Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Festus Manor during CMS and state inspections, most recent first.
A resident with multiple health issues, including pressure ulcers, did not receive wound care as ordered by a consulting wound clinic. The facility failed to update treatment orders and did not notify the physician of the resident's refusal of care. Interviews revealed that the facility's wound nurse did not update orders, and the primary physician was unaware of the refusals.
The facility did not maintain the required surety bond amount for residents' personal funds, as their policy mandates. The bond should be one and one-half times the average monthly balance of the funds, but the facility's bond was insufficient at $120,000 instead of the required $136,500. Interviews with staff confirmed awareness of the requirement, yet the bond was not adjusted, affecting the security of funds for 121 residents.
The facility did not document its Antibiotic Stewardship Program from November 2023 to May 2024, despite 12 residents receiving antibiotics. The program, which requires tracking antibiotic usage and outcomes, was not addressed since November 2023. Interviews revealed that the Infection Preventionist expected adherence to facility policy and CMS/CDC guidelines, but the Regional Support Specialist confirmed the program's neglect.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as damaged walls, stained ceiling tiles, missing bathroom doors, and strong urine odors. Interviews revealed poor communication and documentation between housekeeping and maintenance staff, leading to unresolved maintenance issues. The Regional Support Specialist and staff had expectations for timely reporting and addressing of concerns, but these were not met, resulting in a disconnect between expectations and actual practices.
The facility failed to provide written transfer/discharge notifications to residents, their responsible parties, and the LTC Ombudsman for five residents. Staff interviews revealed a lack of awareness and understanding of the notification process, and the facility's policy did not address notifying the Ombudsman.
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives during hospital transfers, affecting five residents. Despite the policy requiring notification and signed authorization for bed-holds, documentation was lacking. Interviews with staff revealed inconsistencies in understanding and implementing the policy.
The facility failed to obtain physician orders, assess abilities, and provide education for colostomy self-care for two residents. Both residents performed their own colostomy care without documented evaluations or tailored care plans, and no physician orders were in place to authorize this self-care.
The facility failed to maintain proper urinary catheter care for two residents, resulting in catheter bags and tubing touching the floor and not being fully covered with dignity bags. One resident was observed with a suprapubic catheter dragging on the floor, while another had a Foley catheter bag partially covered and touching the floor. Staff interviews confirmed the requirement for catheter bags to be off the floor and fully covered, indicating a lapse in adherence to care protocols.
The facility failed to provide proper respiratory care for two residents, including undated oxygen tubing for a resident and incorrect tracheostomy care for another. The facility did not follow physician's orders for daily inner cannula changes, and staff demonstrated poor hand hygiene and sterile technique during trach care. Additionally, necessary tracheostomy supplies were not readily available, indicating a lack of preparedness.
A facility failed to address PTSD in a resident's care plan, despite the resident's history as a war veteran and police officer. The resident's PTSD diagnosis and triggers were not documented or managed, contrary to the facility's trauma-informed care policy. Interviews revealed staff were unaware of the resident's PTSD needs, and the Social Service Director had not discussed the diagnosis with the resident.
The facility did not reconcile narcotics at each shift change for one medication cart, missing 24 out of 132 opportunities. Staff interviews confirmed the expectation for narcotics to be counted and signed off by both offgoing and oncoming nurses, as per facility policy. This failure had the potential to affect all residents.
The facility failed to properly label and store medications, including insulin pens and controlled substances, affecting all residents. Insulin pens were used beyond their expiration dates, and medication room refrigerators containing controlled substances were left unlocked. Staff interviews revealed confusion over responsibilities for checking and disposing of expired medications, and a lack of adherence to storage policies.
The facility failed to ensure a hospice coordinated plan of care was provided and signed by both hospice and facility staff for two residents. One resident, admitted with multiple diagnoses, lacked a documented plan upon hospice admission, while another's plan did not address necessary treatments and equipment. Interviews revealed staff did not adhere to the policy requiring signed care plans on the day hospice services begin.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hand hygiene and glove-changing protocols during care for three residents. Observations showed that an LPN and an RN did not perform hand hygiene or change gloves appropriately during wound care and PEG tube site dressing. Additionally, infection logs were incomplete, and the Infection Prevention/Antibiotic Stewardship had not been updated since June 2023, potentially affecting all residents.
