Inspection Reports for
The Bungalows at Chesterfield Village

19 CSR 30-86.042(40) Physicians Orders & Proper Care: Based on interview and record review, the facility failed to transcribe orders for labs related to Coumadin (warfarin), obtain routine PT/INR monitoring or follow up with the physician/clinic after faxing results, resulting in lack of monitoring and documented resident bruising.

19 CSR 30-86.042(11)(B) EDL inquiry: Based on record review and interview, the facility failed to ensure newly hired employees were checked against the employee disqualification list (EDL) prior to allowing four staff members to have contact with residents.

19 CSR 30-86.042(18) TB Screen Resident/Staff: Based on interview and record review, staff failed to ensure required two-step tuberculosis screening was completed for multiple residents and did not document annual evaluations to rule out signs and symptoms of TB for two residents.

19 CSR 30-86.042(45) Self-Control of Medication: Based on observation, record review, and interview, the facility failed to ensure a resident who self-administered medications had a physician order permitting self-administration.

19 CSR 30-86.042(46)(A) Resident Controlled Access to Meds: Based on interview, observation, and record review, staff failed to ensure residents who self-administered medications kept them secured in a locked container or locked drawer for three residents.

19 CSR 30-87.020(9) Air Ducts-Maintain: Based on observation, interview, and record review, the facility failed to maintain cleanliness of the intake and exhaust air duct in the kitchen, with louvers approximately 90% covered with grime and dust.

19 CSR 30-87.020(12) Floor Surfaces: Based on observation, interview, and record review, the facility failed to ensure floors, particularly in high traffic areas of the kitchen and dining room entry, were clean and maintained in good repair with visible dirt, crumbs, and blackened grout joints.

19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Based on observation, interview, and record review, the facility failed to ensure walls and kitchen wall areas were kept clean and maintained, with tan, yellow, and black splashes and discoloration above sinks and dishwashers.

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 stored to protect it from contamination/spoilage when staff failed to label and date food not kept in original containers in the refrigerator.

19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: Based on observation, interview, and record review, the facility failed to ensure food-contact surfaces of cooking equipment including the microwave were clean, with splatters and stains inside the microwave and potential contaminated food placed in it.

19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed: Based on observation, interview, and record review, the facility failed to ensure nonfood-contact surfaces of equipment were cleaned as often as necessary, with drain boards, refrigerator doors, counters, pans and lids covered with crumbs, flour and grime.

19 CSR 30-86.022(5)(E) Fire Drill Records: Fire Drills and Emergency Preparedness: The facility failed to keep a record of all fire drills; no fire drills had been recorded for several months and the deficiency affected all 60 residents.

19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems: The facility failed to test by activating the complete fire alarm system at least once a month; monthly activation tests were not recorded for several months and the deficiency affected all 60 residents.

19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. Sprinkler Systems: Observations showed sprinkler heads with corrosion and foreign material and the facility failed to maintain inspections and written certifications of the sprinkler system as required; the deficiency affected all 60 residents.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to have electrical wiring inspected every two years by a qualified electrician; the last recorded inspection was more than two years prior and the deficiency affected all 60 residents.

19 CSR 30-86.042(11)(B) EDL Inquiry: Based on record review and interview, the facility failed to check to ensure that newly hired employees were not listed on the employee disqualification list (EDL) prior to allowing staff to have contact with any residents for four of five sampled staff members (Certified Medication Aide (CMA) A, Business Office Manager (BOM) B, Housekeeping C, and Facilities Director D).

19 CSR 30-88.010(26)(A) Restraints-Medical Symptom Must Be Authorized: Based on observation, interview, and record review the facility failed to protect residents' right to be free from physical restraint when staff placed a piece of furniture (a bench) in front of a resident's door to prevent the resident from leaving and the facility did not provide a policy regarding resident safety/restraint use.

19 CSR 30-86.042(4) Operator/Administrator Responsibilities: Based on observation, record review, and interview the facility failed to ensure compliance with laws and regulations by not providing DHSS surveyors access to residents' electronic medical records during inspection; corporate staff indicated DHSS surveyors did not have access and the administrator could not provide access to the EMR.

