Inspection Reports for
Abbey Senior Health
206 NORTH MAIN ST, O'FALLON, MO, 63366-2299
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
12.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
82% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
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
Facility census: 53
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
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal and physical abuse by a Dietary Aide towards a resident.
Complaint Details
The complaint was substantiated. Dietary Aide E verbally and physically abused Resident #1 on 12/15/24 by throwing a plate and using abusive language. The Dietary Aide was terminated on 12/16/24 after investigation and interviews with staff and the resident confirmed the abuse.
Findings
The facility failed to ensure one resident was free from verbal and mental abuse when a Dietary Aide threw a ceramic plate near the resident and used abusive language. The Dietary Aide was suspended, investigated, and terminated following the incident.
Deficiencies (1)
F 0600: The facility failed to protect a resident from verbal and mental abuse when a Dietary Aide threw a ceramic plate at the wall behind the resident and called the resident a derogatory name.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide E | Dietary Aide | Named in verbal and physical abuse of Resident #1 |
| Director of Nursing | Director of Nursing | Documented the incident and obtained statements |
| Human Resources Director | Human Resources Director | Reviewed video footage and confirmed incident |
| Registered Nurse A | Registered Nurse | Witnessed and reported the abuse incident |
| CNA B | Certified Nurse Assistant | Witnessed and reported the abuse incident |
| CNA C | Certified Nurse Assistant | Witnessed and reported the abuse incident |
| Administrator | Administrator | Notified of the abuse allegation and confirmed termination |
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a regulatory inspection of Abbey Senior Health. The visit was conducted to address and document a past noncompliance involving abuse and neglect of a resident.
Findings
The facility failed to ensure Resident #1 was free from verbal and physical abuse by Dietary Aide E, who threw a ceramic plate at the resident and used abusive language. The facility took corrective action by terminating Dietary Aide E and educating staff on abuse and neglect policies.
Deficiencies (1)
F600 Freedom from Abuse, Neglect, and Exploitation was not met as Dietary Aide E verbally and physically abused Resident #1 by throwing a ceramic plate at the resident and using derogatory language.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide E | Named as the staff member who verbally and physically abused Resident #1 and was terminated | |
| Director of Nursing | Director of Nursing | Reviewed resident's Nurses' Note documenting the incident |
| Administrator | Administrator | Notified of the abuse and noncompliance on 12/19/24 |
| Registered Nurse RN | Registered Nurse | Witnessed and reported the abuse incident |
| Certified Nurse Assistant CNA B | Certified Nurse Assistant | Witnessed and reported the abuse incident |
| Certified Nurse Assistant CNA C | Certified Nurse Assistant | Witnessed and reported the abuse incident |
| Human Resources Director | Human Resources Director | Reviewed video evidence of the abuse incident |
Inspection Report
Life Safety
Census: 49
Capacity: 55
Deficiencies: 11
Date: Oct 25, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey to evaluate the facility's compliance with fire safety regulations and building construction requirements.
Findings
The facility failed to meet several Life Safety Code requirements including building construction type for a three-story building, vertical openings enclosure, sprinkler system maintenance, elevator inspection certificates, and fire drill documentation. These deficiencies had the potential to affect all 49 residents in the facility.
Deficiencies (11)
K161: The facility failed to meet construction type requirements for a three-story building, including non-protected noncombustible basement construction not allowed by NFPA 101. This affected 49 residents in 11 smoke compartments.
K311: The facility failed to maintain fire-resistant barriers between floors, with unsealed openings in ceilings and gaps around conduits, affecting 26 residents and others in three smoke compartments.
K353: The sprinkler system was not properly maintained; sprinkler heads had debris buildup, improper spacing, and missing five-year internal pipe inspection documentation. This affected all 49 residents in 11 smoke compartments.
K531: The facility failed to have current inspection certificates posted for elevators #2, #3, and #4, with inspections past due. This affected all residents, visitors, and staff in 11 smoke zones.
K712: The facility failed to conduct fire drills quarterly on each shift as required, missing timing for a second shift drill by one hour. This affected all residents in 11 smoke compartments.
A1087: The facility did not meet Life Safety Code test certification requirements for fire-resistant structural elements as required by the 1985 Life Safety Code.
A1140: The facility failed to conduct required elevator overspeed tests and maintain proper certification documentation, violating elevator testing and certification rules.
A2007: Openings between floors were not properly fire-stopped with suitable noncombustible material, violating noncombustible material requirements between floors.
A2034: The sprinkler system was not properly inspected, maintained, and tested according to requirements for facilities with pre-2007 sprinkler systems.