The facility failed to maintain an effective pest control program, resulting in multiple observations of flies and gnats in resident rooms, hallways, and common areas. Residents and staff reported that flies were a common issue, with some attributing the problem to certain resident conditions and warmer room temperatures. Pest control invoices indicated targeted services for various insects, but recommended replacing non-functional insect light traps. Staff used sprays and fly strips as needed, and a pest control log was maintained for reporting observations.
The facility did not post daily nurse staffing data in a clear and accessible manner as required. Observations showed outdated or missing staffing sheets on several occasions. The Staffing Coordinator, responsible for posting the sheets, was still organizing their routine since starting the position.
The facility failed to provide the required twelve hours of in-service education for two CNAs, M and V, affecting their ability to meet training requirements. CNA M, hired in November 2022, and CNA V, hired in December 2022, both lacked documentation of the necessary training hours and specific training in abuse and neglect. The facility did not provide an in-service training policy, and the issue was confirmed by an RN/Regional Nurse.
Failure to Provide and Document Wound Care
Penalty
Summary
The facility failed to provide wound treatments as ordered by the wound clinic and did not notify the physician of a resident's non-compliance with wound treatment and the worsening of a wound. The resident, who had multiple diagnoses including COPD, quadriplegia, and pressure ulcers, was admitted to the facility and had specific wound care orders from a consulting wound clinic. The care plan required regular assessment and documentation of wound healing, as well as physician notification of any changes or refusals of treatment. The resident's medical records showed that the facility did not update the physician's orders for the pressure injuries as per the consulting wound clinic's recommendations. There was no documentation of wound care treatment provided for the coccyx pressure injury on several occasions, and no treatment was provided for the left lateral lower leg pressure injury. Additionally, the facility failed to notify the physician when the resident refused wound care treatments and to be seen by the wound clinic. Interviews with facility staff and the resident's primary physician revealed that the facility's wound nurse was responsible for updating wound orders, but this was not done. The resident expressed dissatisfaction with the wound clinic and preferred facility nurses to perform dressing changes. The primary physician was not informed of the resident's refusals, and the facility did not follow the correct wound treatment orders, leading to a deficiency in care.
Failure to Maintain Adequate Surety Bond for Residents' Personal Funds
Penalty
Summary
The facility failed to maintain the required bond amount for the residents' personal funds, as mandated by their policy. The policy, revised in March 2021, stipulates that the facility must hold a surety bond to assure the security of all residents' funds deposited with the facility. This bond is meant to compensate residents for any loss of funds due to the facility's failure to properly manage these funds. The bond amount should be at least one and one-half times the average monthly balance of the residents' personal funds over the last twelve months. However, the facility's current bond amount was $120,000, which was insufficient compared to the required $136,500, based on an average monthly balance of $91,000. Interviews with the Business Office Manager and the Regional Support Specialist confirmed that they were aware of the requirement for the bond to be one and one-half times the average monthly balance of the residents' personal funds. Despite this understanding, the facility did not adjust the bond amount accordingly, resulting in a deficiency. The facility census at the time was 121, indicating a significant number of residents whose funds were potentially at risk due to this oversight.
Failure to Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to provide documentation of its Antibiotic Stewardship Program, which is designed to measure and improve how antibiotics are prescribed and used. The policy requires that antibiotic usage and outcomes be documented using a facility-approved tracking form, and that all clinical infections treated with antibiotics undergo review by the Infection Preventionist (IP) or a designee. However, there was no documentation of completed antibiotic stewardship tracking from November 2023 to May 2024, despite 12 residents currently receiving antibiotics as of May 23, 2024. Interviews conducted during the survey revealed that the Infection Prevention/Antibiotic Stewardship had not been addressed since November 2023. The IP expected the nursing department to adhere to the facility's policy and guidelines from the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). The Regional Support Specialist and Registered Nurse (RN) I/Corporate Nurse confirmed the lack of attention to the program, indicating a lapse in the facility's adherence to its own policies and regulatory guidelines.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. These included dark markings and scrapes on walls, exposed sheetrock, peeled paint, stained ceiling tiles, missing and cracked ceramic tiles, and strong urine odors in various halls and rooms. Additionally, some rooms lacked bathroom doors and privacy curtains, and there were broken window blinds and damaged drywall. The laundry room and other areas also showed a buildup of dust and debris. Interviews with housekeeping and maintenance staff revealed a lack of communication and documentation regarding maintenance needs. Housekeepers reported writing down issues on cleaning sheets to inform maintenance, but there was no evidence of these concerns being addressed. The new Maintenance Supervisor noted that the previous supervisor did not keep records of repairs, and staff were expected to use a computer system to report issues, which was not being utilized effectively. The Regional Support Specialist and other staff members expressed expectations for timely reporting and addressing of environmental concerns, but there was a disconnect between these expectations and the actual practices. Housekeeping staff were aware of the need to clean floors and address odors, but there was confusion about responsibilities, particularly regarding cleaning behind appliances and addressing persistent odors in certain areas. The lack of awareness about missing bathroom doors further highlighted the facility's failure to maintain a homelike environment.
