Inspection Reports for
Alpine Breeze Health and Wellness
6124 RAYTOWN RD, RAYTOWN, MO, 64133-4007
Back to Facility Profile19 Reports
Inspection Report — Jan 30, 2025
Complaint Investigation
Date: Jan 30, 2025
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation for MO00248678.
Complaint Details
Complaint MO00248678; at the time of the complaint investigation the violation was determined to be at an imminent danger Class I level; the imminent danger was removed at exit.
Findings
Two deficiencies: one federal health citation for administration failures that resulted in the facility's running water being shut off and an Immediate Jeopardy determination, and one Missouri licensure citation referencing the same issue.
Deficiencies (1)
19 CSR 30-85.042(16) No Adverse Effect-Res Health/Safety/Property: Refer to F835.
Report Facts
outstanding balance (USD): 14000.81
Inspection Report — Oct 9, 2024
Complaint Investigation
Date: Oct 9, 2024
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Federal CMS-2567 health survey (F-tags) and Missouri Department of Health and Senior Services State Form licensure survey (A-tags) are included; a complaint number is cited indicating a complaint investigation.
Findings
Six deficiencies were cited: two federal deficiencies involving transfer/discharge notice requirements and permitting a resident to return after hospitalization, and four Missouri state licensure citations addressing 30-day notice for transfer/discharge, reasons to transfer/discharge, discharge appeal rights, and emergency discharges.
Deficiencies (4)
19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: See the deficiency cited at F626.
19 CSR 30-88.010(16) Reasons to Transfer/Discharge: See the deficiency cited at F623.
19 CSR 30-88.010(17) Discharge Appeal Rights: See the deficiency cited at F626.
19 CSR 30-88.010(18) Emergency Discharges: See the deficiency cited at F623.
Report Facts
sampled residents: 1
sampled residents (denominator): 5
Inspection Report — Jul 6, 2023
Complaint Investigation
Date: Jul 6, 2023
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation citing MO00219992.
Complaint Details
MO00219992; substantiation not stated.
Findings
Two deficiencies were cited: a federal health citation for failure to provide required notice before transfer/discharge, and a Missouri licensure citation for emergency discharges referencing the federal finding.
Deficiencies (1)
19 CSR 30-88.010(18) Emergency Discharges: See the deficiency cited at F623.
Report Facts
residents affected: 1
residents sampled: 4
Inspection Report — Jun 12, 2023
Complaint Investigation
Date: Jun 12, 2023
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation numbers MO00219685 and MO00218576 are cited in the file.
Complaint Details
Complaint investigation numbers MO00219685 and MO00218576 are cited; the file does not state whether the complaints were substantiated.
Findings
There are 3 federal health deficiencies regarding dementia care/behavioral monitoring, lack of signage/other environmental issues, and missing corridor handrails; and 5 Missouri state licensure deficiencies addressing handrails, construction/maintenance, operational policies/procedures, nursing care per resident condition, and clinical record assessment/interventions.
Deficiencies (5)
19 CSR 30-85.012(67) Handrails: Refer to F924. MO 00218576.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to F924. MO 00218576.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to F921. MO 00218576.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F744. MO 00219685.
19 CSR 30-85.042(98)(B) Clinical Records - assessment/interventions: Refer to F744. MO 00219685.
Report Facts
residents potentially affected (signage/access): 39
residents potentially affected (handrails): 77
sampled resident with inadequate monitoring: 1
Inspection Report — Jun 12, 2023
Life Safety
Date: Jun 12, 2023
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CMS-2567 Life Safety survey (K-tag) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Two deficiencies were cited: one federal life-safety deficiency for exit signage and one Missouri state deficiency regarding exit sign placement and letter size.
Deficiencies (1)
19 CSR 30-85.022(23) Exit Sign Placement/Letter Size: Refer to K293.
Report Facts
residents potentially affected: 39
smoke zones in affected section: 3
total smoke zones: 16
Inspection Report — Apr 20, 2023
Complaint Investigation
Date: Apr 20, 2023
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO00217150) was conducted.
Complaint Details
MO00217150; at the time of the complaint investigation the violation was determined to be at an imminent danger Class I level.
Findings
Two deficiencies were cited: one federal health deficiency and one Missouri state licensure deficiency. Both concern administrative failures to pay vendors that resulted in utility shutoff (loss of running water) and unpaid service balances affecting fire alarm service.
Deficiencies (1)
19 CSR 30-85.042(16) No Adverse Effect-Res Health/Safety/Property: Refer to F835.
Report Facts
outstanding balance (Vendor D): 2558
payment to Vendor A: 8697.47
outstanding amount owed (Vendor A): 5251.6
total owed (including April): 18376.78
open invoices total: 5116
Inspection Report — May 26, 2022
Complaint Investigation
Date: May 26, 2022
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Federal health survey (CMS-2567) and Missouri State Form licensure pages; complaint investigation cited (MO00200992).
Complaint Details
Complaint MO00200992 is cited in the survey; the record includes a root cause analysis for Resident #73 that determined the injury was not from abuse.
Findings
The file contains 14 federal health deficiencies and 22 Missouri state licensure deficiencies. Main topics include residents' rights/advance directives, sanitation/housekeeping and pest control, required reporting/investigation of alleged violations, assessments and care planning, catheter/continence care and UTI prevention, nutrition and weight loss interventions, dialysis care coordination, food service safety and temperatures, staff in-service training, and building/maintenance issues.
Deficiencies (22)
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to F921.
19 CSR 30-85.032(38) Furniture/Equip, Provide Comfort & Safety: Refer to F921.
19 CSR 30-85.032(39) Rooms Neat, Orderly, Cleaned Daily: Refer to F584.
19 CSR 30-85.042(22) In-service Training-Nursing Personnel: Refer to F730.
19 CSR 30-85.042(66) Nursing Care per Resident Condition: Refer to F690, F692, F698.
19 CSR 30-85.042(71) Mealtime Assistance/Supervision: Refer to F692.
19 CSR 30-85.052(5) Hot Food Hot, Cold Food Cold: Refer to F804.
19 CSR 30-87.020(12) Floor Surfaces: Refer to F584 and F812.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Refer to F812.
19 CSR 30-87.020(32) Outside Dumpsters Cleanable/Covered: Refer to F814.
19 CSR 30-87.020(45) Lavatory/Fixtures Clean/Good Repair: Refer to F921.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Refer to F812.
19 CSR 30-87.030(26) Hazardous Food Cooking Temperatures: Refer to F812.
19 CSR 30-87.030(28) Whole/Pasteurized Eggs Used Only: Refer to F812.
19 CSR 30-87.030(34) Food - 120 Degrees/Above, 45 Degrees/Below: Refer to F804.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Refer to F812.
19 CSR 30-87.030(85) Protect Equipment/Utensils From Contamination: Refer to F812.
19 CSR 30-87.030(93) Light Intensity in Food Prep & Work Areas: Refer to F812.
19 CSR 30-88.010(10) Advance Directive Requirements: Refer to F578.
19 CSR 30-88.010(13) Right to Plan Care/Refuse Treatment: Refer to F657.
19 CSR 30-88.010(23) Develop/Implement A/N Policies (abuse/neglect reporting): Refer to F610.
19 CSR 30-88.010(25) Report Allegations to DHSS/DMH When Needed: Refer to F609.
Report Facts
sampled residents: 24
residents potentially affected by housekeeping/pest issues: 40
residents potentially affected by kitchen food safety issues: 111
Inspection Report — May 26, 2022
Life Safety
Date: May 26, 2022
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Federal CMS-2567 Life Safety / Emergency Preparedness survey (CMS-2567) and Missouri Department of Health and Senior Services State Form licensure inspection; the survey type is a Life Safety/Emergency Preparedness inspection (no separate complaint or revisit stated).
Findings
28 deficiencies were cited: 15 federal Life Safety / Emergency Preparedness deficiencies addressing emergency preparedness planning, subsistence and communications, fire-resistance construction, exits and egress, hazardous areas, cooking/hood/grease protection, alarm and sprinkler systems, fire watches/drills, corridors/doors, smoke barriers, and electrical equipment; and 13 Missouri state licensure deficiencies that refer to and mirror the federal Life Safety findings.
