6 Reports
Inspection Report — May 23, 2025
Routine
Date: May 23, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One Missouri state licensure deficiency was cited regarding the absence of a licensed administrator. The surveyor found the administrator had vacated the position and an unlicensed Senior Executive Director was acting in charge.
Deficiencies (1)
19 CSR 30-86.047(5) Administrator - Licensed: Based on interview and record review, the facility failed to ensure a licensed Administrator was present for the management of the facility; the Administrator vacated the position and the Senior Executive Director was not a licensed administrator.
Inspection Report — Dec 20, 2024
Follow-Up
Date: Dec 20, 2024
Visit Reason
Missouri Department of Health and Senior Services State Form surveys (state licensure); includes an initial state survey completed 2024-09-24 and a reinspection/recheck completed 2024-12-20.
Findings
Twelve state licensure deficiencies were cited across the two State Form reports (ten on 09/24/2024 and two repeated on 12/20/2024). Deficiencies addressed elevator certification and maintenance, combustible storage under stairways, fire drill consultation and drill completion, fire alarm testing and key control, use of non-UL/FM trash receptacles, TB screening of staff, medication storage/security, food storage/labeling, and residents' personal possessions/inventory; two items were rechecked on 12/20/2024 and remained uncorrected.
Deficiencies (12)
19 CSR 30-86.012(25) Elevator Requirements: Based on observation, interview and record review, facility staff failed to ensure elevators were maintained in good repair and did not have current Missouri state operating certificates.
19 CSR 30-86.022(2)(H) Combustibles Not Stored Under Stairways: Based on observation and interview, staff allowed storage under two exit stairways including ladders, an air conditioner, mattresses, metal bed frames and cardboard boxes, obstructing exit pathways.
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation: Based on interview and record review, the facility failed to obtain or document an annual consultation of its emergency plans with the local fire unit or state fire marshal.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on interview and record review, the facility failed to ensure required fire drills were completed on each shift and quarterly for specified periods; records showed missing drills for multiple quarters and shifts.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on observation, interview and record review, the facility failed to complete smoke detection sensitivity testing and failed to ensure keys to the main fire alarm panel were secured to prevent general access.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Based on observation and interview, the facility used plastic trashcans without UL or FM ratings in resident use areas and outdoor patio locations.
19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, the facility failed to ensure hired staff completed the required two-step TB testing (or equivalent) with several employees missing the second step of testing.
19 CSR 30-86.047(41) Medication Storage/Accessibility: Based on observation, interview, and record review, the facility failed to store medications securely and to maintain required double-locking for controlled substances; medication room doors, cabinets and medication refrigerators were found unlocked and medications accessible.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation, interview and record review, the facility failed to ensure food items were covered, labeled and dated and failed to ensure equipment (stand mixer, food slicer) was covered when not in use; uncovered and unlabeled food items were observed in kitchen refrigeration and storage.
19 CSR 30-88.010(36) Personal Clothing/Possessions: Based on interview and record review, the facility failed to maintain an inventory/record of residents' personal items for three of three sampled residents.
19 CSR 30-86.012(25) Elevator Requirements: (Recheck 12/20/2024) This deficiency is uncorrected; reinspection found repairs and certification issues remained and the facility continued to lack current state operating certificates for the elevators.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: (Recheck 12/20/2024) Reinspection found prior food storage and labeling deficiencies remained uncorrected, with uncovered and unlabeled food items observed and corrective in-service planned.
Report Facts
sampled staff missing required TB second step: 5
smoke compartments potentially affected: 5
Inspection Report — Jan 30, 2023
Routine
Date: Jan 30, 2023
Visit Reason
Missouri Department of Health and Senior Services State Form (Statement of Deficiencies and Plan of Correction); the survey type is not stated in the form.
Findings
Twelve state licensure deficiencies were cited, primarily concerning fire alarm system testing/maintenance and out-of-service procedures, smoke section partitions and dampers, sprinkler maintenance and out-of-service procedures, wastebasket and oxygen storage practices, electrical inspection, TB screening for staff, timeliness of community-based assessment, and kitchen/food safety (covered/labeled/dated items). Some deficiencies were re-evaluated on later state-form pages and the facility submitted plans of correction.
Deficiencies (12)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on observation, interview and record review, the facility failed to ensure required inspection and testing of the fire alarm system were completed, failed to complete reported repairs, and allowed unauthorized access to silence and reset the main fire alarm panel.
19 CSR 30-86.022(9)(H) Fire Alarm System Out of Service > than 4hrs: Based on interview and record review, the facility failed to develop an adequate fire watch policy for staff to follow when the fire alarm system was out of service.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: Based on observation, interview and record review, the facility failed to maintain required smoke walls and failed to ensure several smoke dampers closed with fire alarm activation, allowing potential smoke travel between smoke sections.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on observation and interview, the facility failed to maintain sprinkler heads free of debris and failed to ensure sprinkler head cover plates were in place and tight against the ceiling.
