Inspection Reports for
Arbor View Nursing and Rehabilitation
6400 THE CEDARS COURT, CEDAR HILL, MO, 63016-2220
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
21.4 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
289% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
55% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding the improper transfer of Resident #1 from a chair to a bed, which raised concerns about resident safety and adherence to care plans.
Complaint Details
The visit was complaint-related based on complaints MO2647279 and 2646309. The complaint involved concerns about the unsafe transfer of Resident #1. The complaint was investigated and substantiated as the facility did not follow proper transfer procedures.
Findings
The facility failed to perform a proper and safe transfer of Resident #1, who was upset and resisted during the transfer. Staff did not follow the care plan or use appropriate transfer techniques such as a gait belt, resulting in minimal harm or potential for harm to the resident.
Deficiencies (1)
Failure to perform a proper transfer from chair to bed for Resident #1, including not following care plan and not using a gait belt.
Report Facts
Facility census: 83
Complaints: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aid | Involved in improper transfer of Resident #1 without using a gait belt |
| CMT B | Certified Medication Technician | Assisted CNA A during transfer and noted lack of gait belt use |
| LPN C | Licensed Practical Nurse | Interviewed regarding transfer procedures and staff training |
| Administrator | Administrator (ADM) | Interviewed about incident and video review with resident's guardian |
| Director of Nurses | Director of Nurses (DON) | Interviewed about proper transfer techniques and staff expectations |
Inspection Report
Routine
Census: 86
Deficiencies: 17
Date: Apr 2, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, staffing, nutrition, environment, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity during meals, failure to honor resident preferences, inadequate notification of transfers and bed hold policies, unsafe and unsanitary food handling practices, insufficient staffing and training, lack of gradual dose reductions for psychotropic medications, failure to maintain essential equipment, and unsafe environmental conditions such as items stored on overbed light fixtures.
Deficiencies (17)
Failure to promote resident independence and dignity while dining when staff served the noon meal on disposable dishware.
Failure to create an environment respectful of resident self-determination through support of resident choice, including bathing and shaving preferences.
Failure to provide a final accounting of a resident's fund balance within 30 days after death.
Failure to monitor and maintain resident equipment in good working order and failure to provide a safe, clean, comfortable, and homelike environment.
Failure to notify residents and/or representatives in writing of hospital transfers and discharges.
Failure to notify residents and/or representatives in writing of bed hold policies at time of transfer.
Failure to provide an ongoing program of activities meeting residents' interests and physical, mental, and psychosocial well-being.
Failure to identify, assess, and provide supportive interventions for a resident with PTSD.
Failure to have a registered nurse on duty for at least eight consecutive hours daily, seven days a week.
Failure to provide annual individual performance reviews and in-service education for nurse aides.
Failure to attempt gradual dose reductions for psychotropic medications unless contraindicated.
Failure to employ a clinically qualified dietitian or certified dietary manager as Food and Nutritional Service Manager.
Failure to ensure bedtime snacks were offered to all residents at bedtime.
Failure to store and distribute food under sanitary conditions, including uncovered food and unlabeled food items.
Failure to maintain essential equipment, including laundry machines, in safe and operable condition.
Failure to provide a safe and functional environment by allowing items to be stored on overbed light fixtures.
Failure to provide at least twelve hours of nurse aide in-service education annually.
Report Facts
Residents affected: 86
Days without RN coverage for 8 consecutive hours: 9
Annual in-service training hours: 2.83
Annual in-service training hours: 5.75
Number of activities per day: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | No annual performance review or sufficient in-service training |
| CNA B | Certified Nursing Assistant | No annual performance review or sufficient in-service training |
| Dietary Manager | Dietary Manager | Not certified, started role Nov 2024, no RD since Aug 2024 |
| Registered Dietitian | Registered Dietitian | Contract started 03/30/25, no RD for months prior |
| Laundry Aide K | Laundry Aide | Reported only one working laundry machine with frequent breakdowns |
| Administrator | Facility Administrator | Provided expectations on multiple deficiencies including RN coverage, transfer notifications, and snack offerings |
| Maintenance Director | Maintenance Director | Acknowledged issues with window units and laundry equipment |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged failure to do gradual dose reductions |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 16
Date: Apr 2, 2025
Visit Reason
Annual inspection survey conducted from 3-30-25 through 4-2-2025 to assess compliance with federal and state regulations for Arbor View Nursing and Rehabilitation facility.
Findings
The facility was found deficient in multiple areas including resident rights, self-determination, notice and conveyance of personal funds, safe and homelike environment, in-service training for nursing personnel, medication management, trauma-informed care, staffing, food service, and environmental safety. Deficiencies ranged from failure to promote resident dignity to inadequate maintenance and training.
Deficiencies (16)
F550 Resident Rights: The facility failed to promote resident independence and dignity during dining by serving meals on disposable dishware. The facility census was 86.
F561 Self-Determination: The facility failed to create an environment respectful of residents' rights to make choices, including bathing schedules and shaving preferences. The facility census was 86.
F569 Notice and Conveyance of Personal Funds: The facility failed to provide final accounting of a resident's funds within 30 days of death and lacked a policy regarding resident funds balance. The facility census was 86.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including maintenance of equipment and physical plant. The facility census was 86.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents or their representatives of transfers or discharges in writing as required. The facility census was 86.
F679 Activities Meet Interest/Needs: The facility failed to provide an ongoing program of activities meeting residents' interests and preferences. The facility census was 86.
F699 Trauma Informed Care: The facility failed to identify, assess, and provide supportive interventions for residents with PTSD. The facility census was 86.