Deficiencies (13)
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K300.
19 CSR 30-85.022(2)(H) Electrical Appliances UL/FM Good Repair: Refer to K919.
19 CSR 30-85.022(4) Hazardous Areas: Refer to K321.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(10)(G) Fire Alarm System-Correct Faults: Refer to K341.
19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr: Refer to K354.
19 CSR 30-85.022(12) Exit Requirements: Refer to K271.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.022(33)(F) Fire Drill Records: Refer to K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161, K324, K362, K363.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K919.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E007, E015, E020.
19 CSR 30-85.042(15) Personnel Informed of Policies/Duties: Refer to E007, E015, E020.
Report Facts
total smoke zones: 16
residents potentially affected: 62
Inspection Report — Mar 9, 2022
Complaint Investigation
Date: Mar 9, 2022
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the file cites a complaint investigation (MO 00197796).
Complaint Details
Complaint number MO 00197796 is cited; substantiation not stated.
Findings
The file contains one federal health citation for environmental/maintenance deficiencies and three Missouri state licensure citations regarding construction/maintenance, floor surfaces, and walls/ceilings. The survey documents water damage, peeling cove base, separated sheetrock/thresholds, missing ceiling tiles and damaged ceiling areas affecting residents and facility areas.
Deficiencies (3)
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Class II*: 1. Refer to F921.
19 CSR 30-87.020(12) Floor Surfaces: Class III 1. Refer to F921.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Class III 1. Refer to F921.
Report Facts
residents sampled: 8
residents affected: 27
Inspection Report — Mar 9, 2022
Life Safety
Date: Mar 9, 2022
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CMS-2567 life safety survey (K-tag) and accompanying Missouri Department of Health and Senior Services State Form; the survey documents life safety deficiencies.
Findings
Four deficiencies were cited: two federal life safety deficiencies involving exit discharge and door maintenance/inspection, and two Missouri state licensure deficiencies referencing exit requirements and facility construction/maintenance.
Deficiencies (2)
19 CSR 30-85.022(12) Exit Requirements: Refer to K271.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K271 and K761.
Report Facts
residents affected by gate issue: 16
residents affected by door inspection deficiency: 40
exit doors not inspected annually: 2
Inspection Report — Oct 8, 2021
Routine
Date: Oct 8, 2021
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CMS-2567 federal health survey and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal deficiency for inadequate supervision/protective oversight related to a resident elopement, and one Missouri licensure deficiency referencing protective oversight/voluntary leave.
Deficiencies (1)
19 CSR 30-85.042(6) Protective Oversight, Voluntary Leave: Refer to F689.
Inspection Report — Sep 29, 2021
Complaint Investigation
Date: Sep 29, 2021
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Federal CMS-2567 health survey and Missouri State Form licensure survey; complaint investigation (M000189728) is cited in the file.
Complaint Details
M000189728; the document cites this complaint/investigation number but does not state whether the allegation was formally substantiated.
Findings
The file includes 3 federal deficiencies concerning failure to report and investigate an alleged sexual incident and insufficient behavioral/mental health services, and 4 Missouri state licensure deficiencies referencing those same areas (protective oversight, nursing care per condition, policies, and reporting).
Deficiencies (4)
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Refer to F610. Refer to F742.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F610. Refer to F742.
19 CSR 30-88.010(23) Develop/Implement A/N Polices: Refer to F609, F610, F742.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Refer to F609. Refer to F610. Refer to F742.
Report Facts
residents sampled: 21
Inspection Report — Mar 17, 2021
Routine
Date: Mar 17, 2021
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The file contains 1 federal health deficiency and 3 Missouri state licensure deficiencies. The federal finding concerns failure to repair the boiler and piping resulting in lack of hot water and laundry issues; the state deficiencies relate to building maintenance, hot water temperatures/availability, and infection control and refer to the federal finding.
Deficiencies (3)
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to F921.
19 CSR 30-85.032(24) Hot Water 105-120 Degrees F: Refer to F921.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F921.
Report Facts
residents affected: 37
Inspection Report — Oct 25, 2019
Life Safety
Date: Oct 25, 2019
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CMS-2567 Life Safety (K-tag) form and Missouri Department of Health and Senior Services State Form (A-tag) for a Life Safety Code survey.
Findings
Thirteen federal life safety deficiencies were cited involving building construction and fire resistance, egress/exit discharge, door locking, sprinkler and alarm systems, cooking/hood grease control, portable heaters, and electrical equipment. Twelve Missouri State Form deficiencies were cited referencing inspection rights, fire hazard, electrical appliances, hazardous areas, range hood certification, fire alarm and sprinkler testing, exit requirements, door locks, smoke sections, construction/maintenance, and electrical wiring.
Deficiencies (12)
19 CSR 30-85.022(2)(C) Inspection Rights: Refer to K100.
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K300 and K781.
19 CSR 30-85.022(2)(H) Electrical Appliances UL/FM Good Repair: Refer to K919.
19 CSR 30-85.022(4) Hazardous Areas: Refer to K362.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Refer to K341.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(12) Exit Requirements: Refer to K271.
19 CSR 30-85.022(16) Door Locks: Refer to K222.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161, K362, K363, and K372.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K919.
Report Facts
residents_affected: 70
residents_affected: 78
residents_affected: 19
residents_affected: 13
residents_affected: 60
residents_affected: 15
smoke_zones_affected: 2
Inspection Report — Oct 25, 2019
Routine
Date: Oct 25, 2019
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Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
There are 9 federal CMS deficiencies addressing resident funds/third-party liability paperwork, activities programming, accident hazards/transfer practices, nutrition/weight loss and documentation, food service temperatures and safety, sanitary conditions in food preparation and storage, infection prevention and catheter care, and multiple environmental maintenance issues; plus multiple Missouri State Form citations referencing those same areas (construction/maintenance, resident care, infection control, food safety, environment, and record/financial requirements).
Deficiencies (15)
19 CSR 30-65.032(2) Substantially Constructed/Maintained: Substantially Constructed/Maintained: This regulation is not met as evidenced by: 1. Refer to F921.
19 CSR 30-65.042(88) Protective Oversight, Voluntary Leave: Protective Oversight/Voluntary Leave: This regulation is not met as evidenced by: 1. Refer to F569.
19 CSR 30-85.042(97) Nursing Care per Res Condition: Nursing Care per Resident Condition: This regulation is not met as evidenced by: 1. Refer to F692.
19 CSR 30-85.052(1) Nutritional Needs Met, Assess Res, Inform Dr: Nutritional Needs Met/Assess/Inform: This regulation is not met as evidenced by: 1. Refer to F692.
19 CSR 30-85.052(5) Hot Food Hot, Cold Food Cold: Hot/Cold Food Service: This regulation is not met as evidenced by: 1. Refer to F804.
19 CSR 30-87.020(12) Floor Surfaces: Floor Surfaces: This regulation is not met as evidenced by: 1. Refer to F812; 2. Refer to F921.
19 CSR 30-87.020(40) Outside Openings Protected Against Rodents: Outside Openings/Protected Against Rodents: This regulation is not met as evidenced by: 1. Refer to F921.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Clean Clothing and Hair Restraints: This regulation is not met as evidenced by: 1. Refer to F812.
19 CSR 30-87.030(17) Food Stored in Identifying Containers: Food Stored in Identifying Containers: This regulation is not met as evidenced by: 1. Refer to F813.
19 CSR 30-87.030(44) Equipment, Utensils & Single-Service Articles: Equipment/Utensils/Single-Service Articles: This regulation is not met as evidenced by: 1. Refer to F812.
19 CSR 30-87.030(54) Nonfood Contact Surfaces, Cleaning: Nonfood Contact Surfaces/Cleaning: This regulation is not met as evidenced by: 1. Refer to F812.
19 CSR 30-88.020(11)(A) Deceased Res, Account of Funds to DSS: Deceased Resident/Account of Funds to DSS: Upon the death of a resident the operator shall notify and provide required documentation to the Department of Social Services; This regulation is not met as evidenced by: 1. Refer to F569.
