Inspection Reports for
Abbey Senior Health
206 NORTH MAIN ST, O'FALLON, MO, 63366-2299
Back to Facility Profile8 Reports
Inspection Report — Oct 25, 2024
Life Safety
Date: Oct 25, 2024
Visit Reason
CMS-2567 Life Safety (K-tags) survey and Missouri Department of Health and Senior Services State Form; life safety survey (no complaint numbers stated).
Findings
Eleven deficiencies were cited: five federal Life Safety deficiencies concerning building construction type/height, vertical openings/enclosures, sprinkler system maintenance/testing, elevator inspection/certification, and fire drills; and six Missouri State deficiencies citing corresponding rules and referring to the federal findings.
Deficiencies (6)
19 CSR 30-85.012(80) LSC Edition Required per Date of Fac Plan: Refer to K161.
19 CSR 30-85.012(133) Elevator Testing/Certification: Refer to K531.
19 CSR 30-85.022(3) Noncombustible Material Between Floors: Refer to K311.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Refer to K712.
19 CSR 30-85.032(36) Elevator Requirements: Refer to K531.
Report Facts
residents potentially affected: 49
smoke compartments: 11
Inspection Report — Jun 15, 2023
Life Safety
Date: Jun 15, 2023
Visit Reason
Federal Life Safety (CMS-2567) and Missouri Department of Health and Senior Services State Form; Life Safety / emergency preparedness survey.
Findings
15 federal Life Safety / emergency preparedness deficiencies covering emergency preparedness policies, evacuation/transportation arrangements, building construction type and vertical openings, hazardous areas, cooking facilities, fire alarm, sprinkler system maintenance, corridor doors, evacuation plans and fire drills, generator/testing, and electrical testing; and 10 Missouri state licensure deficiencies (19 CSR citations) that refer to and mirror the Life Safety findings.
Deficiencies (10)
19 CSR 30-85.012(80) LSC Edition Required per Date of Fac Plan: Class II. Refer to K161.
19 CSR 30-85.022(3) Noncombustible Material Between Floors: Class II*. Refer to K311.
19 CSR 30-85.022(4) Hazardous Areas: Class II. Refer to K321.
19 CSR 30-85.022(9) Range Hood Certification: Class II*. Refer to K324.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: Class II. Refer to K341.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Class II. Refer to K353.
19 CSR 30-85.022(33)(C) Plan Accessible/Evacuation Diagram Posted: Class II*. Refer to K711.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Class II*. Refer to K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Class II*. Refer to K363 and K918.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Class II*. Refer to K921.
Report Facts
residents potentially affected: 10
fuel-fired boilers: 4
Inspection Report — Apr 22, 2021
Routine
Date: Apr 22, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: a federal health citation for failure to notify a resident's representative of condition and code status changes, and a Missouri state licensure citation for failure to notify the responsible party.
Deficiencies (1)
19 CSR 30-85.042(80) Notify Responsible Party-Change in Condition: Refer to F580.
Report Facts
residents sampled: 6
Inspection Report — Nov 7, 2019
Routine
Date: Nov 7, 2019
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
Seven deficiencies were cited: four federal health survey deficiencies addressing transfer/discharge notice and emergency transfer procedures, preparation for transfer, baseline care plan development, and infection control; and three Missouri State Form deficiencies addressing employee TB screening/infection control, infection control/communicable disease (referenced to the federal infection control finding), and emergency discharge procedures (referenced to the federal transfer finding).
Deficiencies (3)
19 CSR 30-85.042(27) Communicable Disease-Employees: Based on interview and record review, the facility failed to follow infection control protocols for tuberculosis for new employees at the time of hire, affecting multiple employees and increasing potential exposure to TB.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F880.
19 CSR 30-88.010(18) Emergency Discharges: See the deficiency cited at F623.
Report Facts
residents affected (F623): 4
residents affected (F624): 4
residents affected (F655): 8
residents affected (F880): 5
employees affected (A4029): 4
Inspection Report — Nov 7, 2019
Life Safety
Date: Nov 7, 2019
Visit Reason
CMS-2567 Life Safety Code survey (K-tag pages) and Missouri Department of Health and Senior Services State Form (state licensure).
