Inspection Reports for
Appleton City Manor
600 NORTH OHIO ST, APPLETON CITY, MO, 64724-1609
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
31 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to a complaint regarding a resident who fell from a wheelchair while being repositioned by a Certified Nurse Aide (CNA A). The visit aimed to investigate the circumstances and compliance with safety policies.
Complaint Details
Complaint Number 2640366 regarding a resident who fell from a wheelchair while being repositioned by CNA A, resulting in a hairline fracture and laceration. The complaint was substantiated by interviews and record reviews.
Findings
The facility failed to keep residents free from accidents when CNA A hurriedly assisted a resident, causing the resident to fall from a wheelchair and sustain injuries including a hairline fracture. The CNA had not completed required training or skills competency reviews. Staff interviews confirmed the incident and lack of proper procedure adherence.
Deficiencies (2)
Failure to keep residents free from accidents resulting in a resident falling from a wheelchair due to hurried assistance by staff.
Lack of documented training and skills competency reviews for CNA A.
Report Facts
Facility census: 31
Resident admission date: Feb 21, 2025
Resident MDS assessment date: Jun 6, 2025
Resident care plan revision date: Oct 9, 2025
Incident date: Oct 9, 2025
CNA A hire date: Jun 30, 2023
CNA A start date: Jul 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings related to hurried assistance causing resident fall and lack of training documentation |
| LPN C | Licensed Practical Nurse | Re-educated CNA A on slowing down and being gentle when providing care |
| CNA B | Certified Nurse Aide | Witnessed the incident and provided details about the fall |
| CNA D | Certified Nurse Aide | Stated staff should announce themselves before repositioning residents |
| RN E | Registered Nurse | Stated staff were to always announce themselves before providing care |
| ADON | Assistant Director of Nursing | Re-educated CNA A and reported concerns about CNA A's speed with residents |
| Administrator | Facility Administrator | Reported staff concerns about CNA A and stated CNA A did not intend to harm resident |
| DON | Director of Nursing | Provided information about nurse educator and CNA A's motivation |
| Physician | Facility Physician | Commented on CNA A rushing with resident and expectation of proper training |
| Nurse Practitioner | Nurse Practitioner | Stated staff should complete new employee training and skills competencies |
Inspection Report
Routine
Census: 26
Deficiencies: 4
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including trauma-informed care, medication management, infection control, and other resident care standards.
Findings
The facility was found deficient in trauma-informed care for a resident with PTSD, failed to adequately monitor blood pressure before administering hypertensive medications, and failed to ensure timely administration of controlled medications for two residents. Additionally, the facility did not maintain a complete infection prevention and control program, specifically failing to timely complete and document admission tuberculosis testing for two residents.
Deficiencies (4)
Failed to acknowledge, assess, provide supportive services, and develop a care plan for a resident with PTSD and trauma history.
Failed to monitor blood pressure prior to administering hypertensive medications for a resident, with multiple instances of undocumented blood pressure checks.
Failed to ensure administration of controlled medication (Klonopin) for two residents due to medication not being received from pharmacy and lack of follow-up.
Failed to maintain a complete infection prevention and control program by not timely completing and documenting admission tuberculosis testing for two residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Facility census: 26
Medication administration dates missing BP check: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Provided information on blood pressure monitoring and medication administration practices |
| LPN I | Licensed Practical Nurse | Confirmed medication orders and discussed medication administration issues |
| CMT C | Certified Medication Technician | Discussed medication administration and follow-up with pharmacy |
| ADON | Assistant Director of Nursing | Provided information on trauma-informed care, medication administration, and TB testing procedures |
| DON | Director of Nursing | Provided oversight information on medication orders, administration, and TB testing |
| Administrator | Provided administrative perspective on medication and TB testing deficiencies |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 4
Date: Nov 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to timely report suspected abuse and failure to provide adequate behavioral health care and social services for a resident exhibiting verbal aggression and psychosocial distress.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to timely report suspected abuse when Resident #1 threatened to bash another resident's head with a hammer. The facility also failed to provide adequate behavioral health care and social services for Resident #1, who exhibited verbal aggression, refusal of care, and psychosocial distress. The facility did not report the abuse allegation to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The resident had multiple incidents of verbal aggression and threats, and staff failed to implement effective interventions or adequately address the resident's psychosocial needs. The Social Services Designee did not follow up on the resident's expressed unhappiness or facilitate transfer despite the resident's statements about wanting to leave. The facility also failed to ensure a safe environment when Resident #4 was found with marijuana and unknown pills on their person and in their room.
