - Restorative Program not indicated at this time due to being unavailable; - Prognosis to maintain current level of functioning good with consistent staff follow-through. Review of the resident's care plan, revised 04/11/25, showed: - The resident has limited physical mobility related to neurological deficits, weakness and hemiplegia; - Provide gentle range of motion as tolerated with daily care; - Provide supportive care, assistance with mobility as needed. Document assistance as needed; - The resident will remain free of complications related to immobility, including contractures, thrombus (clot) formation, skin breakdown, and fall-related injury through the next review date. During an interview on 05/16/25 at 12:00 P.M., the Administrator said their therapy department does not regularly evaluate residents; they only do it if staff asks them. The facility doesn't have a restorative program. It hasn't had one since she started as administrator a year ago. It's on the list, but they just don't have one yet. During an interview on 05/16/25 at 1:21 P.M., the Administrator said therapy does not routinely evaluate residents for therapy. The nursing team will let therapy know if there is someone who has had a decline or falls. After residents discharge from therapy, there is no program in place to make sure residents maintain their function. During an interview on 05/16/25 at 1:58 P.M., the Administrator and Director of Nursing (DON) said they would expect to have a restorative nursing program in place to ensure residents maintain range of motion and prevent further decreases in range of motion.

Based 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. - The Charge Nurse will monitor charts of all residents with unplanned weight loss to ensure that interventions and documentation are appropriate; - The Unit Nurse will list residents that weights should be obtained on assignment sheets every shift; - The Unit Nurse will calculate weight losses and notify the resident's physician and dietician if there has been a weight loss of five percent (%) in one month, seven point five percent in three months or ten percent in six months; - Supervise Nursing Assistants to ensure all resident intakes are calculated correctly and recorded; - Nursing Assistants (NA) must obtain weights for all residents listed; - Notify charge nurse when resident's intake is inadequate or refuses food or fluids. 1. Review of resident #3's medical record showed: - admitted on [DATE]; - Diagnoses include bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder, schizoaffective disorder (a mental health condition including schizophrenia-a disorder that affects the way one thinks, feels or behaves, and mood disorders), and gastroesophageal reflux disease (GERD-a digestive disease which stomach acid or bile irritates the food pipe lining). Review of the resident's Physician's Order Sheet (POS), showed: - On 01/05/25, an order for monthly weights; - On 02/18/25, an order for weekly weights, related to weight loss; - On 03/20/25, an order for house supplements, three times daily mixed with vanilla ice cream. Review of Resident #3's weights showed: - On 01/07/25, a weight of 180.2 pounds (lbs.); - On 02/11/25, a weight of 176.5 lbs.; - On 02/18/25, a weight of 171.8 lbs.; - On 03/04/25, a weight of 160.9 lbs.; - On 03/18/25, a weight of 175.2 lbs.; - On 04/01/25, a weight of 168.0 lbs.; - On 04/08/25, a weight of 165.4 lbs.; - On 05/06/25, a weight of 157.6 lbs.; - From 02/11/25 until 05/06/25, a significant weight loss of 10.7%. Review of the Registered Dietitian (RD) Monthly Weight Evaluations showed: - On 01/22/25, significant weight loss over last month, regular diet. Resident aware of weight loss and attributes to not always liking food. Food preferences updated on meal ticket to serve when available, recommend vanilla health shakes twice daily (BID); - On 02/21/25, current Body Mass Index (BMI-a calculation that uses height and weight to establish whether weight is healthy, overweight or obese) is appropriate for age, intake between 26-50 percent, supplements include nighttime (HS) snack and house shake BID. Will let Dietary Manager (DM) know to try adding yogurt on next order; - On 03/18/25, BMI of 23.8=Within Normal Limits (WNL), discussed mixing vanilla health shakes with vanilla ice cream. Resident agreeable to this. Increase health shakes to three times daily (TID); - On 05/12/25, BMI of 23.3 (WNL), discussed trying new supplement in different flavor. Will speak to DM. Review of the resident's Care Plan, revised on 05/12/25, showed: - Risk for nutritional problems related to elevated BMI and recent weight loss, ice cream and yogurt at lunch and dinner, health shake at each meal, HS snack at bedtime, RD to evaluate and make diet recommendations as needed; - Unexplained/unexpected weight loss related to depression and recent decline in activities of daily living (ADLs), give supplements as ordered, alert nurse/dietician if not consuming on routine basis, monitor and evaluate any weight loss, offer substitutes as requested or indicated. Observation on 05/13/25 at 1:30 P.M., showed Resident had a health shake (still in original container-not mixed with ice cream) that appeared to have been consumed, on bedside table along with a few other drinks. Staff was asked if resident ever received a tray and it was said that when the tray was taken to Resident, he/she had refused, so staff member took it away and left the shake. Observation on 05/15/25 at 12:40 P.M. showed Resident received his/her noon meal. No shake or ice cream received. Observation on 05/15/25 at 12:55 P.M. staff served him/her a health shake that had been sitting on ice on the drink cart. During an interview on 05/16/25 at 9:00 A.M., the Dietary Manager said he/she was unaware that the health shakes were supposed to have been mixed with ice cream. During an interview on 05/16/25 at 9:10 A.M., Certified Nurse Aide (CNA) B said Resident #3 wouldn't eat breakfast that morning, but did eat a couple of oatmeal cream pies and some cheese crackers. Another staff member overheard the question and responded that the Resident had drunk a whole health shake. During an interview on 05/16/25 at 9:15 A.M., Registered Nurse (RN) C said he/she was unaware that there was an order for the health shakes to be mixed with ice cream, but would make sure it is done. During an interview on 05/16/25 at 9:25 A.M., the Director of Nursing (DON) said the ice cream should have been mixed with the health shakes and after looking into the order summary, it should have been done three times a day for nutritional supplement since March. During an interview on 05/16/25 at 1:58 P.M., the Administrator and DON said they would expect the RD's recommendations and physician orders to be followed.

