16 Reports
Inspection Report — Apr 17, 2025
Routine
Date: Apr 17, 2025
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three deficiencies were cited: one federal health citation for inadequate hot water/environmental conditions and two Missouri state licensure citations concerning hot water temperature limits and plumbing code compliance.
Deficiencies (2)
19 CSR 30-85.032(24) Hot Water 105-120 Degrees F: Refer to F921.
19 CSR 30-87.020(25) Plumbing per Code: Refer to F921.
Inspection Report — Feb 8, 2024
Routine
Date: Feb 8, 2024
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Missouri state licensure survey (State Form); the survey type is not stated.
Findings
4 Missouri state deficiencies: failures related to smoke partition door closure, smoking in non-designated areas, improper oxygen storage, and use of portable space heaters.
Deficiencies (4)
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds Protection from Hazards: Based on observation and interview the facility failed to ensure smoke partition doors would properly close; the smoke separation door by Suite 19 would not close all the way due to a weak closer.
19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised: Based on observation and interview the facility failed to prevent smoking in non-designated areas; cigarette butts were found in Suite 36's wastebasket and the resident was bringing smoked cigarette butts back into the room.
19 CSR 30-86.022(17) Oxygen Storage Requirements: Based on observation and interview the facility failed to ensure oxygen storage in a resident's room met requirements; four oxygen bottles were openly stored in a cardboard rack in Suite 2.
19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: Based on observation and interview the facility failed to ensure portable space heaters were prohibited; a portable electric heater was observed running unattended in Suite 27.
Report Facts
oxygen bottles observed: 4
Inspection Report — Jan 16, 2024
Complaint Investigation
Date: Jan 16, 2024
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CMS health survey (CMS-2567) and Missouri State Form licensure survey; the file includes a complaint investigation (MO00230038, MO00229841).
Complaint Details
MO00230038, MO00229841; the allegation of abuse was investigated and the facility's Investigation Conclusion indicated it could not substantiate that physical or verbal abuse took place.
Findings
12 federal health deficiencies covering abuse reporting, resident assessments/MDS accuracy, medication management, supervision/elopement, food safety and infection control; and 11 Missouri state licensure deficiencies addressing smoking supervision, medication systems and review, assessments, care planning, food safety, infection control and related policies. The survey includes a complaint investigation and notes the facility's investigation could not substantiate physical or verbal abuse.
Deficiencies (11)
19 CSR 30-85.022(31) Smoking-Designated Areas/Assess Supervision: Refer to F689.
19 CSR 30-85.042(46) Safe/Effective Medication System: 1. Refer to F658. 2. Refer to F757. 3. Refer to F758.
19 CSR 30-85.042(50) Self-Administration of Medication: Refer to F658.
19 CSR 30-85.042(52) Drug Regimen Review-Monthly: Refer to F756.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F658 and F689.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(23) Hot Food-Storage, Temperatures: Refer to F812.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Refer to F812.
19 CSR 30-88.010(18) Emergency Discharges: Refer to F623.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F609.
Report Facts
residents sampled: 12
Inspection Report — Jan 16, 2024
Life Safety
Date: Jan 16, 2024
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Federal CMS-2567 Life Safety (LSC) and Emergency Preparedness survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not otherwise stated.
Findings
Thirteen federal deficiencies cited on emergency preparedness and Life Safety topics (range hood/cleaning and suppression, sprinkler coverage and out-of-service issues, smoke barriers, elevators, fire plans/drills, door maintenance, electrical systems, power cords, gas cylinder storage), and twelve Missouri State Form deficiencies largely mirroring life safety, sprinkler, electrical and oxygen/gas storage concerns.
Deficiencies (12)
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K923.
19 CSR 30-85.022(2)(H) Electrical Appliances UL/FM Good Repair: Refer to K920.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(11)(B) No Complete Sprinkler System Prior to 8/28/07: Refer to K351.
19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr: Refer to K354.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K761.
19 CSR 30-85.022(33)(C) Plan Accessible/Evacuation Diagram Posted: Refer to K711.
19 CSR 30-85.022(33)(F) Fire Drill Records: Refer to K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K372.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K918.
19 CSR 30-85.032(36) Elevator Requirements: Refer to K531.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E013 and E015.
Report Facts
packs of emergency water observed: 8
computed emergency water requirement (3 gal/person/day for 7 days): 714
Inspection Report — Jun 29, 2023
Complaint Investigation
Date: Jun 29, 2023
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation (complaint number MO00220523).
Complaint Details
MO00220523; substantiation not stated in the document.
Findings
2 deficiencies: a federal health deficiency for failure to ensure a resident was free from accident/abuse/supervision failures (staff rough handling causing a resident's inner left forearm bruise), and a Missouri licensure deficiency for nursing care per resident that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F689.
Report Facts
residents sampled: 3
residents sampled: 3
Inspection Report — Feb 15, 2023
Routine
Date: Feb 15, 2023
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Federal health survey (CMS-2567) and Missouri State Form; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to ensure resident safety during transfers and inadequate staff training and use of gait belts, and one Missouri state deficiency for nursing care per resident condition that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: See the deficiency cited at F689.
Report Facts
sampled residents affected: 2
Inspection Report — Oct 13, 2022
Life Safety
Date: Oct 13, 2022
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CMS-2567 Life Safety survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not otherwise stated in the documents.
Findings
4 deficiencies were cited: 2 federal Life Safety (K) deficiencies addressing emergency lighting and essential electrical/generator systems, and 2 Missouri state licensure deficiencies concerning emergency lighting and electrical wiring/equipment maintenance which reference the Life Safety findings.
Deficiencies (2)
19 CSR 30-85.022(25) Emergency Lighting: 1. Refer to K218.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: 1. Refer to K918.