19 CSR 30-88.020(11)(B) Deceased Resident Fund Use Requirements: Deceased Resident Fund Use Requirements: This regulation is not met as evidenced by: 1. Refer to F569.
19 CSR 30-88.020(11)(C) DSS To Determine Aid/Notify Operator: DSS Determination/Notify Operator: This regulation is not met as evidenced by: 1. Refer to F569.
19 CSR 30-88.020(11)(D) Payment on Behalf of Deceased Resident within 60 days: Payment on Behalf of Deceased Resident within 60 days: This regulation is not met as evidenced by: 1. Refer to F569.
Inspection Report — Dec 7, 2018
Routine
Date: Dec 7, 2018
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
24 deficiencies were cited: 11 federal deficiencies (topics included resident mail delivery, transfer/discharge notices, bed-hold notices, pain management documentation, ADL assistance, pressure ulcer treatment, dialysis care, dental services, food temperature and sanitary food handling, and infection control) and 13 Missouri state licensure citations that refer to the federal findings.
Deficiencies (13)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F658. Refer to F677. Refer to F698.
19 CSR 30-85.042(75) Pressure Sore Prevention/Treatment: Refer to F686.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-85.042(92) Social Service Program: Refer to F791.
19 CSR 30-85.052(5) Hot Food Hot, Cold Food Cold: Refer to F800.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: Refer to F812.
19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below: Refer to F800.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Refer to F812.
19 CSR 30-87.030(63) Food-Contact Surfaces Washed/Rinsed/Sanitized: Refer to F812.
19 CSR 30-87.030(86) Store Equip/Utensils to Prevent Contamination: Refer to F812.
19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure: Refer to F625.
19 CSR 30-88.010(18) Emergency Discharges: Refer to F623.
19 CSR 30-88.010(34) Mail: Refer to F576.
Report Facts
sampled residents (total): 22
sampled residents affected: 6
Inspection Report — Dec 7, 2018
Life Safety
Date: Dec 7, 2018
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Federal CMS-2567 Life Safety (K) and Emergency Preparedness (E) forms and Missouri Department of Health and Senior Services State Form are included; the survey type is not stated.
Findings
There are 1 Emergency Preparedness (E) deficiency, 9 Life Safety (K) deficiencies, and 10 Missouri state deficiencies. Findings address a lack of complete emergency preparedness planning (temperature monitoring and EP training), and multiple life-safety issues including smoke barrier penetrations/building construction, emergency lighting failures, unprotected cooking equipment, incomplete fire alarm notification coverage, sprinkler impairment/fire watch policy deficiencies, unsafe smoking area/ashtray practices, missing/untested smoke/door inspections, and electrical/power cord hazards.
Deficiencies (10)
19 CSR 30-85.012(128) Emergency Lights, Generator for Life Support: Refer to K291.
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K324.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: Refer to K343.
19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr: Refer to K354.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K761.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Refer to K741.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K919.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Refer to K920.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E0001.
Report Facts
areas with smoke barrier failures: 7
total facility smoke zones: 16
Inspection Report — Feb 22, 2018
Routine
Date: Feb 22, 2018
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Federal health survey (CMS-2567) with accompanying Missouri state licensure Statement of Deficiencies (State Form); the survey type is not stated in the documents.
Findings
There are 15 federal health deficiencies primarily involving resident care domains (nutrition/food service, medication management, infection control, pressure ulcers, falls, discharge summaries, enteral feeding and communication) and 19 Missouri state licensure deficiencies that reference and cross‑refer to the federal findings (medication errors/storage, nursing care, infection control, food service and sanitation).
Deficiencies (18)
19 CSR 30-85.042(62) Medication Errors/Adverse Reactions Reported: Refer to F760.
19 CSR 30-85.042(65) Medication Storage: Refer to F761.
19 CSR 30-85.042(86) Protective Oversight, Voluntary Leave: Refer to F689.
19 CSR 30-85.042(67) Nursing Care per Resident Condition: Refer to F558; Refer to F676; Refer to F693.
19 CSR 30-85.042(75) Pressure Sore Prevention/Treatment: Refer to F686.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-85.042(99)(C) Clinical Records - discharge/transfer: Refer to F661.
19 CSR 30-85.052(3) Foods-Nutritive Value/Flavor/Appearance: Refer to F800; Refer to F804; (state form notes higher classification when combined with other deficiencies).
19 CSR 30-85.052(4) Food Texture-Chewing Difficulty: Refer to F804.
19 CSR 30-85.052(5) Hot Food/Hot, Cold Food Cold: Refer to F804.
19 CSR 30-85.052(21) Menus/Plan/Post/Keep, List Substitutes: Refer to F803 and F802-related findings.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources: Refer to F803.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812 and related food safety findings.
19 CSR 30-87.030(10) Refrigerator Temperatures/Thermometers: Refer to F812.
19 CSR 30-87.030(26) Hazardous Food Cooking Temperatures: Refer to F812.
19 CSR 30-87.030(30) Steam Tables/Warmers Not for Rapid Reheating: Refer to F803/F812 food service findings.
19 CSR 30-87.030(34) Food-120 Degrees/Above/45 Degrees/Below: Refer to F800/F804/F812 food temperature/holding findings.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Refer to F812.
Report Facts
Inspection Report — Feb 22, 2018
Life Safety
Date: Feb 22, 2018
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Federal CMS-2567 health and life safety surveys and Missouri state licensure survey; the survey type is not stated.
Findings
25 deficiencies were cited: 3 federal emergency preparedness (E) deficiencies concerning subsistence needs/sewage disposal, waiver roles, and emergency preparedness testing/exercises; 11 life safety (K) deficiencies involving fire-resistance/ceiling penetrations, exit discharge obstructions, emergency lighting, cooking hood/flue and sprinkler maintenance, smoke barriers, smoking/ashtray disposal, and electrical systems/testing/extension cord use; and 11 Missouri state (19 CSR) deficiencies referencing noncombustible materials, range hood certification, sprinkler testing/maintenance, exit requirements, emergency lighting, smoke section walls/doors, ashtray disposal, general construction/maintenance, electrical wiring/equipment, extension cords, and policies/procedures.
Deficiencies (11)
19 CSR 30-85.022(3) Noncombustible Material Between Floors: Refer to K161.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(12) Exit Requirements: Refer to K271.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Refer to K741.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161 and K372.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K914, K918, and K921.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Refer to K920.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E015, E026, and E039.
Report Facts
employees potentially affected: 15
total smoke zones: 16
29 CMS Surveys
Inspection Report — Apr 23, 2025
Complaint Investigation
Date: Apr 23, 2025
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Federal health survey (CMS-2567); complaint investigation (MO00252926).
Complaint Details
MO00252926; substantiation not stated.
Findings
One federal health deficiency for failure to ensure residents were free from abuse/neglect; the survey documents a resident-to-resident incident in which a rock was thrown causing a head laceration and a hospital visit, and notes past noncompliance.
Deficiencies (1)
F 600 Free from Abuse and Neglect: Based on observation, interview and record review, Resident #1 struck Resident #2 on the head with a rock on 4/17/25 resulting in an approximately 3 cm laceration and a hospital visit; the facility failed to ensure the sampled resident was free from physical abuse. The facility noted past noncompliance and corrected the immediate issue.
Report Facts
residents sampled: 8
Inspection Report — Jan 30, 2025
Complaint Investigation
Date: Jan 30, 2025
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation for MO00248678.
Complaint Details
Complaint MO00248678; at the time of the complaint investigation the violation was determined to be at an imminent danger Class I level; the imminent danger was removed at exit.
Findings
Two deficiencies: one federal health citation for administration failures that resulted in the facility's running water being shut off and an Immediate Jeopardy determination, and one Missouri licensure citation referencing the same issue.
Deficiencies (1)
F835 Administration: The facility failed to ensure payments were issued/processed which resulted in Vendor A shutting off the facility's running water for non-payment, affecting all residents and prompting an Immediate Jeopardy determination. The IJ was removed during the survey.