Failure to Provide Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide a written copy of the notice of transfer or discharge to the residents and/or their responsible parties, as well as to the representative of the Office of Long-Term Care (LTC) Ombudsman, for five out of six sampled residents. This deficiency was identified through interviews and record reviews, revealing that the facility did not document the written notifications in the medical records of the affected residents. The facility's policy on transfer or discharge documentation, revised in December 2016, did not include the requirement to notify the Office of the LTC Ombudsman, which contributed to the oversight. Interviews with various staff members, including Licensed Practical Nurses (LPNs), the Social Service Director (SSD), the Business Office Manager (BOM), and the Regional Support Specialist, indicated a lack of awareness and understanding of the requirement to provide written transfer/discharge notices. The staff members were either unaware of the need for such documentation or did not know the process for handling and distributing these notices. The Regional Ombudsman Coordinator confirmed that the facility did not send transfer notifications on a monthly basis, further highlighting the facility's failure to comply with the notification requirements.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for five residents out of six sampled, despite the facility's policy requiring such notification. The policy mandates that residents or their representatives be informed of the bed-hold policy upon discharge, and a signed authorization must be obtained if they wish to hold the bed. However, there was no documentation of this notification for the transfers of the five residents involved. Interviews with facility staff, including LPNs, the Social Service Director, the Business Office Manager, and the Corporate Nurse, revealed inconsistencies in the understanding and implementation of the bed-hold policy. While some staff members acknowledged the requirement to provide the policy upon transfer, others, like the Business Office Manager, were unaware of its existence. This lack of consistent communication and documentation led to the deficiency, as the facility did not ensure that residents and their representatives were adequately informed about the bed-hold policy during transfers.
Deficiency in Colostomy Self-Care Management
Penalty
Summary
The facility failed to obtain a physician's order, evaluate and assess the residents' abilities, and provide education for self-care of a colostomy for two residents. Resident #71, diagnosed with paraplegia and a colostomy, had no documentation of evaluation or assessment for self-care of the colostomy, nor any education provided by the staff. The resident's care plan did not include specific interventions tailored to their needs for self-care. Despite the resident performing their own colostomy care, there was no physician's order authorizing this self-care. Similarly, Resident #110, also with a colostomy, lacked documentation of evaluation or assessment for self-care, and no education was provided by the staff. The care plan did not address specific interventions for the resident's self-care of the colostomy. Although the resident preferred to perform their own colostomy care, there was no physician's order for this, and the resident was unsure if any education or assessment had been conducted to ensure proper self-care.
Improper Urinary Catheter Care for Two Residents
Penalty
Summary
The facility failed to ensure proper urinary catheter care for two residents, leading to deficiencies in maintaining catheter hygiene and dignity. Resident #34, who has a suprapubic catheter due to neuromuscular dysfunction of the bladder and other medical conditions, was observed multiple times with the catheter bag and tubing dragging on the floor without a dignity bag. This observation was made on several occasions, indicating a lack of adherence to the facility's policy that requires catheter bags and tubing to be kept off the floor. Similarly, Resident #84, who has a Foley catheter due to urine retention and other bladder disorders, was observed with the catheter drainage bag hanging on the bed frame and touching the floor, with the dignity bag only partially covering it. The resident reported a previous hospitalization due to the catheter bag not being emptied, causing urine to back up into the bladder. Interviews with nursing staff confirmed that catheter bags should be fully covered with dignity bags and should not touch the floor, highlighting a failure in following proper catheter care protocols.