Findings
The facility failed to report allegations of possible abuse within the required timeframe when a resident threatened others verbally. The facility also failed to provide adequate behavioral health care and social services for a resident with depression and aggressive behaviors, including failure to develop and implement resident-specific nonpharmacological interventions and failure to address the root cause of the resident's distress and unhappiness. Additionally, the facility failed to ensure a safe environment when a resident was found with marijuana and unknown pills on their person and in their room.
Deficiencies (4)
Failure to timely report suspected abuse when a resident threatened physical violence towards other residents.
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision when a resident was found with marijuana and unknown pills on their person and in their room.
Failure to provide necessary behavioral health care and services including failure to develop and implement resident-specific nonpharmacological interventions for a resident exhibiting psychosocial distress and verbal aggression.
Failure to provide appropriate medically-related social services to help a resident achieve the highest possible quality of life, including failure to address the root cause of the resident's yelling, cursing, refusal of care, and general unhappiness.
Report Facts
Resident census: 28
Medication dosage: 250
Medication dosage: 10
Medication dosage: 20
Medication dosage: 0.5
Medication dosage: 50
PHQ-9 score: 17
Incident report timeframe: 72
Observation frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Completed incident report and documented resident's aggressive behavior and threats |
| CNA F | Certified Nurse Aide | Witnessed resident's verbal aggression during smoke break |
| CNA G | Certified Nurse Aide | Witnessed resident's verbal aggression during smoke break |
| CNA H | Certified Nurse Aide | Witnessed resident's verbal aggression and assisted in redirecting |
| Social Services Director | Social Services Director (SSD) | Involved in investigation and resident care planning; did not follow up on resident's expressed unhappiness or facilitate transfer |
| CNA A | Certified Nurse Assistant | Reported resident's verbal aggression and stated verbal abuse should be investigated |
| LPN I | Licensed Practical Nurse | Described resident-to-resident altercation management and reporting |
| LPN C | Licensed Practical Nurse | Described facility policies on reporting abuse and medication management |
| DON | Director of Nursing | Provided oversight on resident care and investigation; ordered medication and interventions |
| Nurse Aide J | Nurse Aide | Described resident's behaviors and interactions with staff and other residents |
| LPN K | Licensed Practical Nurse | Described resident's behaviors and staff interactions |
Inspection Report
Routine
Census: 29
Deficiencies: 2
Date: Nov 13, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to pressure ulcer care and infection prevention and control practices at Appleton City Manor.
Findings
The facility failed to provide appropriate pressure ulcer care by not consistently assessing, documenting, and obtaining treatment orders for wounds on one resident. Additionally, the facility failed to implement an effective infection control program, including failure to follow enhanced barrier precautions and proper hand hygiene during wound care for two residents.
Deficiencies (2)
Failure to consistently assess and document complete, thorough, and accurate weekly skin assessments and wound tracking, and failure to obtain treatment orders for all wounds for one resident with pressure ulcers.
Failure to establish and maintain an effective infection control program, including failure to implement enhanced barrier precautions and failure to perform hand hygiene at appropriate times during wound care for two residents.
Report Facts
Residents affected: 1
Residents affected: 2
Facility census: 29
Wound measurements: 4
Wound measurements: 3
Wound measurements: 1
Wound measurements: 27
Wound measurements: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in findings related to wound care and infection control deficiencies, including failure to perform hand hygiene and gown use. |
| LPN E | Licensed Practical Nurse | Named in findings related to wound care and infection control deficiencies, including failure to perform hand hygiene and gown use. |
| Nurse Practitioner | Provided clinical observations and orders related to wound care. | |
| Corporate Nurse | Provided interviews regarding wound care and infection control practices and deficiencies. | |
| Nurse Aide B | Nurse Aide | Provided interview regarding wound monitoring and reporting. |
| Certified Nurse Aide A | Certified Nurse Aide | Provided interview regarding wound monitoring and reporting. |
| Registered Nurse F | Registered Nurse | Provided interview regarding infection control practices. |
Inspection Report
Routine
Census: 38
Deficiencies: 3
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident personal funds management, safe resident transfers, and nursing staff coverage.