Report Facts
outstanding balance (USD): 14000.81
Inspection Report — Jan 24, 2025
Complaint Investigation
Date: Jan 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of funds from a resident's bank account by a Certified Nurses Aide (CNA A).
Complaint Details
The complaint was substantiated involving financial exploitation of Resident #1 by CNA A who made unauthorized withdrawals totaling $617.89 from the resident's bank account using Cash App. The resident was cognitively intact and reported the incident. The facility notified the Administrator, Director of Nursing, family, physician, local police, and CMS. CNA A was terminated and denied knowledge of the debit card. Police investigation was ongoing.
Findings
The facility failed to prevent the financial exploitation of one resident by a former CNA who used the resident's bank card for unauthorized transactions totaling $617.89. The facility replaced the missing funds and educated staff on abuse and exploitation protocols. The incident was reported to law enforcement and investigated.
Deficiencies (1)
Failed to prevent misappropriation of resident's funds by a staff member using Cash App for unauthorized withdrawals.
Report Facts
Unauthorized withdrawals: 617.89
Accounted for amount: 244
Total unauthorized purchases: 861.89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurses Aide | Named in financial exploitation finding involving unauthorized use of resident's bank card |
| Administrator | Notified of the incident, involved in investigation and replacement of missing funds | |
| Police Officer A | Dispatched to facility for larceny investigation related to resident's financial exploitation | |
| Police Officer B | Follow-up investigation of CNA A's prior similar case and contacted Administrator | |
| Family Member A | Reviewed charges with resident and assisted in closing resident's bank card |
Inspection Report — Oct 9, 2024
Complaint Investigation
Date: Oct 9, 2024
Visit Reason
Federal CMS-2567 health survey (F-tags) and Missouri Department of Health and Senior Services State Form licensure survey (A-tags) are included; a complaint number is cited indicating a complaint investigation.
Findings
Six deficiencies were cited: two federal deficiencies involving transfer/discharge notice requirements and permitting a resident to return after hospitalization, and four Missouri state licensure citations addressing 30-day notice for transfer/discharge, reasons to transfer/discharge, discharge appeal rights, and emergency discharges.
Deficiencies (2)
F623 Notice Requirements Before Transfer/Discharge: Based on interview and record review, the facility failed to provide a discharge notice for one sampled resident (Resident #1) that included required appeal information and required location information.
F626 Permitting Residents to Return to Facility: Based on interview and record review, the facility failed to permit one sampled resident (Resident #1) to return to the facility after hospitalization (out of five sampled residents).
Report Facts
sampled residents: 1
sampled residents (denominator): 5
Inspection Report — Oct 17, 2023
Routine
Date: Oct 17, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations including resident care, safety, infection control, nutrition, and facility maintenance.
Findings
The facility had multiple deficiencies including failure to ensure resident privacy and dignity during care, inadequate call light accessibility, untimely submission of third party liability forms, poor environmental cleanliness, failure to follow wound care orders and documentation, improper use and monitoring of pressure relief mattresses, unsafe resident transfers, inadequate infection control handwashing practices, failure to monitor dialysis sites, improper food temperature maintenance, poor dietary supplement documentation, incomplete hospice documentation, delayed invoice payments, and inadequate pest control measures.
Deficiencies (18)
Failed to ensure privacy and dignity for a resident during incontinence care.
Failed to ensure call light was appropriate, within reach, and properly care planned for residents.
Failed to submit Third Party Liability form within 30 days after resident death.
Failed to maintain cleanliness and repair environmental issues including grime, mouse droppings, damaged flooring and mattresses, and peeling paint.
Failed to ensure adequate grooming by not removing facial hair for a resident.
Failed to follow physician's orders for wound treatments, assess wounds weekly, document wound care, and transcribe physician's orders when wound treatments changed.
Failed to obtain physician's orders for use and monitoring of low air loss mattress and failed to monitor mattress settings according to resident's weight.
Failed to ensure safe smoking practices and supervision for a resident with seizures and non-compliance with smoking rules.
Failed to ensure safe transfer practices including use of gait belts and proper transfer techniques.
Failed to ensure infection control practices including handwashing during incontinence care to prevent cross contamination.
Failed to ensure catheter drainage bag was kept below bladder level during transfer and care to prevent infection.
Failed to maintain food temperatures at safe levels during meal service and failed to prepare pureed garlic bread according to recipe.
Failed to properly dispose of garbage and maintain trash areas clean and covered.
Failed to ensure required negative backflow ventilation in multiple resident and non-resident areas.
Failed to pay invoices timely for pest control, water, construction, laboratory testing, medical waste disposal, and laundry repair companies.
Failed to ensure hospice nursing visit notes and routine visit documentation were obtained and maintained.
Failed to develop a quality assurance program to ensure Registered Dietitian interventions and documentation of supplement consumption were included in medical records for residents with weight loss.
Failed to ensure pest control program prevented and addressed mice and insect infestations including dead flies and bird entry points.
Report Facts
Weight loss percentage: 12.61
Weight loss percentage: 16.4
Temperature: 89
Temperature: 112
Temperature: 50.1
Outstanding invoice amount: 2701.53
Outstanding invoice amount: 4835.63
Outstanding invoice amount: 6840
Outstanding invoice amount: 1299.35
Outstanding invoice amount: 1728.13
Outstanding invoice amount: 775.62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in handwashing and incontinence care deficiency |
| CNA D | Certified Nursing Assistant | Named in handwashing and incontinence care deficiency |
| CNA E | Certified Nursing Assistant | Named in handwashing and incontinence care deficiency |
| LPN C | Licensed Practical Nurse | Named in wound care and dialysis monitoring deficiency |
| DON | Director of Nursing | Named in multiple deficiencies including wound care, dialysis, hospice, infection control |
| DM | Dietary Manager | Named in food temperature and food preparation deficiencies |
| CMT A | Certified Medication Technician | Named in dietary supplement documentation deficiency |
| RN A | Registered Nurse | Named in wound care, dialysis, hospice, and dietary deficiencies |
Inspection Report — Jul 6, 2023
Complaint Investigation
Date: Jul 6, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; complaint investigation citing MO00219992.
Complaint Details
MO00219992; substantiation not stated.
Findings
Two deficiencies were cited: a federal health citation for failure to provide required notice before transfer/discharge, and a Missouri licensure citation for emergency discharges referencing the federal finding.
Deficiencies (1)
F 623 Notice Requirements Before Transfer/Discharge: The facility failed to provide proper notice for an immediate discharge for one sampled resident who was discharged to the hospital.
Report Facts
residents affected: 1
residents sampled: 4
Inspection Report — Jun 12, 2023
Complaint Investigation
Date: Jun 12, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation numbers MO00219685 and MO00218576 are cited in the file.
Complaint Details
Complaint investigation numbers MO00219685 and MO00218576 are cited; the file does not state whether the complaints were substantiated.
Findings
There are 3 federal health deficiencies regarding dementia care/behavioral monitoring, lack of signage/other environmental issues, and missing corridor handrails; and 5 Missouri state licensure deficiencies addressing handrails, construction/maintenance, operational policies/procedures, nursing care per resident condition, and clinical record assessment/interventions.
Deficiencies (3)
F744 Treatment/Service for Dementia: The facility failed to provide increased behavioral monitoring and updated documentation/interventions for a resident with dementia, which was associated with a resident-to-resident altercation.
F921 Safe/Functional/Sanitary/Comfortable Environ: The facility failed to place signage restricting access to the 400 hall during renovation, potentially affecting residents on that side of the facility.
F924 Corridors have Firmly Secured Handrails: The facility failed to ensure handrails were installed on both sides of multiple resident-occupied halls, potentially affecting residents who resided on those halls.
Report Facts
residents potentially affected (signage/access): 39
residents potentially affected (handrails): 77
sampled resident with inadequate monitoring: 1
Inspection Report — Jun 12, 2023
Life Safety
Date: Jun 12, 2023
Visit Reason
CMS-2567 Life Safety survey (K-tag) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Two deficiencies were cited: one federal life-safety deficiency for exit signage and one Missouri state deficiency regarding exit sign placement and letter size.