A2061: The facility failed to conduct a minimum of twelve fire drills annually with required unannounced drills and simulated resident evacuations involving emergency services.
A3036: The facility failed to comply with elevator installation and maintenance requirements per local and state codes and NFPA 70.
Report Facts
Facility capacity: 55
Resident census: 49
Smoke compartments affected: 11
Fire drills missed: 1
Fire drills required annually: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding sprinkler system maintenance, elevator inspections, and fire drills |
Inspection Report
Routine
Census: 49
Deficiencies: 8
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
Resident census: 49
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
Life Safety
Census: 44
Capacity: 55
Deficiencies: 22
Date: Jun 15, 2023
Visit Reason
The inspection was conducted as an emergency preparedness investigation and life safety code survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found deficient in multiple areas including emergency water supply agreements, evacuation policies, fire safety construction standards, maintenance of fire barriers, sprinkler system maintenance, fire alarm system notification, and fire drill compliance. Deficiencies had the potential to affect all 44 residents in the facility.
Deficiencies (22)
E015 Emergency preparedness policies lacked a current water supply agreement for residents during emergencies. The facility census was 44.
E020 Emergency evacuation policies failed to address resident refusal to evacuate and lacked transportation agreements. The facility census was 44.
E025 The facility failed to maintain current mutual aid agreements with other providers for resident transfer during emergencies. The facility census was 44.
K161 The building did not meet fire safety construction requirements for a three-story building with a non-protected basement. The facility capacity was 55 with a census of 44.
K311 The facility failed to maintain fire-resistant barriers between floors and had multiple unsealed openings in ceilings and walls. The facility capacity was 55 and census was 44.
K321 Doors to hazardous areas were not self-closing or automatic, affecting safety in combustible storage and administrative areas. The facility capacity was 55 and census was 44.
K324 The facility failed to ensure proper operation of kitchen range hood fire suppression and lacked Class K extinguishers in satellite kitchens. The facility capacity was 55 and census was 44.
K341 The fire alarm system lacked audible and visible notification on the elevated patio, potentially affecting all residents. The facility capacity was 55 and census was 44.
K353 The sprinkler system was not maintained with annual and quarterly inspections, and sprinkler heads were obstructed by debris. The facility capacity was 55 and census was 44.
K363 Corridor doors did not resist smoke passage and were held open with wedges or wood, compromising fire safety. The facility capacity was 55 and census was 44.
K711 The evacuation maps were inaccurate and did not correctly identify resident rooms or evacuation routes. The facility capacity was 55 and census was 44.
K712 Fire drills were not conducted quarterly on all shifts at unexpected times, affecting emergency preparedness. The facility capacity was 55 and census was 44.
K918 The emergency generator was not properly tested monthly and lacked documentation of transfer times. The facility capacity was 55 and census was 44.
K921 The facility failed to assess all electrical receptacles annually, risking electrical safety. The facility capacity was 55 and census was 44.
K932 The facility failed to ensure inspection of fuel-fired boilers within the required time frame. The facility capacity was 55 and census was 44.
A1087 Exterior walls and structural elements did not meet fire-resistant rating requirements for the building. Refer to K161.
A2007 Openings between floors were not fire-stopped with noncombustible materials. Refer to K311.
A2017 The facility failed to maintain range hood certification and proper extinguishing systems. Refer to K324.
A2018 The fire alarm system did not meet requirements for complete audible and visual notification. Refer to K341.
A2060 The evacuation diagram was not posted conspicuously on each floor. Refer to K711.
A2061 Fire drills were not conducted as required annually and quarterly on all shifts. Refer to K712.
A3001 The building was not maintained in good repair and did not comply with construction standards. Refer to K363 and K918.
Report Facts
Facility census: 44
Facility capacity: 55
Deficiency count: 21
Inspection Report
Routine
Deficiencies: 2
Date: Jun 9, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safety regulations related to accident hazards, supervision to prevent accidents, and proper investigation of resident falls and injuries.
Findings
The facility failed to ensure residents were protected from accident hazards, specifically related to hot coffee spills causing burns and inadequate supervision and investigation of resident falls. The Director of Nursing and Administrator failed to ensure proper follow-up, comprehensive fall investigations, and consistent skin assessments. The facility also lacked proper training and monitoring systems for fall prevention and did not ensure the Activities Director was properly certified.
Deficiencies (2)
F 0689: The facility failed to ensure residents were free from accident hazards and received adequate supervision to prevent accidents, resulting in actual harm from hot coffee spills and falls with inadequate investigations and supervision.