Inspection Report — Sep 30, 2021
Routine
Date: Sep 30, 2021
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CMS-2567 federal health survey (statement of deficiencies) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
Six deficiencies were cited: three federal deficiencies addressing misappropriation/diversion of a resident's controlled medication, failure to report alleged diversion, and failure to properly label/store/count controlled drugs; and three Missouri state deficiencies concerning controlled substance reconciliation/recordkeeping, development/implementation of abuse/neglect policies, and staff training on reporting.
Deficiencies (3)
19 CSR 30-85.042(63) Controlled Substance Reconcile/Record: Refer to F761.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F602.
19 CSR 30-88.010(24) Staff Trained on Reporting A/N: Refer to F609.
Report Facts
residents affected: 1
sampled residents: 3
Inspection Report — Sep 11, 2020
Complaint Investigation
Date: Sep 11, 2020
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation for MO00175242.
Complaint Details
MO00175242; substantiation not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to maintain comfortable and safe indoor temperatures and one Missouri state licensure deficiency for failure to meet heating system/temperature requirements (Class II).
Deficiencies (1)
19 CSR 30-85.032(29) Heating System 68-86 Degrees: Refer to F584.
Report Facts
residents sampled: 10
residents affected (sampled): 5
Inspection Report — Sep 11, 2020
Life Safety
Date: Sep 11, 2020
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The file contains a federal CMS-2567 emergency preparedness (E-tag) survey and Missouri Department of Health and Senior Services state licensure forms; the survey is classified as life_safety. Complaint MO 00175242 is referenced in the state form.
Findings
Three deficiencies were cited: one federal emergency preparedness deficiency concerning subsistence needs and temperature control, and two Missouri state licensure deficiencies regarding policies/procedures and personnel informed (both Class III) which refer to the federal E015 finding.
Deficiencies (2)
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E 15.
19 CSR 30-85.042(15) Personnel Informed of Policies/Duties: Refer to E 15.
Inspection Report — Sep 18, 2019
Routine
Date: Sep 18, 2019
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CMS-2567 federal health survey and accompanying Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 13 federal deficiencies and 21 state deficiencies. Federal findings address environmental/housekeeping concerns, abuse/neglect/background checks, quality of care (medication administration, inhaler/pacemaker/wound care issues), falls documentation, pharmacy/drug regimen review and psychotropic medication monitoring, multiple medication administration and insulin/blood-glucose errors, medication storage/labeling, food safety and kitchen maintenance, refuse/dumpster closure, infection prevention and control lapses (hand hygiene, wound care, storage of supplies) and building maintenance. State findings mirror and cross-reference the federal findings and cite failures in furniture/equipment maintenance, room cleanliness, communicable disease (TB) screening of staff, medication systems and storage, nursing care, infection control, environmental maintenance, dumpster/food storage and related state regulatory items.
Deficiencies (19)
19 CSR 30-85.032(38) Furniture/Equip, Provide Comfort & Safety: Refer to F921.
19 CSR 30-85.032(39) Rooms Neat, Orderly, Cleaned Daily: Refer to F584.
19 CSR 30-85.042(17) Communicable Diseases-Employees: The facility failed to ensure staff and volunteers were screened and documented for communicable disease (TB) per rules; employee health files lacked required Mantoux/PPD documentation and follow-up testing.
19 CSR 30-85.042(47) Safe/Effective Medication System: Refer to F759.
19 CSR 30-85.042(51) Self-Administration of Medication: Refer to F684.
19 CSR 30-85.042(52) Medication Errors/Adverse Reactions Reported: Refer to F759.
19 CSR 30-85.042(53) Drug Regimen Review-Monthly: Refer to F756.
19 CSR 30-85.042(66) Medication Storage: Refer to F761.
19 CSR 30-85.042(67) Nursing Care per Resident Condition: Refer to F684.
19 CSR 30-85.042(68) Clean, Dry, Odor Free: Refer to F584.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-87.020(11) No Deodorizers/Sprays to Eliminate Odors: Refer to F584.
19 CSR 30-87.020(12) Floor Surfaces: Refer to F812.
19 CSR 30-87.020(14) Outside Dumpsters Cleanable/Covered: Refer to F814.
19 CSR 30-87.020(41) Toilet Room Requirements: Refer to F921.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.020(18) Refrigerator Temperatures, Thermometers: Refer to F812.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Refer to F812.
19 CSR 30-88.010(23) Develop/Implement A/VN policies: Refer to F607.
Inspection Report — Sep 18, 2019
Life Safety
Date: Sep 18, 2019
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CMS Emergency Preparedness and Life Safety survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form; the survey is a Life Safety/Emergency Preparedness survey (no complaint numbers stated).
Findings
There are 9 federal deficiencies (4 emergency preparedness E-tags and 5 Life Safety K-tags) addressing emergency preparedness planning, alternate care arrangements, communication and testing requirements, and multiple life safety issues including building penetrations, storage of combustibles, cooking hood maintenance, smoking regulations and oxygen cylinder storage. There are 7 Missouri state deficiencies addressing combustibles stored under stairways, fire hazards, oxygen storage, range hood certification, facility construction/maintenance, and deficiencies in policies/procedures and staff notification.
Deficiencies (7)
19 CSR 30-85.022(2)(D) Combustibles Not Stores Under Stairways: This regulation is not met as evidenced by: Class II. Refer to K300.
19 CSR 30-85.022(2)(E) No Fire Hazard: This regulation is not met as evidenced by: Class II. Refer to K741.
19 CSR 30-85.022(6) Oxygen Storage: This regulation is not met as evidenced by: Class III.
19 CSR 30-85.022(9) Range Hood Certification: This regulation is not met as evidenced by: Class II**. Refer to K324.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: This regulation is not met as evidenced by: Class III. Refer to K161.
19 CSR 30-85.042(13) Policies/Procedures-Operational: This regulation is not met as evidenced by: Class II**. 1. Refer to E4. 2. Refer to E25. 3. Refer to E32. 4. Refer to E39.