F727 RN 8 Hrs/7 Days/Wk: The facility failed to provide a registered nurse for at least eight consecutive hours a day, seven days a week. The facility census was 86.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to provide annual in-service education for nurse aides. The facility census was 86.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to attempt gradual dose reduction for psychotropic medications and failed to properly document PRN orders. The facility census was 86.
F801 Qualified Dietary Staff: The facility failed to employ a qualified dietitian or nutrition professional and maintain required certifications. The facility census was 86.
F809 Frequency of Meals/Snacks at Bedtime: The facility failed to provide bedtime snacks and ensure snacks were offered to residents unable to get to the nurses' station. The facility census was 86.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: The facility failed to maintain food safety, including proper storage, labeling, and cleanliness of kitchen and food service areas. The facility census was 86.
F908 Essential Equipment, Safe Operating Condition: The facility failed to maintain essential mechanical and patient care equipment in safe operating condition. The facility census was 86.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain a safe and comfortable environment by allowing clutter, broken fixtures, and unsafe storage. The facility census was 86.
F947 Required In-Service Training for Nurse Aides: The facility failed to provide required annual in-service training for nurse aides. The facility census was 86.
Report Facts
Facility census: 86
Resident sample size: 18
Resident funds account balance: 2694
Annual training hours required: 12
Psychotropic drug PRN order limit: 14
Nursing coverage hours: 8
Nursing coverage days: 7
Inspection Report
Life Safety
Census: 86
Deficiencies: 4
Date: Apr 2, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code and related fire safety regulations at Arbor View Nursing and Rehabilitation.
Findings
The facility failed to maintain exit signage in working order, maintain the sprinkler system free of dust and debris, ensure fire extinguishers were properly inspected and maintained, and properly use power strips and extension cords in patient care areas. These deficiencies potentially affected all residents and staff.
Deficiencies (4)
K293 Exit Signage: The facility failed to maintain exit signage in working order; exit signs above fire doors did not illuminate when tested.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinklers were clean and free of corrosion and debris; sprinkler heads in the laundry room had dust and debris.
K355 Portable Fire Extinguishers: The facility failed to maintain fire extinguishers including the Anhydrous sulfur dioxide fire suppression system; inspections were not completed monthly.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure proper use of power strips and extension cords, allowing unapproved cords in resident rooms and offices.
Report Facts
Facility census: 86
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Feb 6, 2025
Visit Reason
The inspection was conducted in response to Complaint #MO00249132 regarding concerns about resident care related to activities of daily living, specifically inconsistent resident showers and hygiene.
Complaint Details
Complaint #MO00249132 was investigated. The complaint concerned residents not receiving showers as scheduled and poor personal hygiene. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to provide consistent care for activities of daily living, including bathing and personal hygiene, for three sampled residents. Observations and interviews revealed residents went extended periods without showers, and staff did not always complete shower sheets accurately.
Deficiencies (2)
F 677 ADL Care Provided for Dependent Residents. The facility failed to provide consistent resident care for activities of daily living, resulting in residents going weeks without showers and inadequate assistance with dressing, grooming, and personal hygiene.
A4077 Residents Groomed/Dressed Appropriately. Residents were not consistently well-groomed or dressed appropriately, as evidenced by disheveled hair, food on clothing, and body odor issues.
Report Facts
Facility census: 92
Showers missed: 6
Showers missed: 7
Showers missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marlene Rose | Interim Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Assistant Director of Nursing | ADON | Interviewed regarding shower schedule and staff compliance |
| Interim Director of Nursing | DON | Interviewed regarding shower sheet process and staff compliance |
| Certified Nurse Aide A | CNA | Interviewed about shower sheet completion |
| Certified Nurse Aide B | CNA | Interviewed about shower sheet completion |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: Dec 13, 2024
Visit Reason
The inspection was conducted in response to complaints regarding food temperature and quality at Arbor View Nursing and Rehabilitation.
Complaint Details
Complaint numbers MO00245733 and MO00246557 were investigated. The complaint was substantiated based on observations and interviews confirming food temperature issues.
Findings
The facility failed to maintain proper hot food temperatures at or above 120 degrees Fahrenheit for 12 sampled residents and did not provide temperature logs for food served on hall trays. Interviews and observations confirmed food was served cold and not at safe temperatures.
Deficiencies (2)
F804: Facility staff failed to maintain hot food temperatures at or above 120 degrees Fahrenheit for 12 sampled residents and did not implement a system to monitor food temperatures at service time.
A5005: Facility did not assure that hot food is served hot and cold food is served cold, violating 19 CSR 30-85.052(5).
Report Facts
Residents with improper food temperature: 12
Facility census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food service cart usage and temperature issues. | |
| Administrator | Interviewed about food service policy and corrective actions. |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration errors involving Resident #1 at Arbor View Nursing and Rehabilitation.
Complaint Details
Complaint #MO 242770 triggered the investigation into medication administration errors for Resident #1, which was substantiated by findings of missed doses and improper medication handling.
Findings
The facility failed to follow physician's orders for Resident #1, resulting in missed doses of seizure medication. The investigation revealed medication was misplaced in the wrong medication cart, leading to multiple missed doses and a resident seizure.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to follow physician's orders for Resident #1, resulting in five missed doses of seizure medication and a subsequent seizure. Medication was placed in the nurse's medication cart instead of the Certified Medication Technician's cart, causing delays in administration.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the medication errors cited in F658.