Findings
Eight deficiencies were cited: four federal Life Safety deficiencies addressing building construction type/height and sprinkler equivalency, hazardous area enclosures, combustible decorations, and electrical/power cord use; and four Missouri state citations concerning LSC edition required by facility plan, electrical system test/certification, hazardous areas, and unnecessary combustible materials.
Deficiencies (4)
19 CSR 30-85.012(80) LSC Edition Required per Date of Fac Plan: Refer to K161.
19 CSR 30-85.012(126) Electrical System-Test/Certify per Code: Refer to K920.
19 CSR 30-85.022(4) Hazardous Areas: Refer to K321.
19 CSR 30-85.022(5) Combustible Materials, Unnecessary: Refer to K753.
Report Facts
smoke_compartments_affected: 11
Inspection Report — Dec 20, 2018
Annual Inspection
Date: Dec 20, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); annual inspection.
Findings
Six deficiencies were cited: four federal deficiencies related to restorative/mobility services, catheter and continence care, PRN psychotropic medication use, and infection prevention and control; and two Missouri state citations addressing nursing care and infection control (both Class II).
Deficiencies (2)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F688 and F690.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
Report Facts
residents sampled: 13
residents with urinary catheters: 4
Inspection Report — Dec 20, 2018
Life Safety
Date: Dec 20, 2018
Visit Reason
CMS-2567 Life Safety (K-tags) and Missouri state licensure (State Form) are present; the survey type is not stated.
Findings
Seven deficiencies were cited: three federal life-safety deficiencies involving building construction type/height, sprinkler system installation, and corridor doors; and four Missouri state deficiencies addressing LSC edition/fire-resistance of structural elements, complete sprinkler system, substantial construction/maintenance, and heating system/portable space heaters.
Deficiencies (4)
19 CSR 30-85.012(80) LSC Edition Required per Date of Fac Plan: Refer to K161.
19 CSR 30-85.022(11)(D) Complete Sprinkler System: Refer to K351.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(28) Heating System-No Portable: The facility failed to maintain the facility free from portable space heaters; observations found portable space heaters in multiple staff areas.
Inspection Report — Mar 23, 2018
Complaint Investigation
Date: Mar 23, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form included; file cites complaint MO 139689 indicating a complaint investigation.
Complaint Details
MO 139689; substantiation not stated.
Findings
Two deficiencies were cited: one federal quality-of-care deficiency related to failure to ensure a resident received prescribed CPM therapy and related orders/equipment, and one Missouri state nursing care deficiency (Class II) that refers to the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F684.
14 CMS Surveys
Inspection Report — Sep 11, 2025
Complaint Investigation
Date: Sep 11, 2025
Visit Reason
The inspection was conducted following a complaint regarding misappropriation of a resident's property by a Certified Nurse Aide (CNA C).
Complaint Details
The complaint was substantiated. CNA C, an agency aide, misappropriated the resident's property by using the resident's debit card for unauthorized payments. The facility and police investigated, and CNA C was barred from the facility.
Findings
The facility failed to protect one resident from misappropriation of property by CNA C, who took the resident's wallet and debit card without permission and used the debit card for unauthorized purchases. The facility notified the police, replaced the resident's wallet and cash, and prohibited CNA C from returning.
Deficiencies (1)
F 0602: The facility failed to protect a resident from wrongful use of belongings when CNA C took the resident's wallet and debit card and made unauthorized purchases totaling over $1,000. The facility notified police and took corrective actions including staff in-service and policy review.
Report Facts
Unauthorized charges: 450
Unauthorized charges: 378
Unauthorized charges: 139.29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Aide | Named in misappropriation of resident property finding |
| Social Services Director | Interviewed regarding the incident and investigation | |
| Director of Nurses | Interviewed and involved in reporting the incident to police | |
| Administrator | Interviewed and involved in investigation and corrective actions | |
| Police Officer A | Conducted investigation and confirmed unauthorized charges |
Inspection Report — Dec 19, 2024
Complaint Investigation
Date: Dec 19, 2024
Visit Reason
Federal CMS-2567 health survey (Statement of Deficiencies) with a complaint investigation cited (MO00246640).