Findings
The facility failed to properly manage residents' personal funds by not depositing funds over the required amounts into interest-bearing accounts and maintaining accurate balances. The facility also failed to ensure safe transfers of a resident using a Hoyer lift as ordered by the physician, and lacked sufficient registered nurse coverage including a full-time Director of Nursing.
Deficiencies (3)
Failed to manage and account for residents' personal funds properly, including failure to deposit funds over $50 into interest-bearing accounts and maintain ongoing balances for seven residents.
Failed to ensure residents were free from accident hazards by not following physician orders to transfer a resident using a Hoyer lift with two staff.
Failed to have a registered nurse on duty 8 hours a day and a full-time Director of Nursing, resulting in periods without RN or DON coverage.
Report Facts
Residents census: 38
Resident funds amounts: 73
Resident funds amounts: 200
Resident funds amounts: 5
Resident funds amounts: 0.78
Resident funds amounts: 9
Resident funds amounts: 2.24
Resident funds amounts: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Named in observation and interview regarding unsafe transfer of Resident #7 without Hoyer lift |
| NA B | Nurse Aide | Interviewed about transfer procedures and lack of DON |
| NA H | Nurse Aide | Interviewed about transfer procedures and Hoyer lift use |
| CNA E | Certified Nurse Aide | Interviewed about transfer procedures and PRN Hoyer lift use |
| RA C | Restorative Aide | Interviewed about therapy recommendations and DON presence |
| CMT D | Certified Medication Tech | Interviewed about following physician orders and DON status |
| LPN F | Licensed Practical Nurse | Interviewed about transfer orders and DON status |
| LPN G | Licensed Practical Nurse | Interviewed about transfer orders and DON status |
| Administrator | Facility Administrator | Interviewed about resident transfers, DON resignation, and RN coverage |
| Business Office Manager | Business Office Manager | Interviewed about resident funds management |
Inspection Report
Routine
Census: 38
Deficiencies: 11
Date: Sep 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to nursing home operations, including staff screening, resident care, medication administration, infection control, and documentation.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks for new hires, lack of bed hold policies, incomplete baseline care plans, medication administration errors, inadequate restorative care, improper incontinence care, insufficient RN coverage, uncertified nurse aides, medication management issues including failure to administer ordered medications and improper medication destruction, incomplete resident documentation, and ineffective infection prevention and control practices.
Deficiencies (11)
Failed to develop and implement abuse policies including proper screening of staff upon hire; criminal background checks not completed for four staff.
Failed to provide a bed hold policy for a resident transferred to hospital on two occasions.
Failed to complete baseline care plan within 48 hours of admission for one resident.
Failed to provide care per standards of practice including medication administration, monitoring, and physician notification for one resident with edema.
Failed to ensure ordered hand splint was used consistently, monitored, and care planned for one resident.
Failed to provide incontinence care per nursing standards including proper hand hygiene and cleansing technique for two residents.
Failed to provide services of a registered nurse for at least eight consecutive hours per day seven days per week.
Failed to ensure eight nurse aides completed certified nurse aide training program within four months of employment.
Failed to provide pharmaceutical services to meet resident needs including failure to administer medications as ordered and failure to implement effective medication destruction system.
Failed to maintain complete and accurate resident records including documentation of changes in condition and hospital transfers for two residents.
Failed to implement a complete and effective infection prevention and control program including Legionella monitoring, covering clean laundry, mask use when coughing, proper infection control during wound care, and enhanced barrier precautions.
Report Facts
Census: 38
Deficiencies cited: 11
Medication cards: 63
Medications awaiting destruction: 63
Nurse aides uncertified: 8
RN coverage gaps: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA D | Nurse Aide | Named in failure to complete criminal background check and incontinence care deficiencies |
| RA G | Restorative Aide | Named in failure to complete criminal background check and restorative care deficiencies |
| NA I | Nurse Aide | Named in failure to complete criminal background check and nurse aide certification deficiency |
| CMT F | Certified Medication Technician | Named in failure to complete criminal background check and medication administration deficiencies |
| LPN C | Licensed Practical Nurse | Named in medication administration, documentation, infection control, and restorative care deficiencies |
| NA E | Nurse Aide | Named in incontinence care and nurse aide certification deficiencies |
| NA H | Nurse Aide | Named in incontinence care and nurse aide certification deficiencies |
| Administrator | Named in multiple interviews regarding facility policies and deficiencies | |
| Director of Nursing | Named in multiple interviews regarding facility policies and deficiencies | |
| Assistant Director of Nursing | Named in multiple interviews regarding facility policies and deficiencies | |
| Nurse Aide E | Nurse Aide | Named in nurse aide certification deficiency |
| Nurse Aide L | Nurse Aide | Named in nurse aide certification deficiency |
Inspection Report
Routine
Census: 38
Deficiencies: 21
Date: Sep 9, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks for new hires, lack of bed hold policies, untimely resident assessments, incomplete care plans, medication administration errors, inadequate infection control practices, insufficient staffing and training, failure to maintain accurate records, and deficiencies in food safety and pharmaceutical services.