Report Facts
Missed medication doses: 5
Resident census: 87
Medication tablets received: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Signed off medication and involved in medication administration errors. |
| LPN D | Licensed Practical Nurse | Signed for medication and interviewed regarding medication administration. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding medication administration policies and expectations. |
| ADON | Assistant Director of Nursing | Interviewed about medication cart management and refill procedures. |
| CMT G and CMT H | Certified Medication Technicians | Notified night nurses about missing medication and involved in medication administration. |
| Pharmacy Manager | Pharmacy Manager | Interviewed about medication supply and delivery for Resident #1. |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Date: Aug 23, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's revocation of residents' Leave of Absence (LOA) privileges and restrictions on visitation based on alleged possession of illegal substances, as well as concerns about resident rights violations.
Complaint Details
Complaint #MO239985 involved concerns about revocation of LOA privileges and resident rights related to substance use policies. Complaint MO00240601 involved issues with resident financial management and access to funds.
Findings
The facility revoked LOA privileges for several cognitively intact residents based on suspected or alleged violations of a new policy prohibiting illegal substances, alcohol, and marijuana. The facility also restricted visitation for a resident's family member based on an assumption of drug possession. Additionally, the facility failed to obtain proper authorization for resident fund withdrawals and did not consistently provide residents access to their funds.
Deficiencies (3)
Facility revoked residents' LOA privileges based on suspected substance use or policy violations without adequate resident consent or oversight.
Facility prohibited visitation of a family member based on assumption of marijuana possession without investigation or offering supervised visits.
Facility failed to obtain written authorization for money withdrawn from residents' accounts and failed to allow ongoing access to resident funds.
Report Facts
Facility census: 86
Resident #6 withdrawal amount: 50
Resident #7 withdrawal amount: 50
Resident #11 balance: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADM) | Discussed revocation of LOA privileges and visitation restrictions; involved in denying family visitation |
| Regional Nurse | Regional Nurse (RGN) | Explained facility policy revisions and resident signing of new policy |
| Medical Director | Medical Director (MD) | Explained rationale for revoking LOA privileges to protect residents and facility |
| Director of Nurses | Director of Nurses (DON) | Confirmed enforcement of physician orders revoking LOA privileges |
| Social Worker | Social Worker (SW) | Expressed concerns about resident rights issues with new policy and visitation restrictions |
| Business Office Manager | Business Office Manager | Reported unauthorized withdrawals from resident accounts and issues with resident access to funds |
| Activities Supervisor | Activities Supervisor | Reported lack of resident petty cash availability affecting resident access to funds |
Inspection Report
Plan of Correction
Census: 86
Deficiencies: 6
Date: Aug 23, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to resident rights, including self-determination and visitation rights, and to review the facility's plan of correction for these deficiencies.
Complaint Details
Complaint #MO239985 involved concerns about resident rights related to leave of absence revocation and visitation restrictions. Complaint MO00240601 related to resident funds management issues.
Findings
The facility failed to protect the rights of residents regarding self-determination by revoking leave of absence privileges without proper oversight and restricting visitation rights based on assumptions about contraband. Deficiencies were found in managing resident funds and ensuring residents' rights to communicate and live without undue restrictions.
Deficiencies (6)
F561: The facility failed to protect the rights of four residents by revoking their leave of absence privileges without adequate protective oversight and restricting their self-determination rights.
F563: The facility failed to protect the rights of one resident by prohibiting visitation based on the assumption that a family member possessed marijuana, violating visitation rights.
F567: The facility failed to obtain written authorization for resident funds withdrawals and did not maintain residents' personal funds properly, affecting all residents' financial affairs.
A8032: The facility failed to allow residents to communicate privately with persons of their choice, violating residents' rights.
A8042: Residents' personal lives were regulated or controlled beyond reasonable adherence to meal schedules and policies, violating their rights.
A9002: The facility failed to ensure that personal funds were used exclusively for the resident and only with proper authorization, violating resident fund use regulations.
Report Facts
Facility census: 86
Residents affected: 4
Residents affected: 1
Residents affected: 14
Withdrawal amount: 50
Resident balance: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADM) | Interviewed regarding resident self-determination and leave of absence revocation |
| Regional Nurse | Regional Nurse (RGN) | Interviewed regarding facility policy revisions and resident visitation |
| Medical Director | Medical Director (MD) | Interviewed regarding protective oversight for residents leaving facility |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding physician orders and resident medication oversight |
| Social Worker | Social Worker (SW) | Interviewed regarding resident rights issues and complaints |
| Business Office Manager | Business Office Manager | Interviewed regarding resident funds withdrawal and signature issues |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 16
Date: Jun 7, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Arbor View Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including accident hazards related to resident smoking supervision, dialysis care documentation, food safety and sanitation, infection prevention and control, and pest control. Several residents were observed smoking unsupervised contrary to facility policy, and lapses in infection control and pest management were noted.
Deficiencies (16)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure safe smoking interventions for residents, with multiple instances of unsupervised smoking observed despite care plans requiring supervision.
F698 Dialysis: The facility failed to provide documentation of ongoing assessments, monitoring, and communication with the dialysis center for one resident.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, with dirt, debris, and unlabeled food items observed in the kitchen and storage areas.
F814 Dispose Garbage and Refuse Properly: The facility failed to ensure dumpsters were closed and maintained to keep pests out, and lacked a sanitation policy.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices, including hand hygiene and cleaning protocols, resulting in risk of infection transmission to residents.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, with flies observed in multiple areas and inadequate pest service documentation.