Complaint Details
MO00246640; substantiation not stated in the record.
Findings
One federal health deficiency was cited for resident abuse and neglect involving a dietary aide who threw a plate and verbally abused a resident; past noncompliance was noted.
Deficiencies (1)
F 600 Free from Abuse and Neglect: The facility failed to ensure Resident #1 was free from verbal and physical abuse when Dietary Aide E threw a ceramic plate toward the resident causing it to shatter near the resident and verbally abused the resident by calling them a "fucking bitch"; Dietary Aide E was terminated.
Inspection Report — Oct 25, 2024
Life Safety
Date: Oct 25, 2024
Visit Reason
CMS-2567 Life Safety (K-tags) survey and Missouri Department of Health and Senior Services State Form; life safety survey (no complaint numbers stated).
Findings
Eleven deficiencies were cited: five federal Life Safety deficiencies concerning building construction type/height, vertical openings/enclosures, sprinkler system maintenance/testing, elevator inspection/certification, and fire drills; and six Missouri State deficiencies citing corresponding rules and referring to the federal findings.
Deficiencies (5)
K161 Building Construction Type and Height CFR(s): NFPA 101: Based on observation and record review, the facility failed to ensure the building met the required construction type for a three-story building; the basement was non-protected noncombustible construction which was not permitted for the three-story configuration.
K311 Vertical Openings - Enclosure CFR(s): NFPA 101: Based on observation and interview, the facility failed to maintain barriers between floors with the required fire resistance rating by not repairing openings in the ceiling, leaving vertical openings in multiple locations.
K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101: Based on observation, interview, and record review, the facility failed to ensure sprinkler heads were clean and annular spaces were covered by escutcheon plates, failed to maintain required storage clearances from sprinkler heads, and failed to maintain documentation of required backflow prevention testing and five‑year internal pipe inspection.
K531 Elevators CFR(s): NFPA 101: Based on observation, interview, and record review, the facility failed to have current inspection certificates posted or a current inspection for elevators #2, #3, and #4 as required.
K712 Fire Drills CFR(s): NFPA 101: Based on record review and interview, the facility failed to conduct and document required quarterly fire drills on each shift, with missing or untimely drills noted.
Report Facts
residents potentially affected: 49
smoke compartments: 11
Inspection Report — Oct 25, 2024
Routine
Date: Oct 25, 2024
Visit Reason
Routine inspection of Abbey Senior Health to assess compliance with regulatory requirements including resident rights, bed hold policies, resident care, infection control, food safety, and bed safety.
Findings
The facility was found deficient in multiple areas including failure to post resident rights accessibly, failure to provide bed hold policy to residents upon hospital transfer, incomplete baseline care plan review and provision, unsafe wheelchair transport practices, inconsistent bed rail assessments and entrapment risk evaluations, improper food handling and sanitation practices, inadequate infection prevention and control including improper use of enhanced barrier precautions, and failure to maintain and monitor dishwashing and ice machine sanitation.
Deficiencies (8)
F 0572: Facility failed to ensure residents were aware of posted resident rights in an easily accessible area for review at their leisure.
F 0574: Facility failed to provide accessible information regarding the State Long Term Care Ombudsman program and State Survey Agency in a location readily accessible and readable by residents.
F 0625: Facility failed to notify two residents or their representatives in writing of the bed hold policy at the time of hospital transfer.
F 0655: Facility failed to review and provide baseline care plans to two residents or their representatives within 48 hours of admission.
F 0689: Facility failed to ensure safe wheelchair transport for six residents by pushing wheelchairs without foot rests, risking foot injury.
F 0700: Facility failed to conduct regular bed frame, mattress, and bed rail inspections to identify entrapment risks for eight residents and failed to document such inspections.
