NEWBRIDGE RETIREMENT COMMUNITY.

PRINTED: 03/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 NEWBRIDGE RETIREMENT COMMUNITY (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4724) 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for | tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to ensure two of six new employees were screened as required for tuberculosis (TB: a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) in a timely manner in accordance with State of Missouri 19 CSR 20-20.100 at the time of hire. This affects all facility residents through the _ increased risk of exposure to tuberculosis. The facility's census was 89. Review of the facility's Policy on Tuberculosis (TB) Testing for Employees, undated, showed: - "New employees must undergo TB testing as part of the pre-employment process, in accordance with current guidelines. Specific timing and requirements will be determined based on applicable regulations at the time of hire." Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities showed: Long Term Care Employees and Volunteers. All new long-term care facility employees and volunteers who work ten (10) or more hours per week are required to obtain a Mantoux Purified Protein Derivative (PPD) (Mantoux, TB skin test, tuberculin skin test, and PPDs are often used interchangeably. Mantoux refers to the technique for administering the test. Tuberculin (also called PPD) is the solution used to administer the test) Missouri Department of Health and Senior Sepvices LABORATORY DIRECTOR'S, OF PROWIDER/SHPRH 'S - NAB TITLE {X6) DATE ATH fa 3/2(,(25 STATE FORM 6899 PRGL11 IF continuation sheetl1 of 2 PRINTED: 03/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERYCLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING: 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S$ MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 NEWBRIDGE RETIREMENT COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION {X5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) | A4724 Continued From page 1 two (2)-step tuberculin test within one (1) month prior to starting employment in the facility. If the initial test is zero to nine millimeters (0-9 mm), the _ second test should be given as soon as possible within three (3) weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one (1) subsequent annual test within the past two (2) years. It is the responsibility of each facility to maintain a documentation of each employee's and volunteer's tuberculin status. (E) Employees | and volunteers with an initial zero to nine | millimeters (0-9 mm) Mantoux PPD two (2)-step test shall be one (1)-step tuberculin tested annually and the results recorded in a permanent record. Review of Facility Staff (FS) D's personnel file showed: - Hire date of 10/30/24; - The first step TB test administered on 10/30/24; - The second step TB test administered on | 01/07/25, 70 days after the first step TB test. Review of FS E's personnel file showed: - Hire date of 09/25/24; - The first step TB test administered on 09/25/24; - The second step TB test administered on 01/08/25, 106 days after the first step TB test. During an interview on 03/18/25 at 11:30 A.M., FS A said he/she had gotten behind on administering TB tests. Missouri Department of Health and Senior Services STATE FORM ali PRGL11 lf continuation sheet 2 of 2 STATE PLAN OF CORRECTION on Newbridge Retirement Community Name STREET ; : ADDRESS, 1205 S. Mount Auburn rd. Cape Girardeau, Mo 63703 CITY, ZIP: Provider = 33246 xi = 3/18/2025 The facility shall screen residents an staff for tuberculosis as required for long-term 4/26/2025 care facility by 19 CSR 20-20.100. The alleged deficient act has the ability to affect all residents. Corrective action will begin immediately. All files will be audited. TB tests administered within the incorrect timeframe will be readministered to compliance standards by Compliance nurse or designee. Compliance nurse and nursing staff will be reminded of the proper timeframe for two- step TB testing. A clear process will be put in place to track and ensure compliance. New Monitoring System: A tracking log will now be used to monitor TB test due dates. Tracking will be overseen by compliance nurse or designee. Ongoing Compliance: Employee files will be checked monthly by compliance nurse or designee for the next three months to ensure all TB tests are done correctly.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. PRINTED: 06/03/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NEWBRIDGE RETIREMENT COMMUNITY 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on May 30, 2024 the facility failed to ensure the complete fire alarm system was tested annually and semi-annually in accordance with NFPA 72, 1999 edition. The facility census was fifty nine (59). This deficiency affects fifty nine (59) of fifty nine (59) residents. Record review showed no current semi-annual fire alarm inspection on file for review. Record showed the last alarm inspection on file was dated 07/18/2023. During an interview on May 30, 2024 at 10:45 A.M. the maintenance director said he did not know why the inspection had not been performed and would contact the alarm company to have it scheduled. During a phone interview on May 30, 2024 at 10:47 A.M. the operator at the alarm company stated they were not aware that the inspection was required every six months and would make sure it was corrected. 