Deficiencies (1)
K293 Exit Signage: Observations, interviews and record review found the facility failed to place a "NO EXIT" sign on the doors to the 400 Hall, a hallway under renovation that did not provide a clear path for exit purposes. This practice potentially affected 39 residents who resided in or used three smoke zones in that section.
Report Facts
residents potentially affected: 39
smoke zones in affected section: 3
total smoke zones: 16
Inspection Report — Apr 20, 2023
Complaint Investigation
Date: Apr 20, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO00217150) was conducted.
Complaint Details
MO00217150; at the time of the complaint investigation the violation was determined to be at an imminent danger Class I level.
Findings
Two deficiencies were cited: one federal health deficiency and one Missouri state licensure deficiency. Both concern administrative failures to pay vendors that resulted in utility shutoff (loss of running water) and unpaid service balances affecting fire alarm service.
Deficiencies (1)
F835 Administration: Based on observation, interview, and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, resulting in the facility's running water being shut off for non-payment and outstanding vendor balances which impacted services.
Report Facts
outstanding balance (Vendor D): 2558
payment to Vendor A: 8697.47
outstanding amount owed (Vendor A): 5251.6
total owed (including April): 18376.78
open invoices total: 5116
Inspection Report — Nov 15, 2022
Routine
Date: Nov 15, 2022
Visit Reason
Federal health (CMS-2567) surveys; the survey type is not stated.
Findings
2 federal health deficiencies for Administration related to untimely payment of utility bills, resulting in outstanding vendor balances and utility disconnect/shutoff notices; one deficiency remained uncorrected on a subsequent CMS-2567.
Deficiencies (1)
F 835 Administration: Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner to the facility's electric, gas, and water companies, with multiple vendor balances and disconnect notices documented.
Report Facts
residents affected: 0
Inspection Report — May 26, 2022
Complaint Investigation
Date: May 26, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form licensure pages; complaint investigation cited (MO00200992).
Complaint Details
Complaint MO00200992 is cited in the survey; the record includes a root cause analysis for Resident #73 that determined the injury was not from abuse.
Findings
The file contains 14 federal health deficiencies and 22 Missouri state licensure deficiencies. Main topics include residents' rights/advance directives, sanitation/housekeeping and pest control, required reporting/investigation of alleged violations, assessments and care planning, catheter/continence care and UTI prevention, nutrition and weight loss interventions, dialysis care coordination, food service safety and temperatures, staff in-service training, and building/maintenance issues.
Deficiencies (14)
F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives: The facility failed to offer or document formulation of advance directives for three sampled residents (#3, #35, and #93) out of 24 sampled residents.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a clean, safe environment, evidenced by mouse droppings in multiple resident rooms, pungent urine odors in resident rooms, heavy dust on wall-mounted fans and ceiling fan blades, and pillows in disrepair; this practice potentially affected at least 40 residents.
F609 Reporting of Alleged Violations: The facility failed to notify the State Agency in a timely manner of an injury of unknown origin involving a sampled resident (#73) as required.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate an injury of unknown origin for one sampled resident (#73) and did not complete a full investigation or document staff interviews to determine whether abuse occurred.
F636 Comprehensive Assessments & Timing: The facility failed to accurately complete comprehensive assessments (MDS) for sampled residents (#48 and #37), resulting in incorrect coding and omission of needed PASRR/assessment elements.
F657 Care Plan Timing and Revision: The facility failed to hold care plan conferences and revise person-centered care plans on a quarterly basis for sampled residents (#3, #48, and #5) and did not document required care plan meeting content.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure a resident with an indwelling urinary catheter (Resident #93) received appropriate treatment and monitoring to prevent urinary tract infections and lacked a policy regarding catheter placement during transfers.
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure correct diets and mealtime assistance for residents, contributing to significant weight loss and inadequate meal assistance for sampled residents (#5, #84, #35, and #106).
F698 Dialysis: The facility failed to ensure a resident receiving dialysis (Resident #35) had correct physician orders and adequate communication/monitoring of the central venous catheter (CVC) and dialysis care documentation.
F730 Nurse Aide Performance Review-12 hr/yr In-Service: The facility lacked evidence of a system to ensure Certified Nurse Aides received required annual in-service education and performance reviews, and could not locate staff competency documentation.
F804 Nutritive Value/Appearance/Palatable/Preferred Temperature: The facility failed to ensure meals were palatable and delivered at appropriate temperatures; residents reported cold or poor-quality food and observations showed improper meal temperatures and poor meal presentation.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain food safety and sanitary conditions in the kitchen (food debris, grease buildup, unclean vents, missing dates on pulled meat, employees without hair coverings) affecting residents who ate food from the kitchen.
F814 Dispose Garbage and Refuse Properly: The facility failed to ensure outdoor dumpster lids were kept closed, with repeated observations of the dumpster lid open, creating potential pest harborage.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain safe and functional environmental conditions (damaged kitchen threshold, grime and debris under equipment, damaged commode seats, missing blinds and window panes, faucet knob in disrepair), affecting resident areas.
Report Facts
sampled residents: 24
residents potentially affected by housekeeping/pest issues: 40
residents potentially affected by kitchen food safety issues: 111
Inspection Report — May 26, 2022
Life Safety
Date: May 26, 2022
Visit Reason
Federal CMS-2567 Life Safety / Emergency Preparedness survey (CMS-2567) and Missouri Department of Health and Senior Services State Form licensure inspection; the survey type is a Life Safety/Emergency Preparedness inspection (no separate complaint or revisit stated).
Findings
28 deficiencies were cited: 15 federal Life Safety / Emergency Preparedness deficiencies addressing emergency preparedness planning, subsistence and communications, fire-resistance construction, exits and egress, hazardous areas, cooking/hood/grease protection, alarm and sprinkler systems, fire watches/drills, corridors/doors, smoke barriers, and electrical equipment; and 13 Missouri state licensure deficiencies that refer to and mirror the federal Life Safety findings.
Deficiencies (15)
E007 EP Program Patient Population: The facility failed to include in its disaster manual a plan for the automated medication dispensing machine (location, backup battery, duration of backup power, and contingency medication access), a practice that potentially affected all residents.
E015 Subsistence Needs for Staff and Patients: The facility's disaster plan did not include the correct temperature ranges and a method for staff to monitor temperatures in extreme heat and cold sections, a practice that potentially affected all residents.
E020 Policies for Evac. and Primary/Alt. Comm.: The facility failed to include locations, radio radius ranges, and staff training for use of handheld radios in the communication plan, and had not trained staff or located radios at nurse stations, potentially affecting all staff and residents.
K161 Building Construction Type and Height: The facility failed to ensure required fire resistance ratings and maintain fire-resistance-rated construction (attic access panels and compromised ceiling tiles), which affected multiple smoke zones and residents.
K271 Discharge from Exits: The facility failed to ensure the exit discharge at the main entrance and the ramp were free from damaged surfaces, pooling water, and gaps, which potentially impeded egress for residents.
K300 Protection - Other: The facility failed to maintain the lint-free condition of the dryer firebox (heavy lint buildup), creating a combustible hazard in the South Basement smoke zone.
K321 Hazardous Areas - Enclosure: The facility failed to ensure doors to hazardous/boiler/maintenance areas and PTAC storage latched or were self-closing and had missing ceiling tiles and combustible storage in an area, affecting staff and some resident-use areas.
K324 Cooking Facilities: The facility failed to maintain the range hood (penetrations and grease buildup) and the deep fat fryer, creating fire and grease accumulation hazards affecting the kitchen and adjacent dining area.
K341 Fire Alarm System - Installation: The facility had a smoke detector improperly installed/suspended in the elevator machine room, compromising detection in that smoke zone.
K354 Sprinkler System - Out of Service: The facility failed to develop an adequate fire watch plan and checklist for sprinkler impairments and did not document required items in the fire watch plan (attic spaces, intervals), affecting all residents while the system was impaired.
K362 Corridors - Construction of Walls: The facility failed to seal penetrations and openings in corridor and smoke barrier walls (housekeeping office, resident room 601, north side medication room), compromising the smoke barrier and affecting residents in affected smoke zones.