F 0812: Facility failed to ensure proper hand hygiene and gloving practices during food service, failed to store food properly, and failed to maintain and monitor dishwashing and ice machine sanitation.
F 0880: Facility failed to implement infection prevention and control program adequately, including failure to use enhanced barrier precautions for residents with urinary catheters and wounds, failure to keep catheter tubing off the floor, failure to cover nebulizer and CPAP masks when not in use, and improper medication administration technique.
Report Facts
Residents sampled: 20
Bed hold policy not provided: 2
Baseline care plan not reviewed/provided: 2
Residents with unsafe wheelchair transport: 6
Residents with bed rail entrapment risk assessment missing: 8
Dishwasher sanitizer test strip missing logs: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT P | Certified Medication Technician | Medication administration with bare hands after pills fell into medication drawer |
| RN A | Registered Nurse | Wound and catheter care without gown use; interview on infection control |
| Dietary Aide I | Improper glove use and hand hygiene during food service on third floor | |
| Dietary Aide H | Improper glove use and hand hygiene during food service on second floor | |
| Dietary Manager | Interview on food safety, dishwashing, and ice machine sanitation | |
| Dietary Supervisor | Interview on food safety and dishwashing monitoring | |
| Dishwasher F | Dishwasher operation and temperature monitoring | |
| Dishwasher Q | Dishwasher sanitizer testing knowledge | |
| CNA J | Certified Nurse Aide | Incontinence care without hand hygiene and glove changes |
| CNA K | Certified Nurse Aide | Urinary catheter care without gown use |
| CNA U | Certified Nurse Aide | Urinary catheter care without gown use |
| Maintenance Director | Interview on bed entrapment assessments | |
| Director of Nursing | Interview on bed entrapment assessments and infection control | |
| Administrator | Interview on bed entrapment assessments and infection control | |
| Physical Therapy R | Interview on bed rail/assist bar evaluations | |
| Assistant Director of Nursing | Interview on enhanced barrier precautions | |
| Education/Staffing Director | Interview on enhanced barrier precautions | |
| Maintenance Assistant | Interview on ice machine maintenance |
Inspection Report — Jun 15, 2023
Life Safety
Date: Jun 15, 2023
Visit Reason
Federal Life Safety (CMS-2567) and Missouri Department of Health and Senior Services State Form; Life Safety / emergency preparedness survey.
Findings
15 federal Life Safety / emergency preparedness deficiencies covering emergency preparedness policies, evacuation/transportation arrangements, building construction type and vertical openings, hazardous areas, cooking facilities, fire alarm, sprinkler system maintenance, corridor doors, evacuation plans and fire drills, generator/testing, and electrical testing; and 10 Missouri state licensure deficiencies (19 CSR citations) that refer to and mirror the Life Safety findings.
Deficiencies (15)
E015 Subsistence Needs for Staff and Patients: Based on record review and interview, the facility failed to have a current arrangement in place for water supply for residents in the event of an emergency and lacked documentation of a current emergency water supply agreement.
E020 Policies for Evac. and Primary/Alt. Comm.: Based on record review and interview, the facility failed to develop a policy which addressed a resident's refusal to leave during an evacuation and lacked a current agreement for transportation services for emergencies.
E025 Arrangement with Other Facilities: Based on record review and interview, the facility failed to ensure mutual aid/transfer agreements with other facilities and providers were current; the facility's agreements were out of date.
K161 Building Construction Type and Height: Based on observation and record review, the facility failed to ensure the building met allowed construction type for a three-story building because the basement was non-protected noncombustible construction; this practice had the potential to affect all residents.
K311 Vertical Openings - Enclosure: Based on observation and interview, the facility failed to maintain fire barriers between floors by leaving openings in ceiling and other penetrations unsealed in multiple locations.
K321 Hazardous Areas - Enclosure: Based on observation and interview, the facility failed to ensure doors to hazardous areas (including combustible storage) were self-closing or automatic-closing and were left propped open.