19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds Protection from Hazards. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 CC1Z11 If continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 NEWBRIDGE RETIREMENT COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 (I) In facilities whose plans were approved or which were initially licensed after December 31, 1987, for more than twenty (20) beds and all facilities licensed after August 28, 2007, each smoke section shall be separated by one- (1-) hour fire-rated smoke partitions. The smoke partitions shall be continuous from outside wall-to-outside wall and from floor-to-floor or floor-to-roof deck. All doors in this wall shall be at least twenty- (20-) minute fire-rated or its equivalent, self-closing, and may be held open only if the door closes automatically upon activation of the complete fire alarm system. II This regulation is not met as evidenced by: Class II Based on observation and interview on May 30, 2024 the facility failed to properly maintain the one (1) hour rated smoke partition doors. The facility census was fifty nine (59). This deficiency affects fifty nine (59) of fifty nine (59) residents. Observation showed the smoke separation doors located next to resident room (1032) failed to fully close when released from their magnetic holders. The door was released from an open position five (5) times. The door failed to fully close all five (5) times. This malfunction of the door, leaves a quarter (1/4") inch opening around the door and would allow smoke and hot gases to pass around the door in the event of a fire. Observation showed the smoke separation doors located next to resident room (2001) failed to fully close when released from their magnetic holders. The door was released from an open position five (5) times. The door failed to fully close all five (5) times. This malfunction of the door, leaves a quarter (1/4") inch opening around the door and Missouri Department of Health and Senior Services STATE FORM 6899 CC1Z11 PRINTED: 06/03/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/30/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 NEWBRIDGE RETIREMENT COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 would allow smoke and hot gases to pass around the door in the event of a fire. Observation showed the smoke separation doors located next to resident room (11) in the memory care unit failed to fully close when released from their magnetic holders. The door was released from an open position five (5) times. The door failed to fully close all five (5) times. This malfunction of the door, leaves a quarter (1/4") inch opening around the door and would allow smoke and hot gases to pass around the door in the event of a fire. During an interview on May 30, 2024 at 11:40 A.M. the maintenance director said he was not aware the door was not functioning properly. He believes it is from the building settling and will adjust the doors. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class III Based on observation and interview on May 30, 2024 the facility failed to store portable oxygen cylinders in accordance with NFPA 99, 1999 Edition. The facility census was fifty nine (59). This deficiency affects fifty nine (59) of fifty nine (59) residents. Missouri Department of Health and Senior Services STATE FORM 6899 CC1Z11 PRINTED: 06/03/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/30/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 4 PRINTED: 06/03/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NEWBRIDGE RETIREMENT COMMUNITY Continued From page 3 Observation showed one (1) oxygen cylinder, standing upright and not stored in an approved rack, or secured by a chain or band in resident room four (4) of the memory care unit. Observation showed two (2) oxygen cylinders, standing upright and not stored in an approved rack, or secured by a chain or band in resident room ten (10) of the memory care unit. During an interview on May 30, 2024 at 11:50 A.M. the maintenance director said he was not aware of the cylinder being stored in the rooms without a rack. He will have them removed and stored properly. Missouri Department of Health and Senior Services STATE FORM 6899 CC1Z11 If continuation sheet 4 of 4 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 05/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED BWING 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 (X4) 1D | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NEWBRIDGE RETIREMENT COMMUNITY A2210 19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check Fire Extinguishers. (D) All fire extinguishers shall bear the label of the Underwriters ' Laboratories (UL) or the Factory Mutual (FM) Laboratories and shall be installed and maintained in accordance with NFPA 10, 1998 edition. This includes the documentation and dating of a monthly pressure check. Ii/tll This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to maintain the documentation and dating of monthly pressure checks for five fire extinguishers. The facility's census was 60. Observation on 05/21/24 fram 9:53 A.M. through 11:30 A.M. showed the following: - The fire extinguisher in the hallway by the sitting area in the Memory Care showed the last