K363 Corridor - Doors: The facility failed to ensure corridor doors (resident rooms 205, 703, 806 and others) latched or resisted passage of smoke and had doors that would not close or were stuck, which could allow smoke passage and affected residents in those areas.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain the smoke barrier (missing drywall, penetrations, uncovered wooden board in attics) between smoke zones, affecting multiple attic and smoke barrier areas and residents.
K712 Fire Drills: The facility failed to maintain documentation of fire drills for the period reviewed (missing or insufficient drill records between specified dates), which potentially affected all residents and staff.
K919 Electrical Equipment - Other: The facility failed to ensure electrical outlets and cords were in safe condition (loose outlet, use of adapters, frayed cords, surge protectors, piggybacking), affecting residents in several smoke zones.
Report Facts
total smoke zones: 16
residents potentially affected: 62
Inspection Report — Mar 9, 2022
Complaint Investigation
Date: Mar 9, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the file cites a complaint investigation (MO 00197796).
Complaint Details
Complaint number MO 00197796 is cited; substantiation not stated.
Findings
The file contains one federal health citation for environmental/maintenance deficiencies and three Missouri state licensure citations regarding construction/maintenance, floor surfaces, and walls/ceilings. The survey documents water damage, peeling cove base, separated sheetrock/thresholds, missing ceiling tiles and damaged ceiling areas affecting residents and facility areas.
Deficiencies (1)
F 921 Safe/Functional/Sanitary/Comfortable Environ: Based on observation, interview and record review, the facility failed to maintain cove base, thresholds, ceiling/sheetrock and related floor/ceiling surfaces in multiple resident rooms and activity/storage areas, resulting in peeling, separation, missing tiles and damaged areas. The conditions affected residents' mobility at thresholds and involved water-damaged ceiling and storage areas.
Report Facts
residents sampled: 8
residents affected: 27
Inspection Report — Mar 9, 2022
Life Safety
Date: Mar 9, 2022
Visit Reason
CMS-2567 life safety survey (K-tag) and accompanying Missouri Department of Health and Senior Services State Form; the survey documents life safety deficiencies.
Findings
Four deficiencies were cited: two federal life safety deficiencies involving exit discharge and door maintenance/inspection, and two Missouri state licensure deficiencies referencing exit requirements and facility construction/maintenance.
Deficiencies (2)
K271 Discharge from Exits: The surveyor found the exit gate at the walkway from the 800 Hall was not maintained and became stuck, preventing easy egress and potentially affecting residents.
K761 Maintenance, Inspection & Testing - Doors: The surveyor found the facility failed to ensure exit discharge doors were inspected and maintained (including corrosion and difficulty opening), affecting egress for residents.
Report Facts
residents affected by gate issue: 16
residents affected by door inspection deficiency: 40
exit doors not inspected annually: 2
Inspection Report — Oct 8, 2021
Routine
Date: Oct 8, 2021
Visit Reason
CMS-2567 federal health survey and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal deficiency for inadequate supervision/protective oversight related to a resident elopement, and one Missouri licensure deficiency referencing protective oversight/voluntary leave.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide protective oversight for a resident who exited the secured unit and left the facility, as evidenced by record review and staff interviews.
Inspection Report — Sep 29, 2021
Complaint Investigation
Date: Sep 29, 2021
Visit Reason
Federal CMS-2567 health survey and Missouri State Form licensure survey; complaint investigation (M000189728) is cited in the file.
Complaint Details
M000189728; the document cites this complaint/investigation number but does not state whether the allegation was formally substantiated.
Findings
The file includes 3 federal deficiencies concerning failure to report and investigate an alleged sexual incident and insufficient behavioral/mental health services, and 4 Missouri state licensure deficiencies referencing those same areas (protective oversight, nursing care per condition, policies, and reporting).
Deficiencies (3)
F609 Reporting of Alleged Violations: The facility failed to promptly report an allegation of possible sexual abuse; interviews and record review showed delays and incomplete reporting when a resident was found naked on top of another resident.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to complete and document a thorough investigation and to report the results related to an alleged sexual incident between residents; record review showed incomplete incident reports and missing follow-up documentation.
F742 Treatment/Srvcs Mental/Psychosocial Concerns: The facility failed to ensure a resident with significant behavioral and psychosocial needs received appropriate treatment, revised behavioral care planning, and staff training; multiple incidents and inadequate behavioral management were documented.
Report Facts
residents sampled: 21
Inspection Report — Mar 17, 2021
Routine
Date: Mar 17, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The file contains 1 federal health deficiency and 3 Missouri state licensure deficiencies. The federal finding concerns failure to repair the boiler and piping resulting in lack of hot water and laundry issues; the state deficiencies relate to building maintenance, hot water temperatures/availability, and infection control and refer to the federal finding.
Deficiencies (1)
F 921 Safe/Functional/Sanitary/Comfortable Environment: Based on observation, interview, and record review, the facility failed to repair the boiler and make necessary piping repairs, resulting in lack of hot water for residents and laundry and inadequate washing of resident items.
Report Facts
residents affected: 37
Inspection Report — Dec 31, 2020
Routine
Date: Dec 31, 2020
Visit Reason
CMS-2567 federal health survey. The survey is a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey as stated on the form; no complaint numbers are cited.
Findings
No deficiencies were cited. The facility was found in compliance with the COVID-19 focused emergency preparedness and infection control requirements.
Inspection Report — Oct 27, 2020
Routine
Date: Oct 27, 2020
Visit Reason
Federal CMS-2567 health survey. The form states a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey were conducted; no complaint numbers are listed.
Findings
No deficiencies were cited; the survey documents the facility was found to be in compliance with Emergency Preparedness and Infection Control requirements.
Inspection Report — Oct 6, 2020
Routine
Date: Oct 6, 2020
Visit Reason
Federal CMS-2567 statement of deficiencies (health/emergency preparedness). The form states the survey was a COVID-19 Focused Emergency Preparedness and Infection Control Survey.
Findings
No deficiencies were cited. Initial Comments state the facility was found in compliance with 42 CFR 483.73 related to E-0024(b)(6) and with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Sep 16, 2020
Routine
Date: Sep 16, 2020
Visit Reason
Federal CMS-2567 health survey (COVID-19 Focused Emergency Preparedness survey and COVID-19 Focused Infection Control Survey) as stated in the Initial Comments; no complaint numbers are cited in the file.
Findings
No health or emergency preparedness deficiencies were cited. The Initial Comments state the facility was found to be in compliance with 42 CFR 483.73 and with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Jun 22, 2020
Routine
Date: Jun 22, 2020
Visit Reason
Federal CMS-2567 health and emergency preparedness infection control survey; a COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted.
Findings
No deficiencies were cited; the facility was found in compliance with the COVID-19 focused Emergency Preparedness and Infection Control survey.
Inspection Report — May 21, 2020
Routine
Date: May 21, 2020
Visit Reason
CMS-2567 health survey (F tags) and Emergency Preparedness (E tags); the forms state this was a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey.
Findings
No federal health (F) or emergency preparedness (E) deficiencies were cited; both forms contain Initial Comments noting the facility was found in compliance.
Inspection Report — Oct 25, 2019
Life Safety
Date: Oct 25, 2019
Visit Reason
CMS-2567 Life Safety (K-tag) form and Missouri Department of Health and Senior Services State Form (A-tag) for a Life Safety Code survey.
Findings
Thirteen federal life safety deficiencies were cited involving building construction and fire resistance, egress/exit discharge, door locking, sprinkler and alarm systems, cooking/hood grease control, portable heaters, and electrical equipment. Twelve Missouri State Form deficiencies were cited referencing inspection rights, fire hazard, electrical appliances, hazardous areas, range hood certification, fire alarm and sprinkler testing, exit requirements, door locks, smoke sections, construction/maintenance, and electrical wiring.
Deficiencies (13)
K100 General Requirements - Other: Based on observation, interview and record review, the facility failed to have access to view portions of the flue/attic from the kitchen area so required inspection could not be performed, potentially affecting one smoke zone.
K161 Building Construction Type and Height: Based on observation, interview and record review, the facility failed to ensure required fire resistance rating and had multiple penetrations and missing ceiling tiles in attic and service areas, affecting multiple smoke zones and residents.