Deficiencies (21)
Failed to complete criminal background checks for four staff members prior to employment.
Failed to provide a bed hold policy and notify resident or representative in writing about bed hold duration.
Failed to complete annual and quarterly Minimum Data Set (MDS) assessments within required timeframes for multiple residents.
Failed to complete and transmit discharge and re-entry MDS assessments timely for several residents.
Failed to develop baseline care plan within 48 hours of admission for one resident.
Failed to have physician orders and care plans related to code status for several residents; conflicting code status information found.
Failed to provide appropriate treatment and monitoring for resident with edema, including medication administration and physician notification.
Failed to provide appropriate pressure ulcer care including wound assessments, care plan updates, physician notification, and following physician orders.
Failed to provide care to maintain or improve range of motion and failed to monitor and care plan for use of hand brace for one resident.
Failed to provide appropriate incontinence care and hand hygiene, resulting in potential infection risk.
Failed to provide recommended dietary interventions and follow-up for resident with weight loss.
Failed to have physician orders and care plan for use and care of CPAP machine for one resident.
Failed to provide the services of a registered nurse for at least eight consecutive hours per day seven days per week.
Failed to post required daily nurse staffing information in a prominent and accessible place with all required details.
Failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) plan with documentation of corrective actions.
Failed to maintain documentation of a functioning Quality Assessment and Assurance (QAA) Committee meeting at least quarterly with required members.
Failed to implement a complete and effective infection control program including Legionella monitoring, proper laundry handling, respiratory hygiene, and enhanced barrier precautions.
Failed to provide pharmaceutical services meeting resident needs including timely medication administration, medication destruction, and monthly drug regimen reviews.
Failed to implement gradual dose reductions and limit PRN psychotropic medication use to 14 days unless evaluated by physician.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including maintaining proper refrigerator temperatures, cleanliness, and food labeling.
Failed to maintain complete and accurate resident records including documentation of changes in condition and hospital transfers.
Report Facts
Census: 38
Medication doses not administered: 9
Nurse Aides without CNA certification: 8
Medication cards in locked cabinet: 63
Residents with medications awaiting destruction: 16
Days PRN psychotropic medication order exceeded: 14
Residents on antibiotic log: 10
Residents on infection control log: 6
Residents with stage 2 pressure ulcers: 3
Residents with unstageable ulcers: 2
Residents with severe cognitive impairment: 4
Residents on psychotropic medications: 2
Residents on antibiotics: 3
Residents with pressure ulcers: 2
Residents with documented hospital transfers without proper documentation: 2
Days medication destruction delayed: 30
Refrigerator temperature: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA D | Nurse Aide | Named in failure to complete criminal background check and incontinence care observation |
| NA H | Nurse Aide | Named in failure to complete criminal background check and incontinence care observation |
| NA E | Nurse Aide | Named in failure to complete criminal background check and incontinence care observation |
| LPN B | Licensed Practical Nurse | Named in medication administration and infection control interviews |
| LPN C | Licensed Practical Nurse | Named in medication administration, infection control, and antibiotic stewardship interviews |
| RN T | Registered Nurse | Hospice nurse assisting with wound care |
| Administrator | Facility Administrator | Named in multiple interviews regarding facility policies and deficiencies |
| Dietary Manager | Director of Food and Nutrition Services | Named in interviews regarding dietary services and food safety |
| DON | Director of Nursing | Named in multiple interviews regarding nursing services, medication management, and infection control |
| ADON | Assistant Director of Nursing | Named in multiple interviews regarding nursing services and infection control |
| NA I | Nurse Aide | Named in failure to complete criminal background check |
| NA K | Nurse Aide | Named in failure to complete criminal background check |
| NA L | Nurse Aide | Named in failure to complete criminal background check and wound care observation |
| NA M | Nurse Aide | Named in failure to complete criminal background check |
| NA N | Nurse Aide | Named in failure to complete criminal background check |
| CMT F | Certified Medication Technician | Named in medication administration and medication destruction interviews |
| RA G | Restorative Aide | Named in failure to complete criminal background check and infection control observation |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Date: Apr 12, 2024
Visit Reason
The inspection was conducted based on complaints regarding resident dignity and respect, medication monitoring, and psychotropic medication use at Appleton City Manor.