Based 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. During an interview on 05/23/25 at 2:23 P.M., the Administrator said she did not have any annual performance reviews for any of these employees. She would expect CNAs to have annual performance reviews and in-service education based on the outcome of these reviews.

Based 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 [DATE] at 12:10 P.M. showed: - A 6 pound (lb) 14 ounce (oz) can of northern beans, undated and dented, on storage shelf; - Four 6 lb 14 oz cans of undated northern beans; - Nine health shakes in a box with no dates; - One pound container of beef base paste, open and dated ,d+[DATE], with a small portion used; - One pound container of beef base paste, open and dated ,d+[DATE], almost empty. - Six packages of 32 oz frozen stir fry vegetables, with an expiration date of [DATE]; - Two packages of 32 oz frozen broccoli, with an expiration date of [DATE]; - Six packages of 32 oz frozen peas, with an expiration date of [DATE]; - One pack of 32 oz frozen carrots, with an expiration date of [DATE]; - Two packages of 32 oz frozen zucchini, with an expiration date of [DATE]; - Twelve packages of 32 oz California Blend vegetables, with a received date of ,d+[DATE], and expired on [DATE]; - An opened, plastic-wrapped box of frozen pizza crusts, approximately half full, with best by date of [DATE], and an opened date of [DATE]; - An opened, plastic-wrapped box of frozen pizza crusts, approximately half full, with a best by date of [DATE], and an opened date of ,d+[DATE]; - Three containers of 6.5 lbs of frozen strawberries, with an expiration date of [DATE] on container, and the production stickers (sticker-type label across the top of lid placed by the food company) on the frozen strawberry containers, showed a date of [DATE]; - One 40 oz bag of frozen, opened, undated lima beans; - Two 40 oz bags of frozen, unopened, undated lima beans; - Two 40 oz frozen packages of maple sweet potatoes, dated [DATE]; - One gallon container of relish, unopened, no expiration date, and a written date of ,d+[DATE]. Observation on [DATE] at 12:25 P.M., showed a vape (a device that is used to inhale vapor containing nicotine and flavoring) and a half-full water bottle placed on top of the stored cans of food. Dishwasher A said, That's my vape. I'll move it if I need to. Dishwasher A then grabbed the items and took them away. Observation on [DATE] at 1:50 P.M. showed the kitchen trash can lid on the floor beside the trash can. During an interview on [DATE] at 8:59 A.M., the DM said he/she would expect the food to not be expired. During an interview on [DATE] at 1:58 P.M., the Administrator and Director of Nursing (DON) said they would expect expired food to be thrown away and not used, trash can lid to be kept on the trash can, dented cans not stored on the shelf to be used, and staff's personal water bottles and/or vapes not to be in the storage area of the kitchen.

Based 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; - The objectives of the QAPI program are to provide a means to measure current and potential indicators for outcomes of care and quality of life, provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators, reinforce and build upon effective systems and processes related to the delivery of quality care and services, and establish systems through which to monitor and evaluate corrective actions; - The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements; - The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action or performance improvement activities, and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Review of the facility's QAPI documentation showed no Performance Improvement Projects (PIPs) in place. During an interview on 05/15/25 at 3:00 P.M., the Administrator said she had a meeting on 06/27/24 with all the members present. She had a meeting with the DON on 01/06/25, and it was just the two of them. They have standup meeting every morning, and if they see an issue, they go to work trying to fix it, but they don't have PIPs in place with problems, interventions, and goals. During an interview on 05/16/25 at 1:58 P.M., the Administrator said she would expect to have a system in place to track performance, and to have PIPS in place for any issues that are identified.