A2056 Smoking-Designated Areas/Assess Supervision: The facility failed to ensure residents capable of smoking unsupervised were properly assessed and reassessed annually.
A4031 Communicable Disease-Employees: The facility failed to ensure employees were screened for communicable diseases and tuberculosis as required.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with resident condition.
A4086 Infection Control/Communicable Disease: The facility failed to report communicable diseases and implement infection control measures as required.
A6032 Outside Dumpsters Cleanable/Covered: Waste containers outside were not properly covered or maintained to prevent pest access.
A6039 Inspect/Rodent Control: The facility failed to implement effective measures to minimize rodents, flies, and other pests.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain proper temperatures.
A7016 Food-Clean Containers, Storage, Covers: Food containers were not properly covered or stored to prevent contamination.
A7019 Food Stored in Identifying Containers: Food was stored in containers without proper identification.
A7067 Nonfood Contact Surfaces, Cleaned as Needed: Nonfood contact surfaces were not cleaned adequately to prevent accumulation of dirt and debris.
Report Facts
Facility census: 83
Deficiencies cited: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee C | Mentioned in relation to tuberculosis testing deficiency | |
| Employee D | Mentioned in relation to tuberculosis testing deficiency | |
| Employee E | Mentioned in relation to tuberculosis testing deficiency | |
| Employee F | Mentioned in relation to tuberculosis testing deficiency | |
| Employee G | Mentioned in relation to tuberculosis testing deficiency | |
| Employee H | Mentioned in relation to tuberculosis testing deficiency |
Inspection Report
Life Safety
Census: 83
Capacity: 150
Deficiencies: 4
Date: Jun 7, 2024
Visit Reason
The inspection was a Life Safety Code (LSC) survey conducted to assess compliance with fire safety regulations and related codes at Arbor View Nursing and Rehabilitation.
Findings
The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, had missing ceiling tiles, lacked proper fire alarm notification devices in the courtyard, and did not install all components of the emergency generator system. Additionally, improper use and installation of power strips and extension cords were observed.
Deficiencies (4)
K321 Hazardous Areas - The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, including a missing 5 foot by 3 foot ceiling tile in the boiler room.
K341 Fire Alarm System - The facility failed to ensure all components of the fire alarm system, including audio and visual notification devices in the courtyard, were properly installed and operational.
K918 Electrical Systems - The facility failed to install all components of the emergency generator system according to NFPA standards, including missing emergency shut off switches.
K920 Electrical Equipment - The facility failed to ensure proper use of power strips and extension cords, including use beyond temporary purposes and improper placement near patient care areas.
Report Facts
Facility capacity: 150
Resident census: 83
Inspection Report
Routine
Census: 83
Deficiencies: 6
Date: Jun 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, dialysis care, food safety, waste disposal, infection control, and pest control at Arbor View Nursing and Rehabilitation.
Findings
The facility was found deficient in ensuring safe smoking supervision for residents, proper dialysis communication and monitoring, sanitary food storage and preparation, proper garbage disposal, infection prevention practices, and effective pest control measures to manage flies within the facility.
Deficiencies (6)
Failed to ensure safe smoking interventions and supervision for residents who smoke, resulting in unsupervised smoking and noncompliance with facility smoking policy.
Failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and dialysis center for a resident requiring dialysis.
Failed to store and distribute food under sanitary conditions, including dirt and debris in refrigerators and freezers, unlabeled food items, and grime buildup on kitchen equipment.
Failed to ensure dumpsters were closed at all times and maintained to keep pests out and garbage contained.
Failed to maintain infection control practices during wound care, including improper hand hygiene, reuse of soiled gloves, and contamination of wound care supplies.
Failed to maintain an effective pest control program to control the fly population inside the facility, with multiple observations of flies in resident rooms and common areas.
Report Facts
Facility census: 83
Missed communication reports: 16
Missed vital sign documentation: 3
Number of flies observed: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in infection control deficiency related to wound care practices |
| Licensed Practical Nurse B | Infection Preventionist | Provided expectations for proper infection control practices during wound care |
| Registered Nurse M | Registered Nurse | Discussed dialysis communication process |
| Licensed Practical Nurse L | Licensed Practical Nurse | Discussed dialysis communication and fly observations |
| Dietary Manager | Discussed food safety and dumpster lid expectations | |
| Housekeeping and Laundry Manager | Discussed dumpster lid expectations and pest control challenges | |
| Administrator | Provided facility expectations on smoking supervision, dialysis communication, food safety, dumpster lids, infection control, and pest control | |
| Director of Nursing | Provided facility expectations on smoking supervision, dialysis communication, infection control, and pest control |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: Oct 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding infection prevention and control practices related to COVID-19 at Arbor View Nursing and Rehabilitation.
Complaint Details
The complaint investigation found an imminent danger Class I level violation related to infection control and COVID-19 transmission. The violation was initially at immediate jeopardy level K but was lowered to serious level E after corrective actions. The facility had not separated COVID-positive and negative residents, increasing exposure risk.
Findings
The facility failed to maintain an infection prevention and control program to prevent the spread of COVID-19, resulting in an immediate jeopardy situation that was later lowered to a serious deficiency. The facility did not properly separate COVID-positive and negative residents, increasing the risk of transmission.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program to prevent the spread of COVID-19, including failure to separate COVID-positive and negative residents, resulting in increased risk of transmission.
A4086 Infection Control/Communicable Disease: The facility failed to report a communicable disease to the Missouri Department of Health within seven days as required by state regulations.