Complaint Details
The complaint investigation was triggered by allegations of staff yelling and cursing at residents, failure to monitor blood pressure as ordered, and inappropriate use of psychotropic medications without specified diagnosis.
Findings
The facility failed to ensure residents were treated with dignity as staff yelled and cursed in the presence of residents. The facility also failed to adequately monitor blood pressure as ordered for one resident and failed to specify a diagnosis for use of a psychotropic medication for another resident. Policies regarding medication administration and psychotropic medications were lacking.
Deficiencies (3)
Failed to ensure all residents were treated with dignity and respect when staff yelled and cursed in the presence of residents.
Failed to ensure residents' drug regimens were free from unnecessary drugs when staff failed to adequately monitor blood pressure as ordered for one resident.
Failed to ensure residents' drug regimens were free from unnecessary drugs when staff failed to specify a diagnosis for use of a psychotropic medication for one resident.
Report Facts
Residents reviewed: 7
Residents reviewed: 4
Census: 37
Dates missing blood pressure monitoring: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in dignity and respect deficiency for yelling and cursing at resident | |
| Nurse Aide B | Witnessed and reported incident involving CNA A | |
| Licensed Practical Nurse C | Overheard incident and provided statement | |
| Licensed Practical Nurse E | Interviewed regarding incident and medication administration | |
| Licensed Nurse Practitioner H | Interviewed regarding blood pressure monitoring | |
| Family Nurse Practitioner J | Interviewed regarding psychotropic medication use | |
| Director of Nursing (DON) | Interviewed regarding staff behavior and medication monitoring | |
| Administrator | Interviewed regarding staff behavior and medication monitoring |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 4
Date: Feb 28, 2024
Visit Reason
The inspection was conducted due to allegations of staff cursing at residents and failure to report suspected abuse promptly, as well as concerns about medication management and resident dignity.
Complaint Details
The complaint involved allegations that a Certified Nurse Aide (CNA A) cursed at two residents. The facility failed to report the allegations to the state within two hours as required. The investigation revealed staff cursing in the presence of residents and failure to report suspected abuse promptly.
Findings
The facility failed to ensure residents were treated with dignity and respect when staff yelled and cursed in their presence. The facility also failed to report allegations of abuse to the state within the required timeframe. Additionally, the facility did not adequately monitor blood pressure as ordered for one resident and failed to specify a diagnosis for the use of a psychotropic medication for another resident.
Deficiencies (4)
Staff yelled and cursed in the presence of residents, failing to treat residents with dignity and respect.
Failure to timely report suspected abuse to management and within two hours to the State Survey Agency.
Failed to ensure residents' drug regimens were free from unnecessary drugs by not adequately monitoring blood pressure as ordered.
Failed to specify a diagnosis for use of a psychotropic medication for one resident.
Report Facts
Residents affected: 7
Facility census: 37
Dates blood pressure not documented: 8
Medication administration shifts missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings related to yelling, cursing at residents, and failure to report abuse |
| NA B | Nurse Aide | Witnessed and reported CNA A's behavior |
| LPN C | Licensed Practical Nurse | Provided statements regarding incident and staff attitude |
| LPN E | Licensed Practical Nurse | Interviewed regarding resident care and medication monitoring |
| DON | Director of Nursing | Oversaw investigation and acknowledged failure to report abuse |
| Administrator | Facility Administrator | Involved in investigation and facility oversight |
| FNP J | Family Nurse Practitioner | Provided information on medication orders and resident care |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 3
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with staffing requirements, nurse aide training and competency, and performance review regulations at the nursing home.
Findings
The facility failed to staff a registered nurse for at least eight hours a day, seven days a week, failed to ensure seven nurse aides completed state-approved CNA training and competency evaluation within four months of hire, and failed to provide annual individual performance reviews and regular in-service education for nursing aides.