Based 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. Review of the facility's QAPI documentation showed: - A QAPI meeting held on 06/27/24 with the required members present; - On 01/06/25 a meeting held with only the Administrator and Director of Nursing. During an interview on 05/15/25 at 3:00 P.M., the Administrator said she had a meeting on 06/27/24 with all the members present. She had a meeting with the DON on 01/06/25, and it was just the two of them. They have standup meeting every morning, and if they see an issue, they try to fix it. During an interview on 05/16/25 at 1:58 P.M., the Administrator said she would expect QAPI meetings to be held at least quarterly with the required members, including the Medical Director, the Administrator, the Director of Nursing, the Infection Preventionist, and two other staff members present.

Based 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; - At 11:25 A.M., room [ROOM NUMBER] Bed A with an approximately 24 inch by 24 inch picture in a frame on the over bed light; - At 12:00 P.M., room [ROOM NUMBER] with a dress hung from a plastic hanger, hanging from the light fixture; - At 12:01 P.M., room [ROOM NUMBER] with a poster propped up on top of the light fixture, a small car, and a faux speaker on one light fixture above the resident's bed, and on the other side of room, a cardboard box placed on the light fixture. During an interview on 05/16/25 at 1:58 P.M., the Administrator and Director of Nursing (DON) said they would expect residents light fixtures not to contain objects or be used as shelves, posing a fire hazard. 46460

Based 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; - No documented annual dementia training. 3. Review of CNA D's in-service record showed: - A hire date of 04/30/24; - A total of two hours annual in-service training for April 2024 through April 2025; - No documented annual dementia training. During an interview on 05/16/25 at 10:28 A.M., the Director of Nursing (DON) said in-services should be given by her or a nurse manager. In-services had been given on an as needed basis, and they are not having routine in-services. The facility is wanting to use an online training and education provider since that is the easiest way for everyone. She is aware that certain topics need to be covered and also aware CNAs have not been getting annual reviews. They are monitored on the floor and educated or written up if there are any issues. During an interview on 05/16/25 at 1:58 P.M., the Administrator and Director of Nursing (DON) said they would expect nurse aides to have at least 12 hours of in-services a year to include the regulatory topics, including dementia care.

Based 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: have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment; have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; have a disciplinary action in effect against their professional license by a state licensure body from a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. 1. Review of Resident #1's face sheet showed: - The resident was admitted on [DATE]; - Diagnoses of schizophrenia (a mental disorder affecting thinking, feeling and behavior), bipolar-manic (chronic mood disorder involving excessively heightened mood and behavior), traumatic brain dysfunction (injury to the brain caused by external force), moderate protein calorie malnutrition (imbalance of essential nutrients in the body), hypertension (high blood pressure), and diabetes mellitus II (condition of high blood sugar in the blood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the staff), dated 3/30/24, showed the resident was cognitively intact. Review of the facility's investigation, dated 09/05/24, showed: - On 09/05/24 at approximately 3:40 P.M., the Administrator heard a verbal altercation in the dining room/courtyard area. The Administrator observed Dietary Staff A and Resident #1 having a verbal altercation. Resident #1 was upset Dietary Staff A did not give him/her a cigarette fast enough during the smoke break. The Administrator instructed Dietary Staff A to walk away from the situation. Dietary Staff A walked through the door to the dining room and went back into the kitchen. The Administrator exited the area. Less than a minute later, the Administrator heard Dietary Staff A and Resident #1 arguing again. The Administrator entered the dining room and witnessed Dietary Staff A pull Resident #1's wheelchair backwards and then to the side using excessive force. The Administrator removed Dietary Staff A from the area and escorted him/her out of the building. The Administrator instructed Dietary Staff A not to return to the facility. Review of Dietary Staff A's personnel file showed: - Hire date of 06/29/24; - The facility's Abuse Inservice policy signed by Dietary Staff A, dated 07/11/24. During a telephone interview on 09/18/24 at 12:58 P.M., CNA C said he/she was in the dirty utility room on the 300/400 Hall when an unknown male resident reported that Dietary Staff A and Resident #1 had gotten into an argument and Dietary Staff A had gone off on Resident #1. CNA B saw Dietary Staff A walking down towards the dining room saying loudly, I'm never smoking another [expletive] ever again. Resident #1 mouthed something to Dietary Staff A in the dining room then Dietary Staff A lost it and started fast walking towards Resident #1. Dietary Staff A said to Resident #1, [Expletive] you [expletive], get me, [expletive] fight me, you can't do anything. Dietary Staff A used arm gestures and cussed Resident #1. Dietary Staff A and Resident #1 were yelling face to face at each other. Dietary Staff A placed his/her hands on Resident #1's wheelchair handles, pushed it off the ground from facing the door to facing the hallway, pushed the wheelchair back and to the side. Dietary Staff A stormed out of the dining room towards the Administrator's office. Resident #1 was mad and cursing at Dietary Staff A. CNA B went to get help. During a telephone interview on 09/18/24 at 1:05 P.M., CNA D said he/she witnessed Dietary Staff A get angry with Resident #1. As Dietary Staff A went into the dining room, he/she started yelling at Resident #1. Dietary Staff A yelled, Do something about it nigger. Right after, Dietary Staff A angrily went up to Resident #1's wheelchair, picked it up a little off the ground and jerked it roughly pulling him/her around 180 degrees by the wheelchair handles. During an interview on 09/18/24 at 1:15 P.M., Resident #1 said he/she went outside to smoke on 09/05/24. He/She asked for his/her cigarettes and Dietary Staff A took too long to pass them out to everyone. Resident #1 asked for his/her cigarettes and Dietary Staff A started cussing him/her. Dietary Staff A left and went into the dining room. When Resident #1 went into the dining room, Dietary Staff A said, [Expletive], you better shut up talking to me like that. Dietary Staff A grabbed Resident #1's wheelchair, jerked it hard and spun it around. Resident #1 told Dietary Staff A to calm down and Dietary Staff A said, No. Resident #1 said, Do you have a beef with me? Dietary Staff A went crazy cussing him/her in front of everyone and said what he/she would and wouldn't do. Resident #1 said he/she was mad and did not understand why Dietary Staff A treated him/her that way. During an interview on 09/18/24 at 1:25 P.M., the Administrator said she would expect all staff to follow policies on abuse, neglect. exploitation and misappropriation. Dietary Staff A was terminated on 09/05/24, following the incident. Complaint #MO241832