Report Facts
Facility census: 85
Number of residents tested positive for COVID-19: 6
Number of residents tested negative for COVID-19: 6
Days for plan of correction completion: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Notified of immediate jeopardy and involved in plan of correction | |
| Director of Nursing (DON) | Notified of immediate jeopardy and involved in infection control and plan of correction | |
| Assistant Director of Nursing/Infection Preventionist (ADON/IP) | Notified of immediate jeopardy and involved in infection control and plan of correction | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding isolation and PPE use for COVID-positive residents |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Date: Aug 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to promptly resolve grievances for residents.
Complaint Details
The complaint investigation found that the facility failed to promptly resolve grievances for two residents, did not conduct investigations or follow-up, and lost grievance documentation. The grievance process was not properly managed or communicated to residents and families.
Findings
The facility failed to make prompt efforts to resolve grievances for two of three sampled residents, potentially affecting all residents. Investigations and follow-ups on grievances were not completed or documented properly.
Deficiencies (2)
F 585 Grievances: The facility failed to make prompt efforts to resolve grievances for two of three sampled residents and did not complete investigations or follow-up with residents or families.
A8020 Exercise Rights/Voice Grievances: The facility did not encourage or assist residents to exercise their rights to voice grievances and recommend policy changes, violating the regulation.
Report Facts
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Miller | Administrator | Signed the report and plan of correction |
| LPN B | Licensed Practical Nurse | Reported grievances from residents and informed about grievance document loss |
| ADON | Assistant Director of Nursing | Interviewed regarding grievance investigations and policy adherence |
| Social Service Worker | Grievance Officer | Described grievance handling process and communication |
| Director of Nurses | DON | Interviewed about grievance awareness and policy compliance |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 31, 2023
Visit Reason
Annual survey inspection of Arbor View Nursing and Rehabilitation facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 0
Date: May 31, 2023
Visit Reason
The inspection was conducted as an infection control survey for regulatory compliance.
Findings
No deficiencies were cited as a result of the infection control survey.
Inspection Report
Routine
Census: 94
Deficiencies: 21
Date: Dec 6, 2022
Visit Reason
The inspection was a routine regulatory survey of Arbor View Nursing and Rehabilitation to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, obtaining physician orders, maintaining a safe and clean environment, notification of transfers and bed hold policies, accurate resident assessments and care plans, medication administration, infection control, food safety, and maintenance of physical plant elements such as handrails.
Deficiencies (21)
Failed to ensure staff treated residents with dignity and respect by leaving a cognitively impaired resident exposed in their room without privacy.
Failed to obtain physician orders for code status for two residents.
Failed to provide a safe, clean, and comfortable environment including maintenance issues such as exposed sheetrock, holes, peeled paint, dried blood and feces, and unclean bathrooms.
Failed to provide timely notification of transfer or discharge to residents and/or their representatives for six residents.
Failed to provide written notification of bed hold policy to residents and/or their representatives for two residents.
Failed to document complete and accurate Minimum Data Set (MDS) assessments for three residents.
Failed to develop and implement baseline care plan within 48 hours of admission for one resident.
Failed to implement individualized care plans with specific interventions for two residents.
Failed to obtain physician orders for oxygen, Foley catheter care, and hospice admission for five residents.
Failed to provide consistent resident care for activities of daily living, including extended periods without showers or bed baths for five residents.
Failed to follow bowel regimen policy and monitor bowel movements for one resident resulting in prolonged constipation.
Failed to provide appropriate pressure ulcer care and repositioning for two residents and failed to follow wound care orders for one resident.
Failed to provide proper incontinent care for two residents, including failure to cleanse perineal area and change gloves between clean and dirty care.
Failed to follow physician orders and facility policy on weight monitoring for two residents, including failure to obtain admission weights and weekly weights.
Failed to provide documentation of ongoing assessments, monitoring, and communication with dialysis center for two residents receiving dialysis.
Failed to post nurse staffing data daily with all required components in a clear and readable format.
Failed to store medications safely and effectively, including leaving medications unattended and storing expired medications.
Failed to maintain kitchen sanitation and food safety, including unlabeled and undated food items, buildup of grime and debris on equipment, and lack of cleaning documentation.
Failed to utilize proper infection control techniques during catheter care, incontinent care, wound care, and medication administration; failed to complete required TB screenings and annual infection control program review.
Failed to provide and document influenza and pneumococcal vaccine education and administration for two residents.
Failed to maintain and repair handrails on multiple halls, with missing end pieces and loose sections, and lack of maintenance documentation.
Report Facts
Residents affected: 25
Residents affected: 2
Residents affected: 94
Residents affected: 6
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 94
Residents affected: 94
Residents affected: 94
Residents affected: 8
Residents affected: 2
Residents affected: 94
Inspection Report
Life Safety
Census: 94
Deficiencies: 5
Date: Dec 6, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including kitchen equipment, sprinkler system maintenance, smoking regulations, and electrical equipment safety.
Findings
The facility failed to meet several fire safety requirements including maintenance of kitchen equipment, proper storage and use of alcohol-based hand rub dispensers, sprinkler system maintenance, smoking area regulations, and electrical equipment wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
K324 Cooking Facilities: The facility failed to maintain kitchen equipment to NFPA standards, with kitchen hood filters observed laden with yellow, greasy substance. This affected all residents and staff.
K325 Alcohol Based Hand Rub Dispenser (ABHR): The facility failed to properly store hand sanitizer, with 106 gallons stored improperly in the main storage room. This affected all residents and staff.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads in proper working order, with two sprinkler heads heavily corroded. This affected all residents and staff.