19 CSR 30-85.042(15) Personnel Informed of Policies/Duties: This regulation is not met as evidenced by: Class II**. 1. Refer to E4. 2. Refer to E25. 3. Refer to E32. 4. Refer to E39.
Report Facts
smoke_zones: 5
oxygen_cylinders_not_in_stand: 4
Inspection Report — Oct 3, 2018
Routine
Date: Oct 3, 2018
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Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One Missouri state licensure deficiency for medication storage/accessibility was cited concerning unsecured medications and an unattended medication cart with an insulin pen left on top.
Deficiencies (1)
19 CSR 30-86.047(41) Medication Storage/Accessibility: Observations, interview, and record review found the facility failed to ensure all medications were safely stored and kept in a secured location behind at least one locked door or cabinet; a medication cart was left unattended in the dining room and an insulin pen was left on top of the medication cart.
Report Facts
Inspection Report — Sep 7, 2018
Routine
Date: Sep 7, 2018
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Federal health survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
31 deficiencies were cited across federal (11) and Missouri state (20) items. Main topics include resident notices/rights, background checks and hiring, care plan timing and fall/wandering monitoring, pain management documentation, medication storage/labeling/temperature control, food preparation and kitchen sanitation, pest control, and infection prevention and control.
Deficiencies (20)
19 CSR 30-85.042(17) Criminal Background Check Request: Refer to F606.
19 CSR 30-85.042(56) Medication Storage: Refer to F761.
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Refer to F689.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F689 and F697.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-85.042(85) Bedpans, Commodes, Urinals Clean/Covered: Refer to F880.
19 CSR 30-85.052(4) Food Texture-Chewing Difficulty: Refer to F805.
19 CSR 30-87.020(12) Floor Surfaces: Refer to F812.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Refer to F812 and F925.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: Refer to F812.
19 CSR 30-87.020(32) Outside Dumpsters Cleanable/Covered: Refer to F814.
19 CSR 30-87.020(39) Inspect/Rodent Control: Refer to F925.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(19) Food-45 Degrees or Less/Rapid Chill/Transport: Refer to F812.
19 CSR 30-87.030(48) Food Contact Surfaces-Cast Iron/Threads: Refer to F812.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: Refer to F812.
19 CSR 30-87.030(85) Protect Equipment/Utensils From Contamination: Refer to F812.
19 CSR 30-87.030(93) Light Intensity in Food Prep & Work Areas: Refer to F812.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: Refer to F574.
19 CSR 30-88.010(13) Right to Plan Care/Refuse Treatment: Refer to F657.
Report Facts
Inspection Report — Sep 7, 2018
Life Safety
Date: Sep 7, 2018
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Federal CMS-2567 life safety survey (including Emergency Preparedness) and Missouri Department of Health and Senior Services State Form; inspection identified life-safety and emergency preparedness deficiencies.
Findings
There are 22 federal life-safety/emergency preparedness deficiencies (K- and E- tags) involving egress/door locking, exterior discharge/pooling water, sprinkler system maintenance and obstructions, hazardous area doors propped, sprinkler systems out of service/fire watch, fire drills and evacuation planning, smoking area controls, electrical receptacle/generator maintenance, and gas/oxygen cylinder storage. There are 13 Missouri state deficiencies citing 19 CSR rules (oxygen storage, hazardous areas, sprinkler testing/out-of-service, exit requirements, door locks, ashtray/disposal, fire drill and training, clothes dryer venting, building maintenance, electrical wiring/testing, and operational policies/procedures).
Deficiencies (13)
19 CSR 30-85.012(36) Oxygen Storage Room: Refer to K923.
19 CSR 30-85.022(4) Hazardous Areas.: Refer to K321.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr: Refer to K354.
19 CSR 30-85.022(12) Exit Requirements: Refer to K271.
19 CSR 30-85.022(16) Door Locks: Refer to K222.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Refer to K741.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Refer to K712.
19 CSR 30-85.022(34)(B)(1 - 10) Fire Safety Training Requirements-elements: Refer to K711.
19 CSR 30-85.022(36) Clothes Dryers Vented, Lint Traps: Refer to K300.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363 and K500.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K914 and K918.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E001, E009, E015, E022, E024, E025, E026, and E036.
Report Facts
residents potentially affected: 22
Inspection Report — Jul 16, 2018
Follow-Up
Date: Jul 16, 2018
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Missouri Department of Health and Senior Services State Form (state licensure) survey; initial survey completed 2018-07-16 with a documented revisit on 2018-10-10.
Findings
Seven state deficiencies were cited, all related to fire protection, fire/smoke separation and resident safety (range hood extinguishing system, fire/smoke separation doors and smoke partitions, sprinkler system installation and fire-watch procedures), smoking policy/supervision, and rooms not kept neat. A revisit record indicates the sprinkler system deficiency remained uncorrected as of the October 2018 follow-up.
Deficiencies (7)
19 CSR 30-86.022(4)(B)(1)(2) Range Hood-After 7/11/80 & Before 10/1/00 Range Hood Extinguishing Systems: The facility failed to maintain the range hood extinguishing system; the remote pull station was obstructed by a storage rack and items preventing ready access.
19 CSR 30-86.022(10)(E) Floor Separation/Doors - on or after 11/13/80 Protection from Hazards: The facility failed to maintain required floor/separation doors; fire/smoke separation doors by the nurse stations did not close and latch, providing openings to interior stairwells.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds Protection from Hazards: The facility failed to maintain smoke section partition doors; several smoke separation doors did not fully close or had broken closing mechanisms preventing proper closure.
19 CSR 30-86.022(11)(C) Sprinkler System Required by 12/31/12 Sprinkler Systems: The facility failed to have an approved sprinkler system in accordance with NFPA 13/13R; attached screened porches serving as exit pathways lacked sprinkler protection, leaving areas unprotected.