K324 Cooking Facilities: Based on observation and interview, the facility failed to ensure proper operation and installation of kitchen range hood baffle filters and failed to ensure satellite kitchens were equipped with Class K extinguishers.
K341 Fire Alarm System - Installation: Based on observation, interview, and record review, the facility failed to ensure audible and visible notification of the facility fire alarm was present for the enclosed elevated second floor patio area.
K353 Sprinkler System - Maintenance and Testing: Based on observation, interview, and record review, the facility failed to maintain the sprinkler system in accordance with NFPA 25 by not ensuring annual and quarterly inspections and backflow/prevention testing documentation and by failing to keep sprinkler heads free of debris.
K363 Corridor - Doors: Based on observation and interview, the facility failed to maintain corridor doors to resist passage of smoke and allowed doors to be held open or had holes and obstacles preventing full closure.
K711 Evacuation and Relocation Plan: Based on observation and interview, the facility failed to ensure the correct evacuation map/plan was posted and accurate for resident areas, with multiple evacuation maps showing incorrect room identifications.
K712 Fire Drills: Based on interview and record review, the facility failed to conduct fire drills at least quarterly on each shift and failed to ensure drills were performed at unexpected times and under varied conditions.
K918 Electrical Systems - Essential Electric Syste: Based on observation, interview, and record review, the facility failed to maintain complete documentation of monthly generator testing, including start/stop and transfer times.
K921 Electrical Equipment - Testing and Maintenance: Based on observation, interview, and record review, the facility failed to assess and document annual electrical receptacle testing throughout the facility.
K932 Features of Fire Protection - Other: Based on observation and interview, the facility failed to ensure required safety inspections were conducted on the fuel-fired boilers within the last two years as required by regulations.
Report Facts
residents potentially affected: 10
fuel-fired boilers: 4
Inspection Report — Jun 9, 2023
Complaint Investigation
Date: Jun 9, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure form; the CMS-2567 notes this was a Recertification and Complaint survey.
Complaint Details
Complaint intake numbers M0000219350, M0000219355, and M0000219432 are referenced in the CMS-2567; the report does not state whether the allegations were substantiated.
Findings
Thirteen federal health survey deficiencies were cited addressing assessment/MDS encoding and transmission, comprehensive care planning, activities director qualifications, quality of care/skin assessments, accident prevention and supervision (including hot liquid incidents and fall investigations), drug regimen/pharmacy and psychotropic medication use, facility administration and assessment, hospice services coordination, infection prevention and control, and staff abuse/neglect training. The Missouri state licensure form included in the file recorded no state licensure or state health deficiencies.
Deficiencies (13)
F 637 Comprehensive Assessment After Significant Chg: The facility failed to complete a required significant change Minimum Data Set (MDS) assessment for one resident (R32) admitted to hospice.
F 640 Encoding/Transmitting Resident Assessments: The facility failed to complete and/or transmit required discharge MDS assessments for two residents (R11 and R47) within the required timeframes.
F 656 Develop/Implement Comprehensive Care Plan: The facility failed to ensure comprehensive, individualized care plans were developed and updated for multiple residents (including R1, R3, and R7).
F 680 Qualifications of Activity Professional: The facility's Activities Director was not licensed or certified as a qualified activities professional as required.
F 684 Quality of Care: The facility failed to ensure consistent weekly skin assessments and appropriate skin care planning for a resident (R3) with blisters, increasing the likelihood of a significant skin issue.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision, safe hot-liquid practices, and thorough fall/incident investigations and follow-up for multiple residents, resulting in resident injuries and incomplete investigations.
F 756 Drug Regimen Review, Report Irregular, Act On: The facility's drug regimen review process failed to identify and report inadequate indications for antipsychotic and other psychotropic medications for multiple residents.
F 758 Free from Unnece Psychotropic Meds/PRN Use: The facility failed to ensure appropriate indications, documented rationale, and duration limits for PRN and antipsychotic use for residents (including R3 and R22).
F 835 Administration: The facility failed to administer its resources and oversight effectively, including failures in supervision, staff training, and follow-up to safety incidents such as hot liquid spills.