K741 Smoking Regulations: The facility failed to maintain smoking areas properly, with a fire blanket being used as a trash can and ashtray. This affected all residents and staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict use of temporary wiring, with power strips 'piggybacked' and plugged into a refrigerator. This affected all residents and staff.
Report Facts
Facility census: 94
Gallons of hand sanitizer: 106
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited as a result of the complaints investigated.
Inspection Report
Plan of Correction
Census: 83
Deficiencies: 1
Date: Mar 15, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Big River Nursing & Rehab following a survey completed on 03/15/2022. It addresses a past non-compliance related to misappropriation/exploitation of residents' narcotic medication.
Complaint Details
Complaint #MO 00197896 is referenced but no substantiation status is provided.
Findings
The facility failed to prevent the misappropriation of narcotic medication for eight residents. The investigation revealed tampering with medication cards and compromised medication packs, with disciplinary actions taken and corrective measures implemented.
Deficiencies (1)
F602: The facility failed to prevent misappropriation of narcotic medication for eight residents, evidenced by tampered medication cards and compromised medication packs. The facility census was 83 at the time of the incident.
Report Facts
Number of residents involved in misappropriation: 8
Facility census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered medications and discovered tampering with medication cards |
| LPN C | Licensed Practical Nurse | Suspected of passing medication improperly and linked to compromised medication packs |
| DON | Director of Nursing | Notified of medication tampering and involved in investigation and audit |
| ADON | Assistant Director of Nursing | Notified of medication tampering and involved in investigation and audit |
| Administrator | Arrived onsite for narcotic count and investigation |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices. No deficiencies were cited during the onsite visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation was conducted on 12/17/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The complaint investigation was related to COVID-19 infection control practices and was found to be unsubstantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this visit.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Plan of Correction
Census: 95
Deficiencies: 5
Date: Feb 25, 2020
Visit Reason
The inspection was conducted to assess compliance with federal regulations and to address deficiencies identified during the survey of Big River Nursing & Rehab.
Findings
The facility was found deficient in developing and implementing comprehensive care plans, meeting professional standards for services provided, tube feeding management, nurse aide in-service training, and infection prevention and control. Deficiencies were documented with specific resident cases and facility policy reviews.
Deficiencies (5)
F656: The facility failed to develop and implement a comprehensive person-centered care plan for one resident, lacking measurable objectives and timeframes.
F658: The facility failed to follow a physician's order for one resident, not meeting professional standards of quality for services provided.
F693: The facility failed to follow physician orders for enteral feeding for one resident, not ensuring appropriate treatment and monitoring.
F730: The facility failed to ensure two of five randomly selected Certified Nurse Aides received required annual in-service training.
F880: The facility failed to maintain infection control practices, including hand hygiene and proper use of gloves, affecting multiple residents.
Report Facts
Facility census: 95
Sampled residents: 19
Deficient residents for care plan: 1
Deficient residents for tube feeding: 1
Deficient CNAs for in-service training: 2
Residents affected by infection control deficiencies: 6
Inspection Report
Life Safety
Census: 95
Deficiencies: 6
Date: Feb 25, 2020
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Big River Nursing & Rehab.
Findings
The facility failed to maintain emergency egress lighting, safeguard hazardous areas with a one-hour fire barrier, and properly mount portable fire extinguishers. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (6)
K281 Illumination of Means of Egress: The facility failed to maintain emergency egress lighting for the building, resulting in a lack of exit illumination along exit pathways.
K321 Hazardous Areas - Enclosure: The facility failed to maintain one-hour fire protection around hazardous areas, including the medical record storage room and corridor, which lacked proper fire barriers.
K355 Portable Fire Extinguishers: Fire extinguishers were mounted over 60 inches from the floor, exceeding the maximum allowed height of 5 feet.
A2008 Hazardous Areas: Hazardous areas were not properly separated by fire-resistant construction or automatic closing doors as required.
A2016 Portable Fire Extinguishers: Fire extinguishers lacked proper labeling and monthly pressure checks as required by NFPA 10 standards.
A2050 Illumination of Means of Egress: Emergency lighting was insufficient to provide safe egress for residents and staff during power failures.
Report Facts
Facility census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irene M. Lucas | Administrator | Signed and dated the plan of correction and educated Maintenance Director on deficiencies |
| Maintenance Supervisor | Acknowledged lack of exit illumination and fire extinguisher mounting issues | |
| Maintenance Director | Educated on egress lighting, hazardous areas, and fire extinguisher requirements; responsible for audits and corrections |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 3
Date: Dec 17, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to quality of care concerns for one resident involving wound care and postoperative management.
Complaint Details
Complaint #MO163453 was substantiated. The investigation found failures in wound care and physician order verification for Resident #1, leading to wound infection and inadequate follow-up care.
Findings
The facility failed to develop and implement a comprehensive baseline care plan addressing postoperative wound care and treatment for one resident. The facility also failed to verify physician orders and provide appropriate wound care, resulting in wound dehiscence, infection, and inadequate follow-up care.
Deficiencies (3)
F655 Baseline Care Plan: The facility did not develop and implement a baseline care plan including postoperative wound care and treatment for one resident within 48 hours of admission.
F684 Quality of Care: The facility failed to verify physician orders and provide appropriate wound care for one resident, resulting in wound dehiscence, infection, and lack of follow-up appointment scheduling.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practices. This was not met as evidenced by deficiencies in wound care and follow-up for one resident.