19 CSR 30-86.042(18) TB Screen Resident/Staff: Based on interview and record review, facility staff failed to ensure required two-step tuberculosis screening was completed or documented for multiple staff and residents and did not document required annual TB screening for some residents.

19 CSR 30-86.042(39) Protective Oversight: Based on interview and record review, the facility staff failed to provide twenty-four hour protective oversight for one resident with short-term memory loss, resulting in the resident leaving facility property alone.

19 CSR 30-86.042(51) Safe/Effective Medication System: Based on observation, interview, and record review, the facility failed to ensure a safe and effective medication administration system was in place for one resident when staff failed to ensure the electronic medication administration record (eMAR) directions and the medication label matched, resulting in doses given that did not match the physician's order.

19 CSR 30-86.042(11)(B) EDL Inquiry: Based on record review and interview, the facility failed to check to ensure that a newly hired employee was not listed on the employee disqualification list (EDL) prior to allowing that person to have contact with residents.

19 CSR 30-86.042(18) TB Screen Resident/Staff: Based on record review and interview, the facility staff failed to ensure the required two-step tuberculosis screening testing was administered on admission as required for two sampled residents.

19 CSR 30-86.042(51) Safe/Effective Medication System: Based on record review and interview, the facility failed to obtain pain medication in a timely manner, resulting in a delay in appropriate pain medication for one resident (Resident #1) after a dental procedure.

19 CSR 30-86.022(2)(E) Fire-24hr Monitor, Hourly Checks, General Requirements: Based on observations, interviews, and record review, the facility failed to complete documented hourly visual checks for 24 hours after a fire occurred in a laundry room of the facility.

19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation: Based on record review and interview during the fire safety inspection on September 4, 2018, the facility failed to request or have a consultation from the local fire department or notify the State Fire Marshal in writing and record review showed no documentation of a request or annual consultation on file; the Executive Director stated the consultation had been completed but documentation could not be located.

19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees: Based on observation and interview during the fire safety inspection on September 4, 2018, the facility failed to ensure fire safety training was provided to all employees at least every six months and record review showed the last documented in-service fire safety training was dated February 21, 2018.

19 CSR 30-86.022(9) Fire Alarm Complete System: Based on observation and interview during the fire safety inspection on September 4, 2018, the facility failed to properly install a complete fire alarm system in accordance with NFPA; observations included missing heat detectors in the attic of the 2009 addition and a junction box with no protective cover and splices protruding from the box.

19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview during the fire safety inspection on September 4, 2018, the facility failed to test and maintain the complete fire alarm system in accordance with NFPA and provided no documentation for the semianual fire alarm inspection.

19 CSR 30-86.022(9)(H) Fire Alarm System Out of Service > than 4hrs: Based on record review and interview during the fire safety inspection on September 4, 2018, the facility failed to have a written fire watch program in place in case the fire alarm or sprinkler system would be down for more than four hours in a 24-hour period.

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: Based on observation and interview during the fire safety inspection on September 4, 2018, the facility failed to install or maintain required self-closing doors on hazardous area doors; observations included no self-closing device on the door to the resident laundry and doors in furnace rooms without self-closing devices.

19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on observation and interview during the fire safety inspection on September 4, 2018, the facility failed to inspect and maintain the sprinkler system in accordance with requirements and record review showed no documentation of monthly checks of gauges and system pressure.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Based on observation and interview during the fire safety inspection on September 4, 2018, the facility used non fire-resistant wastebaskets (wire mesh, plastic and wicker) throughout resident rooms, offices and common areas instead of metal, UL-listed, or FM-rated wastebaskets.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Based on observation and interview during the inspection on September 4, 2018, the facility had electrical hazards including a fan with loose electrical wiring and junction boxes in the attic with no protective covers (one junction box located seven feet south of the attic access in the 300 East hall lacked a protective cover).

19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Based on interview and record review, facility staff failed to notify the Department of Health & Senior Services (DHSS) of a required allegation of physical abuse involving one resident and failed to immediately notify the facility administrator.