19 CSR 30-86.022(11)(G) Sprinkler System Out of Service More Than 4hr Sprinkler Systems: The facility failed to ensure proper procedures when the sprinkler system is out of service; policy and procedure did not include required notification of the local fire jurisdiction and appropriate fire watch notification procedures.
19 CSR 30-86.022(14)(A) Smoking in Designated Areas & Supervised Smoking: The facility failed to ensure smoking occurred only in designated supervised areas; surveyors observed evidence of smoking and discarded cigarette butts in resident areas and a storage area.
19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily: The facility failed to ensure resident rooms were kept neat and orderly; excessive combustible materials were observed impinging on an exit pathway in a resident room.
Report Facts
residents affected: 31
19 CMS Surveys
Inspection Report — May 28, 2025
Complaint Investigation
Date: May 28, 2025
Visit Reason
The inspection was conducted due to a complaint and investigation regarding misappropriation of controlled substances by a Registered Nurse (RN A) who repeatedly signed out duplicate doses of narcotics for three sampled residents.
Complaint Details
The visit was complaint-related due to allegations of misappropriation of controlled substances by RN A. The complaint was substantiated as RN A was found to have signed out additional narcotic doses without proper documentation or administration. RN A was suspended, drug tested, and terminated. Law enforcement was notified and investigation remained open as of 6/3/25.
Findings
The facility failed to prevent misappropriation of controlled substances involving RN A, who signed out additional doses of narcotics without proper documentation or administration records. RN A was suspended and terminated following the investigation. Training was conducted for all nursing staff on abuse, neglect, and controlled substance administration. No residents were reported to have been harmed or overdosed.
Deficiencies (1)
Failure to prevent misappropriation of controlled substances by RN A signing out duplicate narcotic doses without proper documentation.
Report Facts
Medication doses signed out by RN A: 6
Medication tablets in bubble pack: 45
Medication tablets remaining: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings for misappropriation of controlled substances and medication errors |
| LPN A | Licensed Practical Nurse, Clinical Coordinator | Reported medication error and participated in controlled substance counts |
| LPN B | Licensed Practical Nurse | Participated in controlled substance counts and reported discrepancies |
| DON | Director of Nursing | Conducted investigation and audits of controlled substances |
| Administrator | Facility Administrator | Informed of controlled substance discrepancy and oversaw investigation |
| Physician | Notified of medication discrepancy and provided clinical input |
Inspection Report — Apr 17, 2025
Routine
Date: Apr 17, 2025
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three deficiencies were cited: one federal health citation for inadequate hot water/environmental conditions and two Missouri state licensure citations concerning hot water temperature limits and plumbing code compliance.
Deficiencies (1)
F921 Safe/Functional/Sanitary/Comfortable Environ: The facility failed to ensure hot water temperatures were maintained in the expected range and staff did not consistently allow faucets to flow before measuring temperatures; multiple resident rooms had water temperatures below 105°F or above 120°F.
Inspection Report — Jan 16, 2024
Complaint Investigation
Date: Jan 16, 2024
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CMS health survey (CMS-2567) and Missouri State Form licensure survey; the file includes a complaint investigation (MO00230038, MO00229841).
Complaint Details
MO00230038, MO00229841; the allegation of abuse was investigated and the facility's Investigation Conclusion indicated it could not substantiate that physical or verbal abuse took place.
Findings
12 federal health deficiencies covering abuse reporting, resident assessments/MDS accuracy, medication management, supervision/elopement, food safety and infection control; and 11 Missouri state licensure deficiencies addressing smoking supervision, medication systems and review, assessments, care planning, food safety, infection control and related policies. The survey includes a complaint investigation and notes the facility's investigation could not substantiate physical or verbal abuse.
Deficiencies (12)
F609 Reporting of Alleged Violations: The facility failed to report an allegation of abuse in a timely manner and did not immediately report the allegation; the investigation began several days after the incident and the facility did not ensure immediate notification to required officials.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide required Ombudsman notification of resident discharges for sampled residents.
F640 Encoding/Transmitting Resident Assessments: The facility failed to submit a resident's discharge assessment to CMS for one supplemental resident (Resident #28).
F641 Accuracy of Assessments: The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for sampled residents.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement a comprehensive care plan that included needed information and measurable objectives for a high-risk medication for a sampled resident.
F658 Services Provided Meet Professional Standards: The facility failed to ensure medications were administered and managed according to professional standards (including insulin pen priming and bedside medication storage issues) for sampled residents.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision and interventions to prevent elopement for a newly admitted resident who left the facility and was found off campus.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to respond to the pharmacist's recommendations and to ensure required monthly drug regimen review actions for a sampled resident.
F757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to ensure adequate monitoring parameters and documentation for medications for a sampled resident.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure monitoring and documentation of psychotropic medication use and PRN orders for a sampled resident.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary food preparation and storage practices (open undated containers, mold residue in equipment, soiled cutting boards and food debris in the walk-in) that could affect residents, visitors and staff.
F880 Infection Prevention & Control: The facility failed to establish and maintain a comprehensive infection prevention and control program and water management plan as evidenced by deficiencies in IPC program elements and water management documentation.
Report Facts
residents sampled: 12
Inspection Report — Jan 16, 2024
Life Safety
Date: Jan 16, 2024
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Federal CMS-2567 Life Safety (LSC) and Emergency Preparedness survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not otherwise stated.
Findings
Thirteen federal deficiencies cited on emergency preparedness and Life Safety topics (range hood/cleaning and suppression, sprinkler coverage and out-of-service issues, smoke barriers, elevators, fire plans/drills, door maintenance, electrical systems, power cords, gas cylinder storage), and twelve Missouri State Form deficiencies largely mirroring life safety, sprinkler, electrical and oxygen/gas storage concerns.