K222 Egress Doors: Based on observation and interview, the facility failed to ensure that sliding bolt locks would not restrict required egress on doors (linen closet in Garden Terrace), potentially affecting employees in smoke zones.
K271 Discharge from Exits: Based on observation, interview and record review, the facility failed to maintain the outdoor walkway, gates and several exit doors which were stuck or difficult to open, potentially affecting residents using multiple smoke zones.
K300 Protection - Other: Based on observation, interview and record review, the facility failed to prevent use of plastic benches with numerous cigarette marks in the resident smoking area, creating a fire risk affecting residents who use that area.
K324 Cooking Facilities: Based on observation, interview and record review, the facility failed to implement a system for range hood cleaning and had heavy grease buildup in the range hood/exhaust, potentially affecting the kitchen and dining smoke zones.
K341 Fire Alarm System - Installation: Based on observation, interview and record review, the facility failed to monitor and ensure integrity of fire alarm components (magnetic door holder loose at HR office), potentially affecting detection in one smoke zone.
K353 Sprinkler System - Maintenance and Testing: Based on observation, interview and record review, the facility failed to maintain sprinkler heads free of obstruction and corrosion in attic and walk-in areas, potentially affecting sprinkler performance in two smoke zones.
K362 Corridors - Construction of Walls: Based on observation, interview and record review, the facility failed to maintain required half-hour resistance at the wall between the Garden Terrace hot water room and the adjoining corridor and had wall openings, potentially affecting residents in the 700 Hall.
K363 Corridor - Doors: Based on observation, interview and record review, the facility failed to ensure corridor/resident room doors (rooms 808, 806, 805) closed without obstruction and were operable, affecting residents in those areas.
K372 Subdivision of Building Spaces - Smoke Barrier: Based on observation, interview and record review, the facility failed to maintain smoke barriers free of penetrations in multiple locations throughout the building, potentially affecting numerous smoke zones and residents.
K781 Portable Space Heaters: Based on observation, interview and record review, the facility failed to prevent use of a space heater in the medical records office without documentation the heating element does not exceed 212°F, affecting that smoke zone.
K919 Electrical Equipment - Other: Based on observation, interview and record review, the facility failed to cover a high voltage box in the attic, had damaged plugs and piggybacked surge protectors, and allowed flexible cord misuse, affecting multiple areas.
Report Facts
residents_affected: 70
residents_affected: 78
residents_affected: 19
residents_affected: 13
residents_affected: 60
residents_affected: 15
smoke_zones_affected: 2
Inspection Report — Oct 25, 2019
Routine
Date: Oct 25, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
There are 9 federal CMS deficiencies addressing resident funds/third-party liability paperwork, activities programming, accident hazards/transfer practices, nutrition/weight loss and documentation, food service temperatures and safety, sanitary conditions in food preparation and storage, infection prevention and catheter care, and multiple environmental maintenance issues; plus multiple Missouri State Form citations referencing those same areas (construction/maintenance, resident care, infection control, food safety, environment, and record/financial requirements).
Deficiencies (9)
F569 Notice and Conveyance of Personal Funds: The facility failed to complete and send required Third Party Liability (TPL)/personal funds paperwork for a resident (Resident #1000) and did not properly document or reconcile the resident's account and transfers as evidenced by review and interviews.
F679 Activities: The facility failed to provide and document individualized and group activities appropriate to residents' interests and abilities, and staff did not consistently engage residents in scheduled or one-on-one activities.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure safe resident transfers and consistent use of assistive devices and procedures, placing residents at risk during transfers.
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure adequate nutritional interventions and documentation (including med-pass supplement administration and/or consumption documentation) for residents with significant weight loss.
F804 Food and Drink: The facility failed to ensure food was prepared and served at safe, palatable temperatures and in a manner consistent with acceptable food service practices.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary conditions in the kitchen and food preparation areas, with observable accumulation of grime, debris, and unsanitary conditions on equipment and surfaces.
F813 Food Safety/Storage/Personal Food: The facility failed to ensure proper identification, storage and handling of food items brought/stored for residents, including unlabeled/undated items in refrigerators.
F880 Infection Prevention & Control: The facility failed to implement an effective infection prevention and control program and failed to follow proper infection control practices (including catheter/bag handling and glove use) as evidenced by observations and record review.
F921 Other Environmental Conditions (Safe/Functional/Sanitary/Comfortable Environment): The facility failed to maintain safe, sanitary environmental conditions in resident areas and utility/commode rooms, including water intrusion/caulking issues, damaged flooring, and debris that created unsanitary conditions.
Inspection Report — Dec 7, 2018
Routine
Date: Dec 7, 2018
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
24 deficiencies were cited: 11 federal deficiencies (topics included resident mail delivery, transfer/discharge notices, bed-hold notices, pain management documentation, ADL assistance, pressure ulcer treatment, dialysis care, dental services, food temperature and sanitary food handling, and infection control) and 13 Missouri state licensure citations that refer to the federal findings.
Deficiencies (11)
F576 Right to Forms of Communication w/ Privacy: The facility failed to ensure incoming mail delivered on Saturdays was distributed to residents on the same day.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide required written transfer/discharge notices and to notify the resident's representative and the Ombudsman for multiple sampled residents.
F625 Notice of Bed Hold Policy Before/Upon Trnsfr: The facility failed to ensure a bed-hold notice was given to the resident or the resident's representative upon transfer to the hospital for sampled residents.
F658 Services Provided Meet Professional Standards: The facility failed to accurately document PRN pain medication administration, including the location, severity and effectiveness of pain, for a sampled resident.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide requested assistance/drinks and appropriate support during meals for a sampled resident in the dining area.
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: The facility failed to complete ordered pressure ulcer treatments and to document wound care and treatment interventions for a sampled resident.
F698 Dialysis: The facility failed to complete an ongoing assessment and monitoring for complications before and after dialysis treatments for a sampled resident receiving dialysis.
F791 Routine/Emergency Dental Svcs in NFs: The facility failed to ensure routine dental services/assistance were provided for a sampled resident.
F800 Provided Diet Meets Needs of Each Resident: The facility failed to ensure food was maintained and monitored at safe temperatures and that steam table temperatures were recorded and verified.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary food storage and equipment and to ensure proper cleaning and storage practices in the kitchen and walk-in refrigerator.
F880 Infection Prevention & Control: The facility failed to use appropriate infection control measures, including proper hand hygiene and glove-change procedures, risking potential transmission of infection.
Report Facts
sampled residents (total): 22
sampled residents affected: 6
Inspection Report — Dec 7, 2018
Life Safety
Date: Dec 7, 2018
Visit Reason
Federal CMS-2567 Life Safety (K) and Emergency Preparedness (E) forms and Missouri Department of Health and Senior Services State Form are included; the survey type is not stated.
Findings
There are 1 Emergency Preparedness (E) deficiency, 9 Life Safety (K) deficiencies, and 10 Missouri state deficiencies. Findings address a lack of complete emergency preparedness planning (temperature monitoring and EP training), and multiple life-safety issues including smoke barrier penetrations/building construction, emergency lighting failures, unprotected cooking equipment, incomplete fire alarm notification coverage, sprinkler impairment/fire watch policy deficiencies, unsafe smoking area/ashtray practices, missing/untested smoke/door inspections, and electrical/power cord hazards.
Deficiencies (10)
E001 Establishment of the Emergency Program (EP): The facility failed to have an Emergency Preparedness plan that included measures for monitoring inside temperatures during a power outage and failed to outline EP training procedures for staff.
K161 Building Construction Type and Height: Walls and ceilings had penetrations, unsealed gaps, missing escutcheon plates and offset ceiling tiles in multiple areas that would allow the passage of smoke.
K291 Emergency Lighting: Emergency lighting was not installed, tested or maintained throughout the facility, with specific units not illuminating and a lack of emergency lighting in the basement laundry.
K324 Cooking Facilities: Cooking equipment, specifically a deep fryer, was located too close to adjacent cooking surfaces with no required baffle or protection, creating a fire hazard.