Based 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; - Within 10 days of hire, recall, or rehire, the HR Director will provide the following information to the state new hire directory for each newly hired, recalled, or rehired employee: employee's name, employee's address, employee's social security number, employer's name, employer's address, and employer's federal employment identification number; 1. Review of Dietary Staff A's personnel record showed: - Hire date of 06/29/24; - No documentation of NA Registry was checked prior to hire. 2. Record review of RN F's personnel record showed: - Hire date of 08/25/23; - No documentation the NA Registry was checked prior to hire. 3. Record review of Activity Director G's personnel record showed: - Hire date of 12/15/23; - No documentation the NA Registry was checked prior to hire. 4. Record review of Housekeeping Supervisor H's personnel record showed: - Hire date of 06/14/23; - No documentation the NA Registry was checked prior to hire. 5. Review of Maintenance Supervisor I's personnel record showed: - Hire date of 06/10/24; - No documentation of NA Registry was checked prior to hire. During an interview on 9/19/24 at 1:40 P.M., the Administrator said NA Registry checks should be completed on any new employee before they were hired and repeated quarterly.

Based 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: Abuse, Neglect, Exploitation and Misappropriation, Advance Directives, Behavioral Health, Communication, Compliance and Ethics, Cardiopulmonary Resuscitation (CPR), Dementia Care Management, Equipment and assistive device training, Infection Control, Emergency Preparedness, Facility policies and procedures, Resident Rights, Assessing Nutritional Needs and Meeting the needs of individuals with Mental Illness/Intellectual Disability/Developmental Delays. 1. Review of CNA K's employee file showed: - A hire date of [DATE]; - No documentation of in-services done in relation to facility assessment and annual review. 2. Review of CNA R's employee file showed: - A hire date of [DATE]; - No documentation of in-services done in relation to facility assessment and annual review. During an interview on [DATE] at 3:30 P.M., CNA K said he/she had not received any annual trainings on abuse/neglect, Alzheimer's, dementia or behavioral health. Employee signed a paper upon hire regarding abuse, but no orientation or training was done. In-services were done from time to time, but he/she did not remember abuse/neglect in-service. During an interview on [DATE] at 3:44 P.M., the Administrator and Director of Nursing (DON) said they would expect CNAs receiving in-services to have the length of the in-services documented. The DON said they were compiling a list of in-services and trainings that need to be done, as it was not being done. The Administrator said she would expect the facility assessment to reflect the resident population and their needs and for annual trainings to reflect the facility assessment.