Deficiencies (13)
E013 Development of EP Policies and Procedures: Based on interview and record review, the facility failed to establish and maintain a facility-specific Emergency Preparedness program and appropriate policies and procedures, including accurate hazard assessments and disaster-specific content.
E015 Subsistence Needs for Staff and Patients: Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive Emergency Preparedness plan to ensure continuity of subsistence needs (water, temperature control, etc.) for residents during emergencies.
K324 Cooking Facilities: Based on observation, interview, and record review, the facility failed to ensure the kitchen range hood, hood components and suppression elements were maintained free of excessive grease buildup and properly cleaned.
K351 Sprinkler System - Installation: Based on observation, interview, and record review, the facility failed to ensure fire sprinklers were installed in all areas to provide adequate coverage, noting an absence of a sprinkler head in the basement sprinkler room.
K354 Sprinkler System - Out of Service: Based on observation, interview, and record review, the facility failed to maintain a complete, feasible, non-conflicting fire watch policy and documentation when sprinkler system impairments occur.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Based on observation, interview, and record review, the facility failed to ensure required walls resisted the passage of smoke throughout the building, evidenced by openings/holes in smoke barrier walls.
K531 Elevators: Based on observation, interview, and record review, the facility failed to provide current, complete documentation of monthly testing of the elevators' Firefighters' Emergency Recall operations and associated records.
K711 Evacuation and Relocation Plan: Based on observation, interview, and record review, the facility failed to maintain a comprehensive fire plan that included specific staff designations, overhead paging procedures, evacuation route maps, and other required plan components.
K712 Fire Drills: Based on observation, interview, and record review, the facility failed to provide thorough documentation of monthly fire drills and concurrent verification from their alarm monitoring company to confirm successful transmission of the fire alarm signal.
K761 Maintenance, Inspection & Testing - Doors: Based on observation, interview, and record review, the facility failed to ensure annual inspection documentation for fire-rated and smoke doors, including correcting numerous identified deficiencies (holes, misalignment, missing hardware, unreadable labels).
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Based on observation, interview, and record review, the facility failed to itemize and document electrical system components, including thermal imaging and adequate inspection records for main and feeder circuit breakers and associated panels.
K920 Electrical Equipment - Power Cords and Extension Cords: Based on observation, interview, and record review, the facility failed to prevent plugging an appliance into a surge protector or to ensure surge protectors and high-draw devices were properly installed and UL-listed.
K923 Gas Equipment - Cylinder and Container Storage: Based on observation, interview, and record review, the facility failed to prevent combustibles from being stored with oxygen tanks and did not meet requirements for storage and handling of oxygen cylinders.
Report Facts
packs of emergency water observed: 8
computed emergency water requirement (3 gal/person/day for 7 days): 714
Inspection Report — Jun 29, 2023
Complaint Investigation
Date: Jun 29, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; complaint investigation (complaint number MO00220523).
Complaint Details
MO00220523; substantiation not stated in the document.
Findings
2 deficiencies: a federal health deficiency for failure to ensure a resident was free from accident/abuse/supervision failures (staff rough handling causing a resident's inner left forearm bruise), and a Missouri licensure deficiency for nursing care per resident that references the federal finding.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview and record review, the facility failed to ensure one sampled resident was free from accidental injury when a Certified Nursing Assistant grabbed and handled the resident roughly, resulting in a bruise to the resident's inner left forearm.
Report Facts
residents sampled: 3
residents sampled: 3
Inspection Report — Apr 25, 2023
Routine
Date: Apr 25, 2023
Visit Reason
Federal CMS-2567 (health and emergency preparedness) form; a COVID-19 Focused Emergency Preparedness and a COVID-19 Focused Infection Control survey were conducted as stated on the form.
Findings
No health or emergency preparedness deficiencies were cited; the facility was found to be in compliance with COVID-19 focused emergency preparedness and infection control practices.
Inspection Report — Feb 15, 2023
Routine
Date: Feb 15, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to ensure resident safety during transfers and inadequate staff training and use of gait belts, and one Missouri state deficiency for nursing care per resident condition that references the federal finding.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure residents were protected from accident hazards and adequately supervised during transfers; staff did not consistently use gait belts and the facility failed to provide timely and consistent transfer training, resulting in improper transfers of sampled residents.
Report Facts
sampled residents affected: 2
Inspection Report — Oct 13, 2022
Life Safety
Date: Oct 13, 2022
Visit Reason
CMS-2567 Life Safety survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not otherwise stated in the documents.
Findings
4 deficiencies were cited: 2 federal Life Safety (K) deficiencies addressing emergency lighting and essential electrical/generator systems, and 2 Missouri state licensure deficiencies concerning emergency lighting and electrical wiring/equipment maintenance which reference the Life Safety findings.
Deficiencies (2)
K291 Emergency Lighting: Based on observation, interview and record review, the facility failed to maintain battery-backed emergency lighting and lacked records of required monthly 30-second and annual 90-minute tests; emergency lighting was not maintained in working order.
K918 Electrical Systems - Essential Electric Syste: Based on observation, interview and record review, the facility failed to maintain the generator and essential electrical system; the generator area had combustible debris and makeshift heating/lighting arrangements and documentation of required maintenance and testing was not available.
Inspection Report — Jul 20, 2022
Routine
Date: Jul 20, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with health and safety standards, including resident rights, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to protect residents' property from loss or theft, failure to protect residents from misappropriation of property, failure to timely report suspected abuse and misappropriation, failure to provide baseline care plans to residents or their representatives, failure to provide adequate oral care and hydration, failure to properly investigate and document resident falls, failure to maintain safe respiratory care equipment, failure to maintain adequate RN staffing, failure to properly label and store medications, failure to maintain food safety and sanitation in the kitchen, and failure to implement a comprehensive infection prevention and control program including tuberculosis screening and waterborne pathogen prevention.
Deficiencies (11)
Failure to document personal belongings upon admission and timely follow-up on grievances related to missing clothes for multiple residents.