F 0835: The facility failed to administer resources effectively and efficiently to maintain residents' well-being, including failure to prevent falls, ensure proper supervision, conduct thorough investigations, and maintain qualified staff.
Report Facts
Resident falls in one month: 27
Coffee temperature: 167.2
Coffee temperature: 164
BIMS scores: 12
BIMS scores: 2
BIMS scores: 0
BIMS scores: 8
BIMS scores: 6
BIMS scores: 13
Number of residents sampled: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Involved in care and documentation related to resident R3's coffee spill and burn treatment |
| CNA1 | Certified Nurse Aide | Witnessed and reported resident R3's coffee spill and burn |
| DON | Director of Nursing | Responsible for investigations, supervision, and fall prevention oversight |
| Medical Director | Provided treatment orders related to resident R3's burns | |
| DA1 | Dietary Aide | Conducted coffee temperature checks and observed coffee serving practices |
| DA2 | Dietary Aide | Observed serving practices and coffee spill incident with resident R40 |
| ADON | Assistant Director of Nursing | Discussed fall packet training and documentation practices |
| Administrator | Facility administrator involved in oversight and interviews |
Inspection Report
Routine
Deficiencies: 13
Date: Jun 9, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, hospice services, staff qualifications, and facility administration.
Findings
The facility was found deficient in multiple areas including failure to complete required Minimum Data Set (MDS) assessments, incomplete care plans, unqualified activities director, inadequate skin assessments, unsafe hot coffee serving practices causing resident burns, insufficient fall investigations and supervision, inappropriate psychotropic medication use without proper indications, incomplete hospice documentation, failure to adhere to enhanced barrier precautions, improper glucometer sanitization, and lack of abuse training for re-hired staff. The facility assessment was outdated and did not reflect current resident population.
Deficiencies (13)
F0637: Facility failed to complete a significant change Minimum Data Set (MDS) for one resident admitted to hospice services.
F0640: Facility failed to complete discharge MDS assessments within required timeframes for two discharged residents.
F0656: Facility failed to develop and implement comprehensive care plans for three residents, missing hospice, venous insufficiency, and anticoagulant care plans.
F0680: Activities program was directed by an unqualified activities professional lacking required certification.
F0684: Facility failed to ensure weekly skin assessments were completed for one resident with blisters, increasing risk of skin issues.
F0689: Facility failed to prevent accidents and ensure adequate supervision for seven residents, including unsafe hot coffee temperatures causing burns and inadequate fall investigations.
F0756: Pharmacist failed to identify and report irregularities related to inadequate indications for antipsychotic medication use for two residents.
F0758: Facility failed to ensure psychotropic medications had appropriate indications and lacked documented rationale for PRN psychotropic medication use beyond 14 days for one resident.
F0835: Facility failed to administer resources effectively and efficiently, including lack of follow-up on falls, skin care, activities director certification, and hot coffee safety.
F0838: Facility assessment was outdated, last updated in 2021 with resident data from 2017, and did not reflect current resident population or administrator.
F0849: Facility failed to maintain hospice care plans, hospice election forms, and physician certification for two hospice residents, risking interruption of hospice care.
F0880: Facility failed to adhere to enhanced barrier precautions for one resident during wound care and failed to properly sanitize glucometers on one nursing unit.
F0943: Facility failed to provide abuse prohibition training for one re-hired Certified Nursing Assistant within the last six months.
Report Facts
Resident sample size: 24
Medication months reviewed: 4
Coffee temperature: 167.2
Resident falls: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in wound care enhanced barrier precaution deficiency. |
| RN1 | Registered Nurse | Named in hot coffee spill incident and glucometer cleaning deficiency. |
| CNA 4 | Certified Nursing Assistant | Named in abuse prohibition training deficiency. |
| Consultant Pharmacist | Named in medication irregularity findings. | |
| DON | Director of Nursing | Named in multiple deficiencies including fall investigations, hospice documentation, and staff training. |
| Administrator | Named in facility administration and oversight deficiencies. | |
| HRN | Hospice Registered Nurse | Named in hospice documentation deficiency. |
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 2
Date: Apr 22, 2021
Visit Reason
The inspection was conducted to evaluate compliance with notification of changes requirements related to resident condition changes and communication with resident representatives.
Findings
The facility failed to ensure notification to the resident's representative of condition changes for one sampled resident. There was a major lack of communication with the resident's family regarding code status changes and condition updates.
Deficiencies (2)
F580 Notification of Changes: The facility did not promptly notify the resident's representative of significant changes in condition, including injury, mental status, or treatment changes, as required by regulation.