Based 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 ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding, showed that: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under Section ,d+[DATE].19, and except as specified under paragraph (B) and in paragraph (C) of this section, time/temperature control for safety food shall be maintained; (1) At 57 degrees Celsius (C) (135 degrees Fahrenheit (F)) or above (for hot foods), except that roasts cooked to a temperature and for a time specified in paragraph ,d+[DATE].11(B) or reheated as specified in paragraph ,d+[DATE].11(E) may be held at a temperature of 54 degrees C (130 degrees F) or above; or (2) At 5 degrees C (41 degrees F) or less (for cold foods). The facility did not provide a policy pertaining to the kitchen or dietary services. 1. Observation on [DATE] at 10:21 A.M., of the white chest-style freezer showed: - A ,d+[DATE] inch buildup of frost/ice on the walls of the freezer; - Five frozen food items in plastic bags or wrapping not labeled or dated. Observation on [DATE] at 10:22 A.M., of the glass door refrigerator showed: - Three heads of unwrapped cabbage sat directly on the shelf; - Three bundles of unwrapped asparagus sat directly on the shelf; - Four large plastic bags of lettuce unlabeled and not dated. Observation on [DATE] at 10:26 A.M., of the walk-in freezer showed: - Food items not labeled or dated, including bags of bread in clear plastic bags and what appeared to be frozen vegetables; - An unlabeled opened box with an unidentified object wrapped in plastic sat on the floor of the freezer; - An unopened box sat on the floor against the back wall of the freezer; - Dirt and debris in the floor of the freezer. Observation on [DATE] at 10:29 A.M., of the dry food storage room showed: - A box of frying oil sat on the floor between two metal shelves; - An opened box of grill cleaner sat on top of a box of cooking oil in the floor; - An opened box of six cans of red beans sat on the floor; - A box of paper towels sat on the floor with a box of chips and marshmallows on top of the paper towels; - A box of canned pineapples sat on the floor; - Scattered dirt and debris throughout the room; - Multiple items of popcorn, chips, and canned good items not labeled or dated. During an interview on [DATE] at 10:30 A.M., the Dietary Manager (DM) said the boxes the food came in had dates on them. The individual cans or items did not have dates. They did not realize that, so the only way to know the best by or expiration dates would be to have the original box the items were shipped in. Observation on [DATE] at 10:18 A.M., of the kitchen showed: - The commercial dishwasher with white grime build up on the interior and exterior surfaces and water ran from the back left side of the dishwasher with the dishwasher not in use; - Debris on and around the sink to the right of the dishwasher and food debris on the floor beneath the sink; - Debris and a puddle of purple liquid under the right side of the dishwasher; - Debris on the shelf with spices and drinking pitchers; - A shelf in the center of the kitchen with a large container labeled flour, cornmeal, rice, and sugar with no use by date listed; - Black grime build-up on the back and top of the stove; - Pots, pans, plates in an upright position, bowls in an upright position, and cups stored on open shelves under the serving window with dirt and debris; - Pots, pizza pans, baking sheets, and skillets with black carbon buildup; - A toaster on the counter by the serving window covered in debris; - The counter by the serving window with debris; - A crate with dirty rags next to the counter where the coffee machine and drink containers sat; - A fan next to the crate with dirty rags covered in dust and debris; - Dirt and debris throughout the kitchen floor; - Cracks in tiles near the wall by the counter with the coffee machine. Observation on [DATE] at 10:01 A.M., of the kitchen showed: - Maintenance attempted to repair the serving window that didn't close correctly. He/She was not wearing a hair net and used a drill that caused saw dust and debris to fall onto the toaster on the counter. Saw dust and debris also fell on the clean dishes on the counter to the left of the window near the steam table; - Six gallons of whole milk on the bottom shelf of the solid door refrigerator with a best by date of [DATE]; - Two drawer style refrigerators located near the stove contained a bag of shredded parmesan cheese dated [DATE], an unlabeled bag of shredded cheese dated [DATE], and a block of undated sliced cheese. Observation on [DATE] at 3:45 P.M., of the kitchen showed: - A plastic container in the refrigerator with glass doors, labeled as cantaloupe, with a prep date of [DATE], and a use by date of [DATE]; - Tomatoes and one bundle of unwrapped asparagus sat directly on the shelf of the refrigerator; - Strawberry and chocolate -flavored health shakes in a box with chocolate flavored health with no use by date on the individual products; - An opened bag of charcoal and a container of lighter fluid sat on a crate in the dry goods storage room; - Debris throughout the kitchen floor and walk in freezer floor; - The commercial dishwasher with white grime build up on the interior and exterior surfaces and water ran from the back left side of the dishwasher with the dishwasher not in use; - Debris and a puddle of purple liquid under the right side of the dishwasher; - Debris on the shelf with spices and drinking pitchers; - A