19 CSR 30-86.022(11)(G) Sprinkler System Out of Service More Than 4hr: Based on interview and record review, the facility failed to develop an adequate fire watch policy for staff to follow when the sprinkler system was out of service.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Based on observation and interview, the facility failed to ensure trashcans were only metal or UL/FM-approved in multiple resident-use areas.
19 CSR 30-86.022(17) Oxygen Storage Requirements: Based on observation and interview, the facility failed to store portable oxygen cylinders in accordance with NFPA 99, including segregation and storage organization of full and empty cylinders.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Based on interview and record review, the facility failed to have an electrical inspection completed every two years as required.
19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, the facility failed to follow its TB testing policy and ensure new hires received the required second step of two-step PPD testing.
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day: Based on interview and record review, the facility failed to complete a community-based assessment (CBA) within five calendar days of admission for one sampled resident.
19 CSR 30-87.020(31) Kitchen Waste Containers Covered: Based on observation and interview, the facility failed to ensure garbage cans in food preparation areas were covered when not in use.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation, interview and record review, the facility failed to ensure food items were stored to prevent contamination, including numerous unlabeled, undated or open food items and improper bulk-bin practices.
Report Facts
residents sampled: 1
staff sampled for TB testing: 5
staff missing required TB second-step: 2
Inspection Report — Mar 4, 2020
Routine
Date: Mar 4, 2020
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
4 state deficiencies were cited addressing sprinkler system maintenance and signage, administrator/operator responsibilities related to a second business license, inadequate food handler handwashing/glove practices, and failure to develop/implement abuse/neglect policies and timely reporting.
Deficiencies (4)
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on observation and interview, the facility failed to maintain sprinkler heads free of debris and ensure sprinkler cover plates and fire department connection signage were in place, leaving multiple sprinkler heads exposed or loaded with dust and some FDC identification missing.
19 CSR 30-86.047(6) Operator/Administrator Responsibilities: Based on observation and interview, the facility failed to obtain a second business license for a therapy company that had an office/salon in the building and provided services to residents.
19 CSR30-87.030(2) Wash Hands/Arms & Clean Fingernails: Based on observation and interview, dietary staff did not use proper handwashing and glove-change practices during meal preparation and service, contaminating food contact areas and food.
19 CSR30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review, the facility failed to implement written policies and procedures and failed to timely intervene and report an alleged staff abuse incident involving a resident.
Inspection Report — Apr 12, 2019
Routine
Date: Apr 12, 2019
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated. The file includes the Statement of Deficiencies page and accompanying facility Plan of Correction pages.
Findings
One Missouri state licensure deficiency was cited related to smoke section partitions and malfunctioning accordion/‘won’ doors; the surveyor found two of five smoke walls were not maintained.
Deficiencies (1)
19 CSR 30-86.022(10)(1) Smoke Section Partitions > than 20 beds: Based on observation, interview and record review, the facility failed to maintain two of five smoke walls, including an 18-inch opening in a third-floor accordion folding partition and a two-foot section separated from a second-floor accordion partition.
Report Facts
smoke walls not maintained: 2
Inspection Report — Feb 21, 2018
Follow-Up
Date: Feb 21, 2018
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated. The file includes the original state survey dated 02/21/2018 and a follow-up/revisit dated 05/07/2018.
Findings
7 state deficiencies were cited concerning individualized evacuation planning, multiple fire-safety issues (fire hazard/inspection rights, fire drill requirements and evacuation, fire alarm activation, smoke dampers), hot water temperatures, and incomplete resident admission records.
Deficiencies (7)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - In Resident ISP: Based on observation, interview and record review, the facility failed to ensure residents who required more than minimal assistance had an individualized evacuation plan in the resident's individualized service plan for one of two sampled residents.
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard: Based on observation and interview, the facility failed to ensure no part of the building presented a fire hazard when a resident activity room with a working oven was left unlocked and accessible to residents for two days.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on interview and record review, the facility failed to conduct a fire drill that included a resident evacuation yearly for 12 of 12 reviewed fire drills.
19 CSR 30-86.022(5)(F) Fire Alarm Activation Requirements: Based on interview and record review, the facility failed to ensure use of a facility-generated predetermined message in lieu of audible and visual alarm components for fire drills conducted between 9:00 P.M. and 6:00 A.M.
19 CSR 30-86.022(10)(H) Smoke Sections: Based on observation and interview, the facility failed to ensure smoke dampers closed with activation of the fire alarm for five of six smoke dampers, which could allow smoke to travel from one smoke section to another.
19 CSR 30-86.032(34) Hot Water 105-120 Degrees F: Based on observation, interview and record review, the facility failed to maintain hot water temperatures at a range of 105 degrees F to 120 degrees F in bathrooms accessible to residents, with multiple observed temperatures above that range.
19 CSR 30-86.047(58)(A) Resident Record Admission Info: Based on interview and record review, the facility failed to ensure resident records included a preferred dentist and funeral director for two sampled residents.
Report Facts
residents sampled: 2
fire drills reviewed: 12
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