Deficiencies in Respiratory Care and Tracheostomy Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, specifically regarding the management of oxygen tubing and adherence to physician's orders. For Resident #118, the facility did not date the oxygen tubing as required, despite having a physician's order to change the tubing and humidifier bottle weekly. Observations over several days showed the resident using undated oxygen tubing, indicating a lack of compliance with the facility's own policy on oxygen administration. Resident #272 experienced multiple deficiencies in tracheostomy care. The facility failed to follow the physician's order to change the inner cannula daily, as the Treatment Administration Record incorrectly documented the order as monthly. Interviews with nursing staff revealed a misunderstanding of the correct procedure, with the night nurses being responsible for the task but not performing it as required. Additionally, the resident was observed receiving oxygen at a higher rate than ordered, and the trach care procedure was not conducted with proper hand hygiene and sterile technique. Further deficiencies were noted in the availability and management of tracheostomy supplies. The facility did not have an unopened outer cannula readily available in the resident's room, which is a critical component for emergency situations. Interviews with nursing staff indicated a lack of awareness and preparedness regarding the availability of necessary tracheostomy supplies, which could compromise the resident's care in case of an emergency.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, a war veteran and former police officer, had a history of trauma-related symptoms such as flashbacks and anxiety. Despite the facility's policy on trauma-informed care, which includes training staff on trauma assessment and identifying triggers, the resident's PTSD and associated triggers were not addressed in their comprehensive care plan. The resident's medical records indicated the use of various psychotropic medications for anxiety and depression, but there was no documentation of specific interventions to manage PTSD symptoms or triggers. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's PTSD diagnosis and triggers. The Social Service Director (SSD) had not discussed PTSD with the resident, and the Registered Nurse (RN) and Certified Nursing Assistant (CNA) were unaware of any specific PTSD-related interventions in the care plan. The resident expressed that no staff had talked to them about their triggers, which included people standing behind them and memories from wartime experiences. This oversight in addressing the resident's PTSD needs highlights a deficiency in the facility's implementation of trauma-informed care practices.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure that narcotics were reconciled at each shift change for one out of five medication carts, as required by their policy. The policy mandates that controlled substances be counted and reconciled by the offgoing and oncoming nurses at the end of each shift. However, a review of the 200/400 Hall Nurse Narcotic Count Log for Controlled Substances revealed that staff missed 24 out of 132 opportunities to perform this reconciliation between May 1, 2023, and May 22, 2024. Interviews with various staff members, including a Certified Medication Technician, a Licensed Practical Nurse, and a Registered Nurse/Corporate Nurse, confirmed that the expectation was for narcotics to be counted and signed off by both the offgoing and oncoming nurses at each shift change. Additionally, it was noted that if the keys to the medication carts changed hands, the narcotics should be counted at that time as well. The failure to adhere to these procedures had the potential to affect all residents in the facility, which had a census of 121.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, specifically insulin pens and controlled substances, which had the potential to affect all residents. Observations revealed that insulin pens, such as Humalog and Novolog, were not disposed of after the recommended 28-day period, with some pens being used 14 to 42 days past their expiration. Interviews with LPNs indicated a lack of clarity and responsibility regarding the checking and disposal of expired insulin pens, with some staff believing it was the night shift's responsibility, while others stated that each nurse should check their own carts. The facility's policy on insulin administration did not address the use of insulin pens, contributing to the oversight. Additionally, the facility failed to secure controlled substances properly. Observations showed that medication room refrigerators on different halls were left unlocked, with controlled substances like lorazepam stored inside. Interviews with LPNs and an RN revealed that the refrigerators should have been locked at all times, especially when storing narcotics, which require double locking. The failure to secure these medications was attributed to staff forgetting to lock the refrigerators after accessing them, indicating a lapse in adherence to the facility's medication storage policies.