Failure to protect a resident from misappropriation of property when unauthorized charges were made on the resident's debit card.
Failure to timely report suspected abuse and misappropriation to the State and local Police within 24 hours.
Failure to provide residents or their representatives with a written summary of the baseline care plan within 48 hours of admission.
Failure to provide daily oral care including teeth brushing and fresh water daily to residents.
Failure to follow fall monitoring policy including incomplete fall investigation documentation, lack of neurological checks, failure to update care plans post-fall, and inadequate notifications.
Failure to store nebulizer mask in a bag when not in use as per facility policy.
Failure to have a Registered Nurse on duty eight hours a day, seven days a week.
Failure to ensure medications are labeled with opened dates, medication containers are clean, and residents' personal belongings are not mixed with medications.
Failure to maintain kitchen and food storage areas in a sanitary condition, including clean floors, operable thermometers, sanitary utensils, proper hair hygiene, and separation of damaged foodstuffs.
Failure to implement a comprehensive infection prevention and control program including tuberculosis screening and waterborne pathogen prevention.
Report Facts
Unauthorized debit card charges: 303.69
Number of falls for Resident #30: 6
Fall risk score: 14
Fall risk score: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Mentioned in relation to missing clothes and nebulizer treatment |
| Licensed Practical Nurse A | Licensed Practical Nurse | Mentioned in relation to missing clothes, nebulizer treatment, and fall interventions |
| Administrator | Mentioned in relation to investigations, staffing, and policy enforcement | |
| Director of Nursing | Director of Nursing | Mentioned in relation to investigations, staffing, and policy enforcement |
| Social Service Designee | Mentioned in relation to grievance process and missing items | |
| Certified Nursing Assistant A | Certified Nursing Assistant | Mentioned in relation to oral care and fall interventions |
| Certified Nursing Assistant B | Certified Nursing Assistant | Mentioned in relation to oral care and missing items |
| Licensed Practical Nurse B | Licensed Practical Nurse | Mentioned in relation to medication cart cleanliness |
| Certified Nursing Assistant C | Certified Nursing Assistant | Mentioned in relation to staffing schedules |
Inspection Report — Sep 30, 2021
Routine
Date: Sep 30, 2021
Visit Reason
CMS-2567 federal health survey (statement of deficiencies) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
Six deficiencies were cited: three federal deficiencies addressing misappropriation/diversion of a resident's controlled medication, failure to report alleged diversion, and failure to properly label/store/count controlled drugs; and three Missouri state deficiencies concerning controlled substance reconciliation/recordkeeping, development/implementation of abuse/neglect policies, and staff training on reporting.
Deficiencies (3)
F602 Free from Misappropriation/Exploitation: Based on observation, interview and record review the facility failed to ensure a sampled resident's controlled substance medication was free from misappropriation; evidence of possible diversion of morphine bottles and discrepancies in narcotic counts was found.
F609 Reporting of Alleged Violations: Based on interview and record review the facility failed to report an allegation of diversion/misappropriation of morphine to the administrator, law enforcement and the state agency for one sampled resident.
F761 Label/Store Drugs and Biologicals: Based on interview and record review the facility failed to keep accurate counts of liquid controlled medications stored in the medication cart and failed to account for controlled drugs while stored.
Report Facts
residents affected: 1
sampled residents: 3
Inspection Report — Aug 20, 2021
Routine
Date: Aug 20, 2021
Visit Reason
CMS-2567 federal health survey; the form states a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey.
Findings
No health survey deficiencies were cited; the survey was COVID-19 focused on infection control and emergency preparedness and the facility was found to be in compliance with CMS and CDC practices.
Inspection Report — Nov 20, 2020
Routine
Date: Nov 20, 2020
Visit Reason
Federal CMS-2567 health survey; the Initial Comments state a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey were conducted.
Findings
No health survey deficiencies were cited; the facility was found in compliance with the applicable COVID-19 emergency preparedness and infection control requirements.
Inspection Report — Sep 11, 2020
Complaint Investigation
Date: Sep 11, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation for MO00175242.
Complaint Details
MO00175242; substantiation not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to maintain comfortable and safe indoor temperatures and one Missouri state licensure deficiency for failure to meet heating system/temperature requirements (Class II).
Deficiencies (1)
F 584 Safe/Clean/Comfortable/Homelike Environment: Based on observation, interview and record review the facility failed to ensure a comfortable and homelike environment; multiple resident rooms and common areas had temperatures below the acceptable range with numerous readings in the 60s°F and residents complained of being cold.
Report Facts
residents sampled: 10
residents affected (sampled): 5
Inspection Report — Sep 11, 2020
Life Safety
Date: Sep 11, 2020
Visit Reason
The file contains a federal CMS-2567 emergency preparedness (E-tag) survey and Missouri Department of Health and Senior Services state licensure forms; the survey is classified as life_safety. Complaint MO 00175242 is referenced in the state form.
Findings
Three deficiencies were cited: one federal emergency preparedness deficiency concerning subsistence needs and temperature control, and two Missouri state licensure deficiencies regarding policies/procedures and personnel informed (both Class III) which refer to the federal E015 finding.
Deficiencies (1)
E015 Subsistence Needs for Staff and Patients: The facility's climate control outage policy did not include required temperature ranges or procedures for monitoring and maintaining temperatures during outages, which potentially affected residents.
Inspection Report — May 21, 2020
Routine
Date: May 21, 2020
Visit Reason
Federal CMS-2567 health (F) and emergency preparedness (E) forms; a COVID-19 Focused Infection Control survey and a COVID-19 Focused Emergency Preparedness survey were conducted (survey type stated on the forms).
Findings
No deficiencies were cited. The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19 and in compliance with 42 CFR 483.73 related to emergency preparedness.