shelf in the center of the kitchen with a large container labeled flour, cornmeal, rice, and sugar with no use by date listed; - Black grime build-up on the back and top of the stove; - Pots, pans, plates in an upright position, bowls in an upright position, and cups stored on open shelves under the serving window with dirt and debris; - Pots, pizza pans, baking sheets, and skillets with black carbon buildup; - A toaster on the counter by the serving window covered in debris; - The counter by the serving window with debris; - Dirt and debris throughout the kitchen floor. Observation on [DATE] at 10:22 A.M., of the dry goods storage showed: - A package of chocolate sandwich cookies with an expiration date of [DATE]; - A box of pie crust mix with a use by date of [DATE]; - Debris throughout floor. During an interview on [DATE] at 12:00 P.M., the DM and Dietary Staff N said when they received food orders on Thursdays, the DM checked everything in. They put away all the freezer and cold items first. Items should be labeled and dated as they were put away. The dry good items were put into the storage area and were put away as they found time to unbox them. Dietary staff were responsible for cleaning the kitchen. The dishwashers would usually clean and mop their area between the lunch and dinner meals, typically around 3:00 P.M. to 4:00 P.M., each day, and the cooks or DM would clean the remaining area of the kitchen. During an interview on [DATE] at 11:19 A.M., the DM said he/she knew the kitchen was dirty, but they didn't have time to clean it. 2. Observations on [DATE] between 12:37 P.M. and 1:14 P.M. showed; - The steam table and food temperatures were not taken during that time; - Cook P with a beard, wore a hair restraint around his/her neck not covering his/her beard while at the steam table and serving food; - Dishwasher Q with a mustache, with no hair restraint while filling plastic food containers with dry good products and filling plates for the residents; - The DM with a hair restraint not wrapped around his/her head, and dangling from the bottom of his/her pony tail; - Baking sheet containing dessert, which appeared to be cake, on the counter in individual bowls with no covering; - Dishwasher Q wore gloves to open packages of dry goods (pasta and cereal) to put into plastic storage containers. He/She opened the refrigerators with gloves, opened packages and, wearing the same soiled gloves, touched a clean plate and food that appeared to be slices of cheese, to put on a plate for a resident. Observations on [DATE] at 01:20 P.M. showed: - Room trays going out without temperatures being taken then, or at any time since the last observation; - Cake that had been sitting uncovered on the counter since 12:37 P.M. was put into the hot cart with no covering to be taken to resident rooms. Review of the log file showed there were no logs completed for the steam table temperatures for the last eleven months. During an interview on [DATE] at 10:01 A.M., the DM said they had been checking the temperature of the food on the steam table, but had not been keeping logs because they couldn't find a form that wasn't confusing for the staff. They just started some forms and provided forms for the last three days. During an interview on [DATE] at 2:00 P.M., the Administrator said they do not have a policy regarding outside food being brought into the facility. He/she said if someone were to bring something in, they would label it and put it in the refrigerator in the kitchen. During an interview on [DATE] at 4:05 P.M., the DM said when they had less residents they used to keep outside food brought in for residents on a tray on the bottom shelf of the refrigerator. He/she said now they have limited room and are at capacity, so they don't accept resident food. He/she did not know of any residents having their own refrigerators and did not know of any unit refrigerators that are used for resident food. During an interview on [DATE] at 12:00 P.M., the DM said staff should wash their hands or change their gloves between tasks and wear hair restraints. During an interview on [DATE] at 11:30 A.M., Resident #40 said sometimes staff will check any outside food they bring in, but he/she stated there was not a specific person or schedule when food would be checked to make sure it's still ok to eat. During an interview on [DATE] at 3:44 P.M., the Administrator said she would expect food to be stored up off the floor, labeled, and dated. She would expect clean dishes to be stored in an enclosed area free from dirt and debris. She would expect food to be covered and dated when stored or waiting to be served. She would expect kitchen equipment to be maintained in working order and free from calcium build up and debris. She would expect floors and surfaces to be free from spills, dirt and debris. She would expect cleaning agents and chemicals to be stored separate from food. She would expect pots, pans, and cooking sheets to be free from carbon and grime build up. She would expect freezers to be free of ice buildup and expired food to be discarded. The Administrator said she would expect staff to wear hair restraints while in the kitchen. She would expect staff to change their gloves after touching equipment or surfaces before touching food. She would expect food temperature to be checked each meal and temperature logs maintained. She would expect food to be covered when being transported or sitting on the counter waiting to be served.