monthly pressure check on 03/28/24; - The fire extinguisher in the Memory Care by room #14 showed the last monthly pressure check on 02/21/24; - The fire extinguisher in the Memory Care across from room #41 showed the last monthly pressure check on 03/28/24; - The fire extinguisher on the first floor by room #1041 showed the last monthly pressure check | on 03/28/24; - The fire extinguisher on the second floor across from room #2023 showed the last monthly pressure check on 03/28/24. The facility did not provide a policy for fire extinguishers. Missouri artment of Healthyand Senior Services LABORATO hee OF PROYIOPRISUPPLIER REPRESENTATIVE'S SIGNATURE TITLE [7 MY sj (x6) +] STATE FORM 6ga9 No6911 If continuation sheet 1 of 3 PRINTED: 05/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X71) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED oo 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} NEWBRIDGE RETIREMENT COMMUNITY A2210 | Continued From page 1 During an interview on 05/21/24 at 2:15 P.M., the Owner/Manager said the maintenance staff was behind on checking the fire extinguishers, but would get them checked and documented as soon as possible. 19 CSR 30-86.047(28)(F)(1)(B) Community | Based Assessment - Semi-Annually The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; !I This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to complete the required semi-annual Community Based Assessment (CBA) for three _ residents (Resident #1, #2 and #3) out of five sampled residents. The facility's census was 60. 1. Review of Resident #1's medical record showed: - Admission date of 07/28/23. - Diagnoses included Type II diabetes mellitus (body is unable to process blood sugar), hypertensive disorder (high blood pressure), hyperlipidemia (high blood level of cholesterol) and gastroesophageal reflux disease Missouri Department of Health and Senior Services STATE FORM e999 No6944 If continuation sheet 2 af 3 PRINTED: 05/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: Acca COMPLETED B. WING J 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 § MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NEWBRIDGE RETIREMENT COMMUNITY A4750 | Continued From page 2 (GERD-stomach acid being forced back into the Athroat region); - The last documented CBA dated 07/27/23. 2. Review of Resident #2's medical record showed: - Admission date of 09/18/23; - Diagnoses included hyperlipidemia, atrial fibrillation (an abnormal heart rhythm), xenograft heart valve (replaces a damaged valve in the | heart), hypertension (high blood pressure), retinal artery branch occlusion (an ophthalmic emergency characterized by the sudden blockage of the central retinal artery) and cerebral ischemic attack (condition that occurs when there isn't enough blood flow to the brain to meet metabolic demana); - The only CBA in the record not dated or signed. 3. Review of Resident #3's medical record showed: - Admission date of 12/08/23; - Diagnoses included heart disease/heart failure, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and muscle weakness; - An uncompleted CBA form not dated or signed. The facility did not provide a policy for CBAs. During an interview on 05/21/24 at 2:15 P.M., the Owner/Manager said he/she was not aware the CBAs were not being done appropriately and would notify the appropriate staff concerning the issue. Missouri Department of Health and Senior Services STATE FORM 6898 No6911 If continuation sheet 3 of 3 STATE PLAN OF CORRECTION ADDENDUM Agency . : . iamé — Newbridge Retirement Community STREET 1205 S. Mount Auburn Rd Cape Girardeau, Mo 63703 ADDRESS, => CITY, ZIP: PROVIDER'S PLAN OF CORRECTION = a All fire extinguishers shall bear the label of the (UL) or (FM) Laboratories and shall 7.7.2024 be installed and maintained in accordance with NFPA 10, 1998 edition. This included the documentation and dating of a monthly pressure check. This alleged deficiency has the potential to affect all residents. The Maintenance Director or designee will continue to do monthly pressure checks throughout building. Attachment A will be used as a guide to ensure no fire extinguishers are being left off the monthly check. The administrator or designee will do a monthly audit for 90 days to ensure the new process is working adequately. spreadsheet with resident admission dates, semi-annual and annual review dates. This spreadsheet will be maintained by the receptionist and updated upon admission. Review dates will be reviewed on the first Monday of the month at the daily stand up meeting. Administrator or designee will ensure compliance with 90 day and 6 month audit of 7.7.2024 The facility may admit or retain an individual for residents in an assisted living only if the individual does not require hospitalization or skilled nursing placement as defined in this rule and only if the facility: completes a community-based assessment by an appropriately trained and qualified individual at least semi-annually. All residents have the potential to be affected by this alleged deficiency. The administrator or designee will audit all resident charts and update out of date community-based assessments to ensure all have been fully completed upon admission, semi annually and annually. A new system will be put in place to ensure compliance. Attachment B shows a resident charts using attachment C.