Inspection Report — Sep 18, 2019
Routine
Date: Sep 18, 2019
Visit Reason
CMS-2567 federal health survey and accompanying Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 13 federal deficiencies and 21 state deficiencies. Federal findings address environmental/housekeeping concerns, abuse/neglect/background checks, quality of care (medication administration, inhaler/pacemaker/wound care issues), falls documentation, pharmacy/drug regimen review and psychotropic medication monitoring, multiple medication administration and insulin/blood-glucose errors, medication storage/labeling, food safety and kitchen maintenance, refuse/dumpster closure, infection prevention and control lapses (hand hygiene, wound care, storage of supplies) and building maintenance. State findings mirror and cross-reference the federal findings and cite failures in furniture/equipment maintenance, room cleanliness, communicable disease (TB) screening of staff, medication systems and storage, nursing care, infection control, environmental maintenance, dumpster/food storage and related state regulatory items.
Deficiencies (13)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a consistently safe, clean and comfortable environment as evidenced by strong urine odor and soiled conditions in resident rooms and inconsistent housekeeping affecting sampled residents.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to ensure background checks and required pre-employment screening/documentation were completed timely for new employees as evidenced by missing or untimely criminal background check and Employee Disqualification Listing documentation.
F684 Quality of Care: The facility failed to ensure physician orders were transcribed and residents received ordered treatments and monitoring; problems included missing or untranscribed inhaler/Ventolin orders, missed pacemaker checks and inconsistently documented wound care and related assessments.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to thoroughly document and investigate resident falls and provide required follow-up evaluations and documentation for sampled residents.
F756 Drug Regimen Review: The facility failed to ensure the monthly pharmacy drug regimen review and follow-up documentation were completed and acted upon as evidenced by missing consultant pharmacist documentation and unaddressed recommendations.
F758 Psychotropic Drugs: The facility failed to ensure appropriate use, monitoring and documentation for psychotropic medications, including PRN orders and lack of timely physician/pharmacist review for psychotropic regimens.
F759 Rate of Medication Errors 5 Percent or More: The facility's medication error rate exceeded acceptable levels as evidenced by observed and documented insulin/medication administration errors and related documentation gaps.
F760 Residents Are Free of Significant Medication Errors: The facility failed to ensure residents were free from significant medication administration errors during insulin administration and related medication passes.
F761 Label/Store Drugs and Biologicals: The facility failed to properly label and store drugs and biologicals as evidenced by expired, unlabeled or improperly stored medications found in medication carts and the medication refrigerator.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to store, prepare and serve food safely as evidenced by soiled dishwasher spray nozzles, damaged/repaired refrigerator gaskets, peeling ceiling/food-prep surface issues and other kitchen sanitation/maintenance concerns.
F814 Dispose Garbage and Refuse Properly: The facility failed to ensure dumpster lids closed without gaps that could allow small animals access, based on observations of gaps at the dumpster.
F880 Infection Control: The facility failed to establish and maintain an effective infection prevention and control program; multiple observations showed lapses in hand hygiene, contaminated wound care practices, improper handling/storage of oxygen/nebulizer supplies, and incomplete TB screening/documentation.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to provide and maintain safe, functional and sanitary environmental conditions as evidenced by needed repairs and maintenance items (broken shower chair removed from service, fans and other maintenance issues).
Inspection Report — Sep 18, 2019
Life Safety
Date: Sep 18, 2019
Visit Reason
CMS Emergency Preparedness and Life Safety survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form; the survey is a Life Safety/Emergency Preparedness survey (no complaint numbers stated).
Findings
There are 9 federal deficiencies (4 emergency preparedness E-tags and 5 Life Safety K-tags) addressing emergency preparedness planning, alternate care arrangements, communication and testing requirements, and multiple life safety issues including building penetrations, storage of combustibles, cooking hood maintenance, smoking regulations and oxygen cylinder storage. There are 7 Missouri state deficiencies addressing combustibles stored under stairways, fire hazards, oxygen storage, range hood certification, facility construction/maintenance, and deficiencies in policies/procedures and staff notification.
Deficiencies (9)
E004 Develop EP Plan, Review and Update Annually: Based on interview and record review, the facility failed to complete a hazard vulnerability analysis in its Emergency Preparedness Plan, leaving the hazard analysis incomplete. This practice potentially affected all residents.
E025 Arrangement with Other Facilities: Based on interview and record review, the facility failed to list alternate care sites in its Emergency Preparedness Plan to which residents would be evacuated if needed. This practice potentially affected all residents.
E032 Primary/Alternate Means for Communication: Based on interview and record review, the facility failed to include a backup communication plan beyond a land line or mobile phones in its Disaster Manual. This practice potentially affected all residents and staff.
E039 EP Testing Requirements: Based on interview and record review, the facility failed to schedule and document a tabletop exercise as part of its emergency plan testing requirements. This practice potentially affected all residents and facility staff.
K161 Building Construction Type and Height: Based on observation, interview and record review, the facility failed to ensure there was not a penetration in the wall of the Director of Nursing's office that could allow passage of smoke into interstitial spaces. This practice potentially affected two smoke zones.
K300 Protection - Other: Based on observation, interview and record review, the facility failed to prevent the storage of combustibles (cardboard box, plastic crates, plastic cart and two plastic bags) under the stairwell in the dietary dry goods storage room. This practice potentially affected two smoke zones.
K324 Cooking Facilities: Based on observation, interview and record review, the facility failed to ensure the range hood exhaust system was cleaned and maintained to prevent heavy buildup of grease in the hood flue. This practice potentially affected the smoke zone on the assisted living side of the facility.
K741 Smoking Regulations: Based on observation, interview and record review, the facility failed to ensure noncombustible, self-closing ash trays were used in staff smoking areas and observed use of improper ash trays and cigarette debris in multiple staff areas. This practice potentially affected multiple smoke zones.
K926 Gas Equipment - Qualifications and Training: Based on observation, interview and record review, the facility failed to provide in-servicing about proper storage of oxygen cylinders and observed cylinders not secured in proper stands. This practice potentially affected one smoke zone.