Deficiencies (3)
Failed to staff a registered nurse (RN) for at least eight hours a day, seven days a week.
Failed to ensure seven nurse aides completed a state approved CNA training program and competency evaluation within four months of hire.
Failed to provide annual individual performance reviews or evaluations and regular in-service education for five nursing aides.
Report Facts
Facility census: 40
Number of nurse aides not completing CNA training within 4 months: 7
Number of nursing aides without annual performance reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Only RN employed, responsible for CNA classes and training, and performance reviews |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding RN staffing and nurse aide training |
| Nurse Assistant A | Nurse Assistant | Interviewed regarding RN staffing and performance reviews |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding RN staffing and nurse aide training |
| Nurse Assistant E | Nurse Assistant | Interviewed regarding CNA training and performance reviews |
| Nurse Assistant F | Nurse Assistant | Interviewed regarding CNA training and performance reviews |
| Administrator | Administrator | Interviewed regarding RN staffing and CNA training responsibility |
Inspection Report
Routine
Census: 31
Deficiencies: 9
Date: Aug 18, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, staffing, medication administration, food safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including maintaining a clean environment, completing required staff registry checks, providing bed hold policy information, ensuring RN coverage, certifying nurse aides, medication administration errors, food safety violations, improper infection control practices including mask usage, inadequate Legionella prevention program, and call light system accessibility.
Deficiencies (9)
Facility failed to maintain a clean, comfortable, homelike environment with multiple dirty, broken, or missing light fixture covers containing dead bugs.
Facility failed to ensure staff completed Nurse Aide Registry checks for three employees.
Facility failed to provide written bed hold policy information to residents or their representatives upon hospital transfer.
Facility failed to have a registered nurse on duty eight hours a day seven days a week.
Facility failed to ensure two nurse aides completed certified nurse aide training within four months of employment.
Facility failed to ensure medication error rates were less than 5%, with insulin administered without priming the pen as per manufacturer instructions.
Facility failed to prepare food in accordance with professional standards, including unclean kitchen surfaces, bare hand contact with food, and lack of proper hair coverings.
Facility failed to maintain an infection control program ensuring proper mask usage and an effective Legionella prevention program.
Facility failed to ensure call light pull cords in resident bathrooms were accessible, with some missing or tied up and inaccessible.
Report Facts
Medication error rate: 7.41
Facility census: 31
Dates with no RN coverage: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide I | Nurse Aide | Named in findings related to unawareness of light fixture issues, lack of CNA certification, improper mask usage, and call light pull cord observations. |
| Nurse Aide J | Nurse Aide | Named in findings related to unawareness of light fixture issues, lack of CNA certification, improper mask usage, and call light pull cord observations. |
| Licensed Practical Nurse M | Licensed Practical Nurse | Named in findings related to missing Nurse Aide Registry check. |
| Dietary Aide N | Dietary Aide | Named in findings related to missing Nurse Aide Registry check. |
| Licensed Practical Nurse G | Licensed Practical Nurse | Named in medication administration and bed hold policy interviews. |
| Registered Nurse C | Registered Nurse | Named in interviews regarding Nurse Aide Registry checks, RN coverage, CNA certification, medication administration, and mask usage. |
| Director of Nursing | Director of Nursing | Named in interviews regarding Nurse Aide Registry checks, RN coverage, CNA certification, medication administration, and mask usage. |
| Administrator | Facility Administrator | Named in interviews regarding Nurse Aide Registry checks, RN coverage, CNA certification, medication administration, food safety, infection control, and call light system. |
| Dietary Manager | Dietary Manager | Named in food safety observations and interviews regarding cleaning and glove usage. |
| Maintenance Director | Maintenance Director | Named in interviews regarding light fixture maintenance, Legionella program, and call light system. |
| Social Services Director | Social Services Director | Named in interview regarding mask usage expectations. |
| Nurse Aide L | Nurse Aide | Named in mask usage observations. |
| Licensed Practical Nurse H | Licensed Practical Nurse | Named in mask usage observations and interviews. |
| Restorative Nurse Aide K | Restorative Nurse Aide | Named in call light system interview. |
| Nurse Aide F | Dietary Aide | Named in food safety observations and interviews. |
| Nurse Aide E | Dietary Aide | Named in food safety observations and interviews. |
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