A4087 Notify Responsible Party-Change in Condition: The facility failed to immediately notify the person designated in the resident's record as responsible for changes in condition, injury, or significant events.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nurses | ADON | Interviewed regarding notification of resident condition changes |
| Director of Nurses | DON | Interviewed regarding notification of resident condition changes |
| Licensed Practical Nurse | LPN | Interviewed regarding notification of resident condition changes |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 1
Date: Feb 26, 2021
Visit Reason
The inspection was conducted to assess compliance with hospice services regulations at Abbey Senior Health, specifically regarding the facility's arrangements and agreements with hospice providers and the provision of hospice care to residents.
Findings
The facility failed to permit entry of hospice providers to provide direct care to two residents receiving hospice services, violating hospice service requirements. The facility census was 51 at the time of inspection.
Deficiencies (1)
F849 Hospice services requirements were not met as the facility failed to permit hospice providers entry to provide direct care to two residents receiving hospice services.
Report Facts
Facility census: 51
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Date: Nov 7, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify residents and their representatives of transfers, inadequate preparation for transfers, failure to develop baseline care plans within 48 hours of admission, and failure to follow infection control protocols for tuberculosis screening.
Complaint Details
The visit was complaint-related, investigating failures in resident transfer notifications, preparation for transfers, baseline care planning, and tuberculosis screening. The deficiencies were substantiated based on record reviews and interviews.
Findings
The facility failed to notify residents and their representatives in writing of transfers to hospitals for four residents. It also failed to document sufficient preparation and orientation for safe transfers for four residents. Additionally, the facility did not develop baseline care plans within 48 hours of admission for eight residents. The facility failed to follow tuberculosis screening protocols for five residents, lacking documentation of initial and annual TB screenings.
Deficiencies (4)
F 0623: The facility failed to provide timely written notification to residents and/or their representatives before transfer or discharge for four residents. The facility census was 53.
F 0624: The facility failed to document sufficient preparation and orientation of residents to ensure safe and orderly transfer from the facility to hospital for four residents. The facility census was 53.
F 0655: The facility failed to develop and implement a baseline care plan within 48 hours of admission for eight residents. The facility census was 53.
F 0880: The facility failed to follow infection control protocols for tuberculosis screening for five residents, lacking documentation of initial and annual TB screenings. The facility census was 53.
Report Facts
Residents affected: 4
Residents affected: 4
Residents affected: 8
Residents affected: 5
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding transfer notification, preparation, baseline care plans, and TB screening practices |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 7
Date: Nov 7, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for Abbey Senior Health, focusing on transfer/discharge procedures, baseline care plans, infection control, and employee health screening.
Findings
The facility was found deficient in notifying residents and representatives before transfers, preparing residents for safe transfers, developing baseline care plans within 48 hours of admission, and following infection control protocols including tuberculosis screening for residents and employees.
Deficiencies (7)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and/or their representatives in writing of transfers for four sampled residents. The facility census was 53.
F624 Preparation for Safe/Orderly Transfer/Discharge: The facility failed to document sufficient preparation and orientation for safe transfer for four sampled residents. The facility census was 53.
F655 Baseline Care Plan: The facility failed to develop and implement a baseline care plan within 48 hours of admission for eight sampled residents. The facility census was 53.
F880 Infection Prevention & Control: The facility failed to follow infection control protocols for tuberculosis screening for five residents, potentially affecting all residents. The facility census was 53.
A4029 Communicable Disease-Employees: The facility failed to follow infection control protocols for tuberculosis screening for four new employees, increasing risk to all residents. The facility census was 53.
A4085 Infection Control/Communicable Disease: The facility failed to make timely reports of communicable diseases and implement acceptable infection control procedures.
A8018 Emergency Discharges: The facility failed to provide timely written notice of emergency discharges to residents and their legally authorized representatives.
Report Facts
Facility census: 53
Sampled residents: 18
Residents affected: 8
Employees reviewed: 6
Residents affected by TB screening deficiency: 5
Employees affected by TB screening deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding transfer notices and infection control practices |
Inspection Report
Life Safety
Census: 53
Capacity: 55
Deficiencies: 4
Date: Nov 7, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (NFPA 101) and related fire safety regulations for the facility's building construction and safety features.
Findings
The facility failed to meet the applicable provisions of the 2012 Life Safety Code, including building construction type and height requirements, hazardous area enclosures, combustible decorations, and electrical equipment safety. Several deficiencies were identified that posed fire safety risks to residents and staff.
Deficiencies (4)
K161 Building Construction Type and Height: The facility failed to ensure the building met construction type for a three-story building; the basement was non-protected noncombustible construction, which is not permitted. This affected 11 of 11 smoke compartments.