Based 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. During an interview on 04/19/24 at 3:45 P.M., the Administrator said she would expect the facility to implement a QAPI Program and Plan with policies and procedures for data collection and monitoring.

Based 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. During an interview on 04/19/24 at 3:45 P.M., the Administrator said she would expect the facility to have a QAPI Plan in place and implement PIPs to address identified issues.

Based 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. During an interview on 04/19/24 at 3:45 P.M., the Administrator said she would expect the facility assessment to reflect the resident population and their needs and for it to be updated annually.

Based 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; - The floor in room [ROOM NUMBER] sticky with particles of food and dirt scattered, and no threshold between the room and the hall flooring; - The 100 Hall floor dirty and sticky with food particles and an approximate two in. by two in. dried black substance; - The 200 Hall floor sticky with debris, and a three in. by three in. dried pink colored substance on the floor outside of room [ROOM NUMBER]; - room [ROOM NUMBER] with dirt and debris throughout the floor of the room, a urinal with a dark yellow dried substance sat on top of clothing items in the floor to the left of the door; - Approximately 10 in. long cracks in the laminate floor in the middle of the hall between rooms [ROOM NUMBERS]. Observation on 04/03/24 from 8:15 A.M. to 6:30 P.M., showed: - A musty and foul odor of urine and fecal material on the 100 and 200 Halls; - The 200 Hall floor sticky, with a three in. by three in. dried pink-colored substance on the floor outside of room [ROOM NUMBER]; - An approximately three foot (ft.) by one ft. brown area from a spill on the floor between rooms [ROOM NUMBERS]; - Thresholds missing on the doorways of rooms [ROOM NUMBER]; - An old hospital bracelet, crumbs, and larger pieces of food in the floor of room [ROOM NUMBER]; - room [ROOM NUMBER] with scratches and holes in the drywall behind both beds in the room. Two bottom drawers in the bathroom dresser not on the hinges and at a 45 degree angle, and the vent cover in the bathroom ceiling hung down 1.5 in. from the ceiling. A small, clear medicine cup with an unidentified yellow liquid sat on top of the dresser at 10:15 A.M. Registered Nurse (RN) B picked up and smelled the unidentified yellow liquid and said it smelled like alcohol, and put the medicine cup back on top of the dresser. The medicine cup still sat on the dresser at 4:25 P.M.; - The courtyard with a broken chair and hundreds of cigarette butts around the perimeter of the courtyard and around the drain grate; - An oxygen concentrator, that was used for multiple residents, sat in the dining room with 1/4 in. of debris/lint lining both filters on each each side of the concentrator. Observation on 04/04/24 from 8:33 A.M. to 1:53 P.M., showed: - A musty and foul odor of urine and fecal material on the 100 and 200 Halls; - The oxygen concentrator used for multiple residents sat in the dining room with 1/4 in. of debris/lint lining both filters on each each side of the concentrator; - A bent metal cover stuck out from the air conditioner located to the left of the entrance to the courtyard, a chair with no seat in the middle of the courtyard, metal bars hung from a broken [NAME], multiple smashed clear plastic cups, plastic wrappers, and various debris throughout the courtyard, and hundreds of cigarette butts around the perimeter of the courtyard and around the drain grate; - room [ROOM NUMBER] with a black cable hanging from above the window to the wall opposite of the closet; red markings on the wall under each light; a green substance smeared across the wall above the light switch; a clear plastic cup under the edge of the closet near the door; a pink plastic straw and disposable gloves under a chair in the corner to the left from the bedroom entrance; dirt and debris throughout the bedroom and bathroom floor; a metal knife, fork, and spoon on the back of the toilet in the bathroom; plastic food wrappers, a plastic bottle, and a plastic fork in an opened paper towel dispenser; plastic food wrappers, an empty soda can, and heath shake cartons sat in the window ledge; and a box of oatmeal cream pies sat on top of the bathroom mirror; - At 10:51 A.M. and again at 4:20 P.M., the small clear medicine cup with a yellow unidentified liquid sat on top of the dresser of room [ROOM NUMBER] since first observed on 04/03/24 at 10:15 A.M.; - Fecal material on the toilet seat and floor by the toilet in room [ROOM NUMBER] at 10:46 A.M., and at 4:00 P.M. Observation on 04/05/24 from 8:17 A.M. to 10:09 A.M., showed: - A musty and foul odor of urine and fecal material on the 100 and 200 Halls; - A three in. by three in. dried pink colored substance outside of room [ROOM NUMBER] on the floor. Observations on 04/09/24 at 8:10 A.M., 04/10/24 at 8:14 A.M., 04/12/24 at 8:15 A.M., and 04/17/24 at 8:35 A.M., showed a musty and foul odor of urine and fecal material on the 100 and 200 Halls. Observation on 04/19/24 from 11:01 A.M. to 1:15 P.M., showed: - A musty and foul odor of urine and fecal material on the 100 and 200 Halls; - A broken ceiling tile hung sideways above the laundry room entrance in front of room [ROOM NUMBER]; - room [ROOM NUMBER] with dirt and debris throughout the floor in the room and bathroom, one square ft. area of a sticky orange substance in the floor in front of the closet next to the bedroom entrance, and a ceiling tile hung sideways in the bathroom; - room [ROOM NUMBER] with a broken window blind and scratches in the paint and paint peeled from the floor; - room [ROOM NUMBER] with paint peeling from the floor, a missing threshold, and debris covered a resident's oxygen concentrator; - room [ROOM NUMBER] with a missing threshold, paint peeled from the floor with a half circle groove in the tile by the bedroom door from the door cutting