F 838 Facility Assessment: The facility failed to maintain and update the facility assessment accurately and did not use current resident population data to determine facility resource needs.
F 849 Hospice Services: The facility failed to ensure proper coordination and documentation of hospice services, including missing hospice plans, election forms, and physician certification/recertification for residents receiving hospice.
F 880 Infection Prevention & Control: The facility failed to implement required infection control practices, including inconsistent enhanced barrier precautions and inadequate cleaning/sanitizing of glucometers.
F 943 Abuse, Neglect, and Exploitation Training: The facility failed to provide required abuse-prohibition training to a recently hired nursing assistant.
Report Facts
residents sampled: 24
Inspection Report — Apr 22, 2021
Routine
Date: Apr 22, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: a federal health citation for failure to notify a resident's representative of condition and code status changes, and a Missouri state licensure citation for failure to notify the responsible party.
Deficiencies (1)
F580 Notify of Changes (Injury/Decline/Room, etc.): Based on interview and record review, the facility failed to ensure Resident #1's representative was notified of condition and code status changes. The resident's medical record and progress notes showed no evidence staff notified the resident's representative of decline or new physician orders and the family reported they were unaware of the code status change.
Report Facts
residents sampled: 6
Inspection Report — Feb 26, 2021
Complaint Investigation
Date: Feb 26, 2021
Visit Reason
Federal health (CMS-2567) complaint investigation; complaint number MO#180928 is cited in the file.
Complaint Details
MO#180928; substantiation not stated in the document.
Findings
One federal health deficiency was cited related to hospice services. The surveyor found the facility failed to permit hospice providers to enter the facility to provide direct care to residents during COVID-19-related restrictions.
Deficiencies (1)
F 849 Hospice Services: Based on interview and record review, the facility failed to permit entry of hospice providers into the facility to provide direct care for two residents who were to receive hospice services, restricting in-person hospice visits and relying on phone/virtual contacts.
Report Facts
residents affected: 2
Inspection Report — Jul 2, 2020
Routine
Date: Jul 2, 2020
Visit Reason
Federal CMS-2567 containing health (F) and emergency preparedness (E) sections; a COVID-19 Focused Infection Control and Emergency Preparedness survey as stated in the Initial Comments.
Findings
No federal health (F) or emergency preparedness (E) deficiencies were cited; the Initial Comments state the facility was found to be in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report — Nov 7, 2019
Routine
Date: Nov 7, 2019
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
Seven deficiencies were cited: four federal health survey deficiencies addressing transfer/discharge notice and emergency transfer procedures, preparation for transfer, baseline care plan development, and infection control; and three Missouri State Form deficiencies addressing employee TB screening/infection control, infection control/communicable disease (referenced to the federal infection control finding), and emergency discharge procedures (referenced to the federal transfer finding).
Deficiencies (4)
F623 Notice Requirements Before Transfer/Discharge: Based on interview and record review, the facility failed to provide written notice of facility-initiated transfers for four sampled residents.
F624 Preparation for Safe/Orderly Transfer/Dschrg: The facility failed to document sufficient preparation and orientation to ensure a safe and orderly transfer for four sampled residents.
F655 Baseline Care Plan: The facility failed to develop and implement a baseline care plan within 48 hours that included the minimum healthcare information necessary for eight sampled residents.
F880 Infection Prevention & Control: The facility failed to follow infection control protocols for tuberculosis, including missing required TB screening/testing for multiple residents.
Report Facts
residents affected (F623): 4
residents affected (F624): 4
residents affected (F655): 8
residents affected (F880): 5
employees affected (A4029): 4
Inspection Report — Nov 7, 2019
Life Safety
Date: Nov 7, 2019
Visit Reason
CMS-2567 Life Safety Code survey (K-tag pages) and Missouri Department of Health and Senior Services State Form (state licensure).
Findings
Eight deficiencies were cited: four federal Life Safety deficiencies addressing building construction type/height and sprinkler equivalency, hazardous area enclosures, combustible decorations, and electrical/power cord use; and four Missouri state citations concerning LSC edition required by facility plan, electrical system test/certification, hazardous areas, and unnecessary combustible materials.