Failure to Ensure Signed Hospice Coordinated Care Plans
Penalty
Summary
The facility failed to ensure a hospice coordinated plan of care was provided upon admission to hospice for one resident and did not have a hospice coordinated plan of care signed by both hospice and facility staff for two residents. Resident 16 was admitted to hospice with diagnoses including dementia, chronic kidney disease, type II diabetes mellitus, osteoarthritis, and pain. However, there was no documentation of a hospice coordinated plan of care upon admission, and the plan dated later was not signed by facility staff. Resident 61, admitted to hospice with cerebral vascular disease, Parkinson's Disease, and vascular dementia, had a hospice coordinated plan of care that did not address necessary treatments and medical equipment, and it was not signed by facility staff. Interviews with facility staff revealed a lack of understanding and adherence to the policy requiring a coordinated plan of care to be completed and signed by both hospice and facility staff on the day hospice services begin. LPNs and RNs expressed that hospice staff completed their paperwork, but facility staff did not sign it, contrary to the facility's policy. The corporate nurse confirmed that the hospice coordinated plan of care should specify responsibilities and be reviewed and signed by the unit manager.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene and glove-changing protocols. Observations revealed that staff did not perform hand hygiene or change gloves appropriately during wound care and other procedures for three residents. For instance, a Licensed Practical Nurse (LPN) did not sanitize the overbed table or perform hand hygiene before and between glove changes while providing wound care to a resident. The LPN also used unsanitized scissors to cut open wound treatment packets, further compromising infection control practices. Another incident involved a Registered Nurse (RN) who failed to change gloves and perform hand hygiene when transitioning from dirty to clean care during the dressing of a percutaneous endoscopic gastrostomy (PEG) tube site. The RN applied a clean dressing without removing gloves after cleaning the site, which is against the facility's infection control policy. Additionally, the RN did not perform hand hygiene or change gloves while administering medications and performing wound care for another resident, further demonstrating a lack of adherence to infection control protocols. The facility's infection control program was also found lacking in documentation and monitoring. Infection logs were incomplete for several months, and the Infection Prevention/Antibiotic Stewardship had not been updated since June 2023. Interviews with staff, including the Infection Preventionist and Regional Support Specialist, confirmed that the facility's infection control practices were not being followed, and there was an expectation for adherence to established guidelines. These deficiencies had the potential to affect all residents in the facility, given the census of 121.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of flies and gnats in various areas of the facility, including resident rooms, hallways, the conference room, the soiled laundry room, and the dining room. The facility census was 121, and the presence of pests was confirmed through both observation and resident interviews. Residents reported that flies were a common nuisance, with one resident noting that flies landed on their bedding and face. Housekeeping staff acknowledged the presence of flies, attributing the issue to certain resident conditions and warmer room temperatures. The facility did not provide a policy on pest control, and the pest control invoices from January to May 2024 indicated targeted services for various insects, including cockroaches, ants, and flies. However, the invoices also recommended replacing insect light traps, which were not functioning properly. Interviews with staff, including housekeepers, an LPN, the Maintenance Supervisor, and the Housekeeping and Laundry Supervisor, revealed that flies were a known issue, with some staff using sprays and fly strips as needed. The Regional Support Specialist and RN stated that pest control was expected to be provided monthly or as needed, and a pest control log was maintained for reporting observations.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing data with all the required components in a clear and readable format in a prominent place readily accessible to residents and visitors on a daily basis. The facility's policy required that the number of nursing personnel responsible for providing direct care to residents be posted daily for each shift within two hours of the beginning of each shift. Observations revealed that on multiple occasions, the staffing sheet was either outdated or missing. Specifically, on 05/20/24 and 05/21/24, the posted nurse staffing sheet was dated 03/25/24, and on 05/23/24, there was no staffing sheet posted at 7:50 A.M., with a sheet dated 05/22/24 only appearing at 9:45 A.M. Interviews with the Regional Support Specialist and the Staffing Coordinator confirmed that the Staffing Coordinator was responsible for posting the staffing sheet daily, but was still getting organized in the role since starting on 04/15/24.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to conduct at least twelve hours of nurse aide in-service education per year, affecting two sampled Certified Nurse Assistants (CNAs), M and V. The facility's policy, revised in October 2017, mandates that sufficient numbers of staff with the necessary skills and competency are provided to care for residents according to their care plans. However, the facility did not provide an in-service training policy, and the records for CNAs M and V showed deficiencies in meeting the required training hours. CNA M, hired on November 21, 2022, had documentation of ten topics covered for annual in-service training from November 2022 through November 2023, but there was no documentation of the length of time for each in-service, nor was there evidence of abuse and neglect training. Similarly, CNA V, hired on December 26, 2022, had documentation of eight topics covered for annual in-service training from December 2022 through December 2023, but also lacked documentation of the length of time for each in-service and did not meet the twelve-hour requirement. During an interview, RN I/Regional Nurse and Regional Support Specialist confirmed that CNAs should receive 12 hours of in-service training, including abuse and neglect training.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Festus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountainbleau Nursing Center | 1.4 mi | ★★★★★ | 12 | 0 |
| Crystal Oaks | 1.7 mi | ★★★★★ | 4 | 0 |
| Superior Manor Of Festus, Llc | 2.4 mi | ★★★★★ | 0 | 0 |
| Scenic Wellness And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Hillcrest Care Center Inc | 9.4 mi | ★★★★★ | 10 | 0 |
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