PRINTED: 11/16/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 11/01/2023 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 NEWBRIDGE RETIREMENT COMMUNITY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (x5) (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG A8017| 19 CSR 30-88.010(17) Discharge Appeal Rights A8017 No resident may be discharged without full and adequate notice of his or her right to a hearing before the department's Administrative Hearings Unit and an opportunity to be heard on the issue of whether his or her discharge is necessary. Such notice shall be given in writing no less than thirty (30) days in advance of the discharge except in the case of an emergency discharge and must comply with the requirements set forth in 19 CSR 30-82.050. II/tII This regulation is not met as evidenced by: Class III | Based on interview and record review, the facility failed to provide full written notice of the resident's right to appeal discharge from the facility for one | resident (Resident #5) out of five sampled residents. The facility's census was 36. Record review of Resident #5's medical chart showed: - Progress note dated 09/21/23 showed resident was extremely aggressive towards staff and family member; - Progress note dated 10/12/23 showed report received from social worker at the hospital, informed that Resident #5 was not doing well and they believe the resident needs skilled placement; - Discharge date of 10/18/23 with financial responsibility through 10/12/23; - No discharge letter available in resident's chart or provided to the resident. During an interview on 11/01/23 at 11:50 A.M., Facility Owner Staff A said that Resident #5 had become physically combative at the facility. He/She said the resident was sent to the hospital for evaluation on iad Over the weekend of Missouri Departme LABORATORY DIRECTGR/E | PLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE jt [oo [a3 ve STATE FORM E00 PZ4E11 If continuation sheet 1 of 2 PRINTED: 11/16/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1205 S MOUNT AUBURN RD CAPE GIRARDEAU, MO 63703 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NEWBRIDGE RETIREMENT COMMUNITY Continued From page 1 10/07/23, a family member of the resident who worked at the facility reported to Staff A that the resident's behaviors were improving and the resident would be released early in the week. The report the facility received from the hospital social worker indicated that Resident #5 was still having behaviors and they recommended a higher level of care. He/She said they received this report on 10/12/23. He/She said they were not able to take Resident #5 back due to risk of her behaviors and the hospital and family were informed verbally. During an interview on 11/01/23 at 2:31 P.M., Facility Owner Staff A said that no discharge letter was provided to Resident #5. He/She said that discharge was discussed verbally with the family. He/She did not think they needed a letter since the family understood the resident could not return due to behavior concerns. During an interview on 11/14/23 at 4:33 P.M., Resident #5's Family Member said that a 30 day notice and appeals information was not received from the facility for Resident #5. He/She was informed the facility would not take the resident back by the hospital social worker. He/She said the facility notified him/her of discharge after the hospital. CMP #MO00226208 Missouri Department of Health and Senior Services STATE FORM 6899 PZ4E11 If continuation sheet 2 of 2 STATE PLAN OF CORRECTION Agency = Newbridge Retirement Community | Name STREET ADDRESS, 1205S Mount Auburn Road CITY, ZIP: Cape Girardeau, Mo 63703 Provider Number => Exit Date = 11.1.2023 11/21/2023 A8017 No resident may be discharged without full and adequate notice of his or her right to a hearing before the department’s administrative hearing unit. Such notice must be given in writing no less than 30 days in advance of the discharge except in the case of an emergency discharge. The alleged deficiency had the potential to affect one resident. Each resident involuntarily discharged from the facility will receive 30 days written notice of discharge via attachment A. Except in the case of an emergency discharge, in which case attachment B will be used. Moving forward, the Facility Administrator will review all discharges, ensuring proper discharge paperwork is presented at time of discharge. A log (attachment C) will be kept by the Administrator or designee for the next 90 days, tracking discharge procedure and effectiveness of corrective plan. Po L