Deficiencies (4)
K161 Building Construction Type and Height: Based on observation and record review, the facility failed to ensure the building met the construction type for a three-story building; the basement was non-protected noncombustible construction and not permitted for a three-story building, potentially affecting occupants.
K321 Hazardous Areas - Enclosure: The facility failed to maintain the required one-hour protection around hazardous areas; doors to electrical rooms on the second and third floors did not have self-closers.
K753 Combustible Decorations: The facility failed to prohibit the use of combustible decorations and was observed to have a candle with a wick in the business office.
K920 Electrical Equipment - Power Cords and Extens: The facility failed to maintain the facility free from permanently used extension cords and surge protectors; extension cords and surge protectors were observed in dining/media areas with TVs plugged into surge protectors.
Report Facts
smoke_compartments_affected: 11
Inspection Report — Dec 20, 2018
Annual Inspection
Date: Dec 20, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); annual inspection.
Findings
Six deficiencies were cited: four federal deficiencies related to restorative/mobility services, catheter and continence care, PRN psychotropic medication use, and infection prevention and control; and two Missouri state citations addressing nursing care and infection control (both Class II).
Deficiencies (4)
F688 Increase/Prevent Decrease in ROM/Mobility: Based on observation, interview, and record review, the facility failed to ensure restorative services, splinting, and passive range of motion were provided as planned to prevent decline in mobility for sampled residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Based on observation, interview, and record review, staff failed to provide appropriate catheter care and to maintain urinary drainage bags and tubing off the floor, placing a resident at risk for urinary tract infection.
F758 Free from Unnec Psychotropic Meds/PRN Use: Based on interview and record review, the facility failed to ensure PRN psychotropic medication orders were limited to 14 days or that appropriate physician documentation supported continued use, and failed to ensure physician response to consultant pharmacist recommendations.
F880 Infection Prevention & Control: Based on observation, interview, and record review, the facility failed to follow appropriate infection control procedures, including hand hygiene and wound dressing practices, increasing risk of spread of infection.
Report Facts
residents sampled: 13
residents with urinary catheters: 4
Inspection Report — Dec 20, 2018
Life Safety
Date: Dec 20, 2018
Visit Reason
CMS-2567 Life Safety (K-tags) and Missouri state licensure (State Form) are present; the survey type is not stated.
Findings
Seven deficiencies were cited: three federal life-safety deficiencies involving building construction type/height, sprinkler system installation, and corridor doors; and four Missouri state deficiencies addressing LSC edition/fire-resistance of structural elements, complete sprinkler system, substantial construction/maintenance, and heating system/portable space heaters.
Deficiencies (3)
K161 Building Construction Type and Height: Based on observation and record review, the facility failed to ensure the building met the required construction type for a three-story building; the basement was non-protected noncombustible construction and ceiling elements were not rated to provide required one-hour protection.
K351 Sprinkler System - Installation: The facility failed to install the sprinkler system in accordance with NFPA 13; there was no sprinkler coverage in the stairwell used by therapy stairs, affecting occupancy in multiple smoke compartments.
K363 Corridor - Doors: The facility failed to ensure corridor doors were equipped with positive latching hardware and resisted passage of smoke; observations included a gift shop door propped open and doors lacking positive latching devices.
Inspection Report — Mar 23, 2018
Complaint Investigation
Date: Mar 23, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form included; file cites complaint MO 139689 indicating a complaint investigation.
Complaint Details
MO 139689; substantiation not stated.
Findings
Two deficiencies were cited: one federal quality-of-care deficiency related to failure to ensure a resident received prescribed CPM therapy and related orders/equipment, and one Missouri state nursing care deficiency (Class II) that refers to the federal finding.
Deficiencies (1)
F 684 Quality of Care: Based on observation, interview and record review, the facility failed to ensure one resident received ordered continuous passive motion (CPM) therapy and that the CPM machine/cord was available and applied as ordered.
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