K343 Fire Alarm System - Notification: Components of the fire alarm notification system were not properly installed or provided adequate coverage, including no audio/visual notification device in the basement laundry.
K354 Sprinkler System - Out of Service: The facility lacked a current, complete, facility-specific sprinkler impairment/fire watch policy and required documentation when the sprinkler system is out of service.
K741 Smoking Regulations: Designated smoking areas lacked proper self-closing ashtrays, signage, and safe disposal practices, with cigarette butts observed on the ground and unsafe ashtray placement.
K761 Maintenance, Inspection & Testing - Doors: Smoke door and smoke window assemblies were not inspected and documented annually as required; maintenance records showed an absence of required annual inspections.
K919 Electrical Equipment - Other: Numerous electrical outlets, receptacles and junction boxes throughout the facility had broken grounding slots, missing plate covers, or exposed wiring compromising integrity.
K920 Electrical Equipment - Power Cords and Extension Cords: Multiple appliances and power strips were improperly used, piggy-backed or plugged into surge protectors, risking overload and fire hazard.
Report Facts
areas with smoke barrier failures: 7
total facility smoke zones: 16
Inspection Report — Feb 22, 2018
Routine
Date: Feb 22, 2018
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri state licensure Statement of Deficiencies (State Form); the survey type is not stated in the documents.
Findings
There are 15 federal health deficiencies primarily involving resident care domains (nutrition/food service, medication management, infection control, pressure ulcers, falls, discharge summaries, enteral feeding and communication) and 19 Missouri state licensure deficiencies that reference and cross‑refer to the federal findings (medication errors/storage, nursing care, infection control, food service and sanitation).
Deficiencies (15)
F558 Reasonable Accommodations/Needs/Preferences: The surveyor found the facility failed to identify and honor the resident's food preferences and monitor/assist intake, contributing to weight loss and inadequate nourishment.
F637 Comprehensive Assessment After Significant Change: The surveyor found the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed for a resident following a significant change in condition.
F661 Discharge Summary: The surveyor found the facility failed to ensure a comprehensive discharge summary was completed and available for transferred residents.
F676 Activities/Communication/Language: The surveyor found the facility failed to provide appropriate communication assistance and methods for a resident with communication impairment (including language barriers) to meet the resident's needs.
F686 Skin Integrity/Pressure Ulcer Prevention and Treatment: The surveyor found the facility failed to identify, prevent and appropriately manage skin breakdown/pressure areas and to follow required assessment and treatment protocols for affected residents.
F689 Fall Prevention/Fall Investigation: The surveyor found the facility failed to implement appropriate fall prevention measures, complete timely and thorough fall investigations, and document interventions and follow up for residents who fell.
F693 Tube Feeding/Enteral Nutrition: The surveyor found the facility failed to ensure appropriate orders, monitoring and care related to residents receiving enteral feedings (PEG/feeding tube) and associated documentation and physician orders.
F760 POS, MAR and TAR Residents are Free of Significant Med Errors: The surveyor found the facility failed to ensure residents were free from significant medication errors, including issues with application/management of prescribed patches.
F761 Label/Storage of Drugs and Biologicals: The surveyor found medications and biologicals were not consistently labeled, stored or controlled per policy and manufacturer guidance (examples included unlabeled or open vials and storage/cart issues).
F800 Provided Diet Meets Needs of Each Resident: The surveyor found the facility failed to provide diets and meals that met residents' nutritional needs, preferences and food texture requirements, including errors in preparation and service of pureed foods.
F803 Menus and Nutritional Adequacy: The surveyor found the facility failed to follow menus/recipes and ensure prepared food met nutritional and menu planning requirements and dietitian guidance.
F804 Food Quality/Palatability/Temperature: The surveyor found the facility failed to ensure food was prepared, served and held at appropriate temperatures and in a palatable, safe manner.
F812 Procure/Store/Prepare/Serve/Sanitary Food Safety: The surveyor found unsanitary food preparation/storage practices in the kitchen, inadequate cleaning, and failures in monitoring temperatures and food-contact surfaces.
F813 Resident/Family Prepared Foods/Brought In Foods: The surveyor found failures in ensuring foods brought in by families/visitors were properly stored, labeled and managed according to facility policy.
F880 Infection Prevention & Control: The surveyor found the facility failed to maintain an effective infection prevention and control program, including lapses in cleaning/ disinfecting practices and device/glucometer hygiene.
Report Facts
Inspection Report — Feb 22, 2018
Life Safety
Date: Feb 22, 2018
Visit Reason
Federal CMS-2567 health and life safety surveys and Missouri state licensure survey; the survey type is not stated.
Findings
25 deficiencies were cited: 3 federal emergency preparedness (E) deficiencies concerning subsistence needs/sewage disposal, waiver roles, and emergency preparedness testing/exercises; 11 life safety (K) deficiencies involving fire-resistance/ceiling penetrations, exit discharge obstructions, emergency lighting, cooking hood/flue and sprinkler maintenance, smoke barriers, smoking/ashtray disposal, and electrical systems/testing/extension cord use; and 11 Missouri state (19 CSR) deficiencies referencing noncombustible materials, range hood certification, sprinkler testing/maintenance, exit requirements, emergency lighting, smoke section walls/doors, ashtray disposal, general construction/maintenance, electrical wiring/equipment, extension cords, and policies/procedures.
Deficiencies (14)
E015 Subsistence Needs for Staff and Patients: Based on record review and interview, the facility failed to develop policies and procedures that address sewage and waste disposal while sheltering in place, potentially affecting all residents, visitors, and staff.
E026 Roles Under a Waiver Declared by Secretary: Based on record review and interview, the facility failed to develop policies and procedures that describe its role in providing care under waivers declared by a federal authority during emergencies.
E039 EP Testing Requirements: Based on record review and interview, the facility failed to develop documentation and procedures to participate in required full-scale or other emergency preparedness exercises and to document participation.
K161 Building Construction Type and Height: Based on observation, interview and record review, the facility failed to ensure required fire resistance rating due to missing or improperly installed ceiling tiles and penetrations in the basement and attic access panel.
K271 Discharge from Exits: Based on observation, interview and record review, the facility failed to ensure the exit discharge from the kitchen/walk-in area to the front main entrance was maintained free of obstructions and a drop off that could hinder wheelchair evacuation.
K291 Emergency Lighting: Based on observation and record review, the facility failed to ensure an emergency light outside the stairwell illuminated during testing and lacked documentation of a 90-minute annual test of emergency lights.
K324 Cooking Facilities: Based on observation and record review, the facility failed to maintain the range hood flue, including a hole in the metal flue, affecting kitchen smoke zone safety.
K353 Sprinkler System - Maintenance and Testing: Based on observation, interview and record review, the facility failed to ensure sprinkler heads in the kitchen were free from corrosion.
K372 Subdivision of Building Spaces - Smoke Barrier: Based on observation, interview and record review, the facility failed to maintain the smoke barrier wall integrity, with multiple penetrations and gaps in attic and wall areas between nurse stations, hallways and the dining/lobby.
K741 Smoking Regulations: Based on observation, interview and record review, the facility failed to ensure proper ashtray/metal liner availability and disposal of cigarette butts, with numerous cigarette butts found outside the south basement shop area.
K914 Electrical Systems - Maintenance and Testing: Based on interview and record review, the facility failed to obtain and maintain records of receptacle assessments at resident bed locations including integrity, grounding circuit continuity, polarity and retention force.
K918 Electrical Systems - Essential Electric System: Based on interview and record review, the facility failed to ensure a detailed record of the annual inspection of the electrical main and circuit breakers was maintained.
K920 Electrical Equipment - Power Cords and Extension Cords: Based on observation, interview and record review, the facility failed to prevent inappropriate use of surge protectors and extension cords for certain appliances and failed to limit extension cord use as required.
K921 Electrical Equipment - Testing and Maintenance: Based on record review and interview, the facility failed to produce documentation showing testing, assessment, and a complete list of surge protectors (locations, integrity, resistance, leakage current and UL listing) and lacked required maintenance/testing records.
Report Facts
employees potentially affected: 15
total smoke zones: 16
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