Report Facts
Facility census: 102
Date of survey: Dec 17, 2019
Inspection Report
Annual Inspection
Census: 97
Deficiencies: 6
Date: Apr 19, 2019
Visit Reason
The inspection was conducted as an annual survey of Big River Nursing & Rehab to assess compliance with federal regulations related to resident care, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including catheter care, tube feeding management, dialysis services, nurse aide training, medication storage, infection prevention and control, and water management. Several residents were affected by these deficiencies, and systemic corrective actions were planned.
Deficiencies (6)
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide appropriate care practices related to indwelling catheter use for three residents, including obtaining physician orders and proper catheter positioning.
F693 Tube Feeding Management/Restore Eating Skills: The facility failed to verify gastrostomy tube functioning before feeding and medication administration for one resident.
F698 Dialysis: The facility failed to provide documentation of ongoing assessments, monitoring, and communication with the dialysis center for two residents receiving dialysis.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to ensure four of five randomly selected CNAs received the required annual 12-hour resident care training based on performance reviews.
F761 Label/Store Drugs and Biologicals: The facility failed to maintain proper refrigerator temperatures and medication storage practices affecting multiple residents.
F880 Infection Prevention & Control: The facility failed to implement an effective infection prevention and control program, including water management to prevent Legionella growth.
Report Facts
Facility census: 97
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Derschwedt | Administrator | Signed the inspection report and plan of correction |
| Director of Nursing | Interviewed regarding catheter care, dialysis, and infection control policies | |
| Registered Nurse E | Registered Nurse | Observed administering medications and interviewed about dialysis communication |
| Certified Nurse Aide D | Certified Nurse Aide | Observed handling catheter bags improperly |
| Certified Nurse Aide F | Certified Nurse Aide | Observed transferring resident with catheter tubing dragging |
| Certified Medication Technician G | Certified Medication Technician | Interviewed about medication refrigerator temperature monitoring |
Inspection Report
Life Safety
Census: 97
Deficiencies: 5
Date: Apr 19, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain fire alarm testing documentation, maintain gas-fired equipment ventilation, maintain smoking regulations, and ensure proper use of electrical equipment. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (5)
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain fire alarm testing documentation as required by NFPA standards. The electronic smoke dampers had not been inspected.
K522 HVAC - Any Heating Device: The facility failed to maintain gas-fired equipment with proper intake air ventilation within 18 inches of the floor, risking accumulation of carbon monoxide.
K741 Smoking Regulations: The facility failed to maintain smoking areas according to NFPA regulations, including improper disposal of cigarette butts in trash cans.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed use of power strips and extension cords beyond temporary installation, creating electrical and fire hazards.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinders properly labeled and separated, and did not comply with NFPA storage requirements.
Report Facts
Facility census: 97
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: Jan 16, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to medication storage and labeling practices at Big River Nursing & Rehabilitation Center.
Complaint Details
Complaint #MO151621 triggered the investigation. The complaint was substantiated based on observations and interviews confirming medication storage and labeling deficiencies.
Findings
The facility failed to label and store medications in a safe and effective manner, with medication carts unlocked and unattended, containing open and unlabeled medications. Staff were not following policies for securing medication carts, and the medication cart lock was broken for two weeks.
Deficiencies (2)
F761 Label/Store Drugs and Biologicals: The facility failed to label and store medications properly, with unlocked medication carts containing open and unlabeled medications. The medication cart lock was broken and not repaired for two weeks.
A4063 Medication Storage: The facility did not store medications at appropriate temperatures or secure them behind locked doors or cabinets as required. Discontinued medications were not stored separately from current medications.
Report Facts
Facility census: 94
Completion date: Jan 28, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding awareness of medication cart lock being broken |
| Certified Medications Technician A | Certified Medications Technician | Interviewed regarding medication cart lock and medication handling |
| Director of Nursing | Director of Nursing | Interviewed regarding medication cart lock and staff compliance |
| Assistance Director of Nurses | Assistance Director of Nurses | Reported broken medication cart lock |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Date: Dec 6, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect a resident from sexual abuse by another resident with a criminal history.
Complaint Details
Complaint #150079 was substantiated. The violation was initially at immediate jeopardy level 'J' but was lowered to 'D' and 'II' levels after corrective actions were implemented during the onsite visit.
Findings
The facility failed to provide sufficient monitoring of a resident with a history of sexual offenses, resulting in an incident where one resident was found with his hand on another resident's peri area. Staff were not informed of the offender's criminal background and no preventive interventions were in place.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to protect one resident from sexual abuse by another resident with a registered sex offender background. Staff were not informed or instructed to monitor or intervene to prevent inappropriate behaviors.
A4073 Protective Oversight, Voluntary Leave: The facility did not have adequate procedures to ensure protective oversight and supervision for residents on voluntary leave, failing to inquire about the resident's whereabouts and length of absence.
Report Facts
Facility census: 98
Complaint number: 150079
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 5
Date: Aug 3, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of deficient care plans, assistance with activities of daily living, food procurement and sanitation, equipment maintenance, and pest control at Big River Nursing & Rehabilitation Center.
Complaint Details
Complaint #MO 00145216 and Complaint #MO 00145326 were investigated. The complaints involved failure to provide adequate care plans, assistance with meals and call lights, food safety violations, equipment maintenance issues, and pest control deficiencies. The complaints were substantiated as evidenced by observations, interviews, and record reviews.
Findings
The facility failed to implement comprehensive care plans addressing residents' specific needs, did not provide timely assistance with meals and call lights, failed to maintain food service sanitation, did not maintain equipment properly, and lacked an effective pest control program. Multiple deficiencies were cited related to care planning, ADL assistance, food safety, equipment maintenance, and pest control.