K321 Hazardous Areas - Enclosure: The facility failed to maintain one-hour fire protection around hazardous areas; doors to electrical rooms on the second and third floors had no self-closers, affecting all residents and staff.
K753 Combustible Decorations: The facility failed to prohibit flammable decorations, including candles with wicks, creating a fire hazard affecting all residents and staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the facility free from permanently used extension cords; surge protectors and extension cords were improperly used in patient care areas.
Report Facts
Facility census: 53
Facility capacity: 55
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 4
Date: Dec 20, 2018
Visit Reason
Annual survey inspection of Abbey Senior Health nursing facility to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including mobility and range of motion services, bowel and bladder incontinence care, psychotropic medication management, and infection control practices. Deficiencies were supported by observations, interviews, and record reviews.
Deficiencies (4)
F688 Mobility: The facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in mobility. Observations showed residents did not receive passive range of motion exercises or splint application as required.
F690 Bowel/Bladder Incontinence: Staff failed to provide appropriate care for a resident with a urinary catheter, including maintaining catheter drainage bag below bladder level and preventing contamination. This led to risk of urinary tract infection.
F758 Psychotropic Drugs: The facility failed to ensure one resident's PRN psychotropic medication orders were limited to 14 days and lacked proper physician documentation for extended use. Medication administration and monitoring were deficient.
F880 Infection Control: The facility failed to establish and maintain an infection prevention program including proper hand hygiene, use of gloves, and prevention of contamination during wound care. Observations showed staff did not follow required infection control procedures.
Report Facts
Facility census: 49
Sampled residents reviewed: 13
Residents with urinary catheters: 4
Inspection Report
Life Safety
Census: 49
Capacity: 55
Deficiencies: 7
Date: Dec 20, 2018
Visit Reason
The inspection was conducted as a Life Safety Code survey to evaluate the facility's compliance with fire safety regulations and building construction requirements.
Findings
The facility failed to meet several Life Safety Code requirements including building construction type for a three-story building, sprinkler system installation, and corridor door hardware. Deficiencies had the potential to affect residents, visitors, and staff in multiple smoke compartments.
Deficiencies (7)
K161: The facility failed to ensure the building met construction type requirements for a three-story building. The basement was non-protected noncombustible construction, which is not permitted for this building type.
K351: The facility failed to install the sprinkler system in accordance with NFPA 13. There was no sprinkler coverage in the stairwell leading from the third to the fourth floor.
K363: Doors protecting corridors were not equipped with positive latching hardware and were propped open, failing to resist smoke passage. The gift shop door was found propped open with a deadbolt lock and lacked a positive latching device.
A1087: The facility did not meet fire-resistant rating requirements for structural elements per Life Safety Code edition requirements.
A2035: The facility failed to maintain a complete sprinkler system as required by regulation.
A3001: The building was not substantially constructed and maintained in good repair as required by regulation.
A3027: The facility failed to maintain the building free from portable space heaters. Observations showed multiple space heaters in use in resident and staff areas.
Report Facts
Facility capacity: 55
Resident census: 49
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Mar 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation regarding quality of care issues related to a resident's treatment and care with a continuous passive motion (CPM) machine following knee replacement surgery.
Complaint Details
The complaint investigation focused on a resident who had right knee replacement surgery and required a CPM machine. The investigation found the CPM machine was delivered without a cord, was not used as ordered, and staff failed to transcribe physician orders properly. Interviews with nursing staff and administration confirmed these issues.
Findings
The facility failed to ensure that a resident's physician's orders for a CPM machine were properly transcribed and that the CPM machine was applied and functioning as ordered. The resident's CPM machine arrived without a cord, rendering it unusable, and staff did not document proper use or follow-up timely.
Deficiencies (2)
F684 Quality of care: The facility failed to ensure a resident received treatment and care in accordance with professional standards, including proper transcription of physician orders and functioning of the CPM machine.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the issues noted in F684.
Report Facts
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding CPM machine availability and use |
| Registered Nurse | Registered Nurse | Interviewed regarding CPM machine delivery and use |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding resident's knee replacement and CPM machine use |
| Director of Nurses | Director of Nurses | Interviewed regarding CPM machine delivery and rental company contact |
| Administrator | Administrator | Interviewed regarding expectations for special equipment delivery and notification |
| Resident's Physician | Physician | Interviewed regarding expectations for CPM machine availability and use |
| Surgeon | Surgeon | Interviewed regarding expectations for CPM machine delivery and use |
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