into the floor, and a broken corner of tile along the left area around the door frame to the entrance of the room; - room [ROOM NUMBER] with a missing threshold; - room [ROOM NUMBER] with a missing threshold and scratches in the paint on the bottom outside of the door; - The hallway in front of room [ROOM NUMBER] with missing baseboard at the left corner of the room's entrance; - room [ROOM NUMBER] with damaged and buckled flooring in front of the bathroom, broken window blinds, missing door handle from the closet next to the bathroom, and a loose frame around the window unit air conditioner; - room [ROOM NUMBER] with chipped and broken tile at the door entrance and around the door frame, and scratches and indentations in the door frame; - room [ROOM NUMBER] with black marks and indentations in the wall next to the room entrance and a broken window blind; - room [ROOM NUMBER] with scratches and holes in the drywall behind both beds in the room. Two bottom drawers in the bathroom dresser not on the hinges and at a 45 degree angle, and the vent cover in the bathroom ceiling hung down 1.5 in. from the ceiling; - The floor very sticky and paint peeling from tile all throughout the 400 Hall; - A missing threshold between the dining room and the 400 Hall; - Quarter and dime size chips in the corner of the flooring tile located in the 300 Hall between the nurses station and the theater room; - Three approximately three in. cracks in the flooring around the threshold of the 300 Hall; - The shower room located near the nurses station with a stick of deodorant and an opened box of gloves lay on the sink, a metal sink stopper in the floor behind the door, a black mold-like substance on the wall above the baseboard to the left of the shower, and a large discolored area around the ceiling vent; - The shower room on the 100 Hall nearest the 300 Hallway entrance with a disposable brief lay on the sink, dirt and debris in the floor and the shower floor, paint peeled from the floor, a half-full shampoo bottle in the floor under a shower chair, dirt and debris on the ceiling vents along with peeled paint around the square vent, and an unpainted area near the toilet; - The shower room on the 100 Hall with dirt and debris throughout the floor, a sippy cup sat on the sink, unpainted drywall next to and across from the toilet, two towels on the back of the toilet, a foam square approximately two ft. by two ft. by two in. thick sat between the toilet and the wall, a gallon plastic jug with approximately one in. of pink liquid in front of the toilet, a spray bottle with approximately one in. of clear liquid sat on the grab bar next to the toilet, a clear plastic cup sat on the grab bar in the shower with approximately one in. of pink liquid, a metal hatch hung open from the ceiling, and a black mold-like substance around the sprinkler head; - A circular white pill with an M on it in the floor outside room [ROOM NUMBER]; - Two missing sections of the handrail on the left side of the 200 Hallway from the direction of the 100 Hallway. Review of the Resident Council Meeting Minutes, dated March 2024, showed: - Residents voiced concerns their rooms were not getting fully cleaned and their beds were not being made; - Both residents that resided in room [ROOM NUMBER] had concerns of the flooring coming up in their room. During an interview on 04/11/24 at 10:00 A.M., Housekeeping Staff (HS) L said he/she did the ordering for housekeeping. He/She ordered once a month and the invoices were sent to the back office to be paid. There had been multiple times in the past the bill had not been paid and they had missed orders. Housekeeping would have to ration supplies during those times. He/she did not feel like housekeeping could adequately do their jobs during those times due to the limited supplies. During an interview 04/11/24 at 11:50 A.M., HS L and HS O said the housekeeping staffing hours were cut in January and again on 03/01/24 and 03/10/24. Since, that time, the housekeeping staff had been unable to complete everything that needed to be done. They just hired a laundry person last week. They had been without laundry help since February. HS L said the owner wanted him/her to clean and do the laundry by himself/herself, but it was not doable. HS L said he/she was able to talk the owner into letting him/her keep HS O on staff. While they were without a laundry person, they cut up towels to use for washcloths at one point. HS L and HS O said they were told by the owner to not clean the window sills, air units, or dust furniture, and to only sweep and mop. They were told to only mop with water in the hallways that have painted floors, because the chemicals they used reacted with the paint due to the floors being painted with wall paint because it was cheaper than concrete paint. Hs L looked at his/her supply orders and said 07/28/23 until 08/10/23, and again 02/15/24 02/27/24, they went without chemicals for cleaning and laundry due to the bill not being paid. The last time the bill was $30,000, for the cleaning chemicals and the washers and dryers were rented. They were told by the rental company they were going to come get the washers and dryers unless a payment was made. HS L said the laundry was not set up as a separate clean/dirty side, but the owner called them when the survey started and told them to set it up that way. During an interview on 04/11/24 at 3:50 P.M., HS L said nursing staff were supposed to clean the oxygen concentrators and change out the tubing. During an interview on 04/19/24 at 3:44 P.M., the Administrator and Director of Nursing (DON) said the RNs were expected to clean and maintain the oxygen concentrators, but wasn't sure how often. The Administrator said it was expected that all floors and surfaces would be free from spills and liquids and that the Maintenance Supervisor would be contacted via text if something needed to be done. It would be written in a book after completed. The jobs were completed as soon as possible and based on the need and importance. 49152