Deficiencies (5)
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement complete care plans with specific interventions to meet individual needs for six of 11 sampled residents. Care plans did not address key medical and psychosocial needs.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide timely assistance with meals and call lights for multiple residents, resulting in uncovered meals and delayed responses.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to prepare and serve food under sanitary conditions, risking cross-contamination and foodborne illness affecting all residents in the main dining room.
F908 Essential Equipment, Safe Operating Condition: The facility failed to maintain a specialized electric bed according to manufacturer recommendations, and lacked a maintenance policy for equipment.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, resulting in flies present in the main dining room and potential exposure to residents.
Report Facts
Facility census: 105
Sampled residents: 11
Residents affected by ADL deficiency: 8
Residents with call light delays: 7
Residents affected by pest control deficiency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Derschmidt | Administrator | Named in interviews regarding care plans, food service, and pest control |
| Director of Nurses | Director of Nursing | Interviewed regarding staffing and call light response issues |
| Certified Nurse Aide A | CNA | Observed assisting residents during meal service |
| Dietary Aide B | Dietary Aide | Observed serving food under unsanitary conditions |
Inspection Report
Annual Inspection
Census: 102
Deficiencies: 17
Date: Apr 27, 2018
Visit Reason
The inspection was conducted as an annual survey of Big River Nursing & Rehabilitation Center to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident rights, safe environment, bed hold policy, quarterly assessments, comprehensive care plans, discharge summaries, quality of care, infection control, medication administration, and staff training. Several systemic measures and plans of correction were implemented to address these deficiencies.
Deficiencies (17)
F550 Resident Rights. The facility failed to treat each resident with respect and dignity for one resident out of 21 sampled. The census was 102.
F584 Safe Environment. The facility failed to maintain two shower rooms in a clean and homelike environment. The census was 102.
F625 Notice of Bed Hold Policy. The facility failed to inform residents and families of the bed hold policy at the time of hospital transfer for six residents. The census was 102.
F638 Quarterly Review Assessment. The facility failed to complete a quarterly assessment for one resident out of 41 sampled. The census was 102.
F656 Comprehensive Care Plan. The facility failed to implement individualized care plans for one resident out of 21 sampled. The census was 102.
F657 Care Plan Timing and Revision. The facility failed to update and revise care plans for two residents out of 21 sampled. The census was 102.
F661 Discharge Summary. The facility failed to complete a comprehensive discharge summary for one resident out of three discharged. The census was 102.
F684 Quality of Care. The facility failed to coordinate a plan of care with hospice for one resident out of 21 sampled. The census was 102.
F688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide restorative nursing services for one resident out of 21 sampled. The census was 102.
F730 Nurse Aide Performance Review. The facility failed to ensure two certified nurse aides received required annual in-service training. The census was 102.
F732 Posted Nurse Staffing Information. The facility failed to post nurse staffing data in a clear and readable format. The census was 102.
F755 Pharmacy Services. The facility failed to accurately document and reconcile narcotic medications for one resident out of 21 sampled. The census was 102.
F759 Free of Medication Error Rates 5 Percent or More. The facility failed to maintain medication error rates below 5 percent, with two errors in 30 opportunities affecting two residents. The census was 102.
F865 QAPI Program. The facility failed to develop a quality assurance and performance improvement plan. The census was 102.
F880 Infection Prevention & Control. The facility failed to maintain an effective infection control program for multiple residents. The census was 102.
F881 Antibiotic Stewardship Program. The facility failed to establish an antibiotic stewardship program. The census was 102.
F883 Influenza and Pneumococcal Immunizations. The facility failed to provide education and documentation for pneumococcal vaccines for several residents. The census was 102.
Report Facts
Resident census: 102
Sampled residents: 21
Sampled residents for quarterly review: 41
Discharged residents sampled: 3
Medication error opportunities: 30
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Named in resident rights deficiency and plan of correction | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and plans of correction |
| Certified Medication Technician G | CMT | Named in medication administration deficiency |
| Certified Nurse Aide CNA B | CNA | Named in nurse aide in-service training deficiency |
| Certified Nurse Aide CNA C | CNA | Named in nurse aide in-service training deficiency |
Inspection Report
Life Safety
Census: 102
Deficiencies: 10
Date: Apr 27, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to meet several life safety requirements including means of egress, emergency lighting, sprinkler system maintenance, fire extinguishers placement, smoke barrier integrity, HVAC safety, portable space heaters, and electrical equipment safety. The deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (10)
K211 Means of Egress - General: The facility failed to maintain exit pathways free of obstructions and impediments to full instant use in case of fire or emergency.
K222 Egress Doors: The facility failed to maintain exit egress doors free from impediments preventing opening during an emergency.
K291 Emergency Lighting: The facility failed to maintain emergency task lighting on the generator, affecting all residents in an emergency.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the fire sprinkler system to NFPA code, with sprinkler heads loaded with dust and debris.
K355 Portable Fire Extinguishers: The facility failed to maintain portable fire extinguishers at proper distances according to NFPA code.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain smoke barrier walls free of penetrations.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to maintain smoke barrier doors with legible fire resistance rating tags.
K522 HVAC - Any Heating Device: The facility failed to maintain gas-fired equipment with proper intake air ventilation, risking fire hazards.
K781 Portable Space Heaters: The facility failed to prohibit the use of portable space heaters in the facility, posing a fire risk.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prohibit use of adapters, power strips, and extension cords beyond temporary installation, creating fire hazards.
Report Facts
Facility census: 102
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