Report Facts
smoke_zones: 5
oxygen_cylinders_not_in_stand: 4
Inspection Report — Sep 7, 2018
Routine
Date: Sep 7, 2018
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
31 deficiencies were cited across federal (11) and Missouri state (20) items. Main topics include resident notices/rights, background checks and hiring, care plan timing and fall/wandering monitoring, pain management documentation, medication storage/labeling/temperature control, food preparation and kitchen sanitation, pest control, and infection prevention and control.
Deficiencies (11)
F574 Required Notices and Contact Information: Based on observation, interview and record review, the facility failed to ensure residents had access to ombudsman contact information and the Resident Rights poster so residents did not know where contact information was located.
F606 Not Employ/Engage Staff w/ Adverse Actions: The facility failed to ensure Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks were completed prior to hire for two newly hired employees.
F657 Care Plan Timing and Revision: The facility failed to update and/or revise residents' care plans to include interventions identified through fall investigations and for a resident with increased wandering risk.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to adequately monitor and document supervision of a resident at high risk for wandering, including lack of documented 30-minute/15-minute checks when indicated.
F697 Pain Management: The facility failed to document attempts at non-pharmacological interventions prior to administering PRN narcotic pain medication for a sampled resident.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure expired medications were removed, opened vials were dated, medication cups did not contain unidentified pills, and refrigerator temperatures were consistently monitored and documented.
F805 Food in Form to Meet Individual Needs: The facility failed to ensure pureed foods and sauces were consistently prepared smooth and without visible bits, potentially affecting residents with physician orders for pureed diets.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain safe food storage and sanitary kitchen conditions, including improper kitchenette refrigerator temperatures, grime/grease under equipment, undated packages of ground beef, damaged cutting boards, and other sanitation concerns.
F814 Dispose Garbage and Refuse Properly: The facility failed to ensure the outdoor dumpster lid was intact and closed snugly, as a crack prevented the lid from closing properly.
F880 Infection Prevention & Control: The facility failed to ensure infection control practices during blood glucose testing, handwashing and glove use during incontinence and Foley care, and prevention of cross-contamination when refilling individual residents' water containers.
F925 Maintains Effective Pest Control Program: The facility failed to prevent conditions that provided harborage for gnats and other pests in the kitchen and failed to remove carcasses of dead insects from windowsills.
Report Facts
Inspection Report — Sep 7, 2018
Life Safety
Date: Sep 7, 2018
Visit Reason
Federal CMS-2567 life safety survey (including Emergency Preparedness) and Missouri Department of Health and Senior Services State Form; inspection identified life-safety and emergency preparedness deficiencies.
Findings
There are 22 federal life-safety/emergency preparedness deficiencies (K- and E- tags) involving egress/door locking, exterior discharge/pooling water, sprinkler system maintenance and obstructions, hazardous area doors propped, sprinkler systems out of service/fire watch, fire drills and evacuation planning, smoking area controls, electrical receptacle/generator maintenance, and gas/oxygen cylinder storage. There are 13 Missouri state deficiencies citing 19 CSR rules (oxygen storage, hazardous areas, sprinkler testing/out-of-service, exit requirements, door locks, ashtray/disposal, fire drill and training, clothes dryer venting, building maintenance, electrical wiring/testing, and operational policies/procedures).
Deficiencies (22)
K222 Egress Doors: Based on observation, interview, and record review, the facility failed to ensure a door to the crawlspace had an inside-unlockable configuration (a barrel bolt/deadbolt on the outside that could not be unlocked from the inside), creating the possibility someone could become trapped.
K271 Discharge from Exits: The facility failed to prevent pooling of water at the end of a ramp exit discharge close to a resident room, creating a slippery/obstructed exit surface.
K300 Protection - Other: The facility failed to ensure mop heads were air dried and not placed in the laundry dryer, posing a combustible/ignition risk due to drying of potentially combustible mop material.
K321 Hazardous Areas - Enclosure: The facility failed to ensure doors to hazardous areas (Medical Records and Soiled Linen rooms) were self-closing and latching, and were found propped open, creating unprotected hazardous area conditions.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure spray patterns of sprinkler heads in the basement Activities Storage room were not obstructed by storage placed too close to heads.
K354 Sprinkler System - Out of Service: The facility failed to include required information in its fire watch plan when the sprinkler system is impaired and out of service, including contact information and a plan for the impairment coordinator.
K363 Corridor - Doors: Based on observation and interview, the facility failed to ensure corridor doors at multiple resident rooms and supply/medical rooms closed and latched properly and resisted passage of smoke, and a basement door was held open with a wedge.
K500 Building Services - Other: The facility failed to provide documentation that dampers located throughout the facility were exercised and inspected every four years in accordance with NFPA requirements.
K711 Evacuation and Relocation Plan: The facility's fire safety plan did not include a directive for employees to call the local fire department in the event of an actual fire in the facility.
K712 Fire Drills: The facility failed to vary the times/dates of fire drills sufficiently; seven of ten drills reviewed were conducted within the first seven days of the month, reducing variability.
K741 Smoking Regulations: The facility failed to prevent disposal of cigarette butts and provide proper self-closing ash receptacles at designated smoking areas, and combustible debris was observed at outside stairs/areas.
K914 Electrical Systems - Maintenance and Testing: The facility failed to assess and document receptacle inspections for integrity, grounding, polarity, and retention force in resident rooms, and was missing annual inspection documentation for circuit breaker boxes.
K918 Electrical Systems - Essential Electric System: The facility failed to provide complete and verifiable documentation for maintenance and testing of the generator and associated emergency power systems, and had debris and storage too close to the generator.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly maintain the fire resistive qualities and secure door for the oxygen storage area in the basement, allowing passage of smoke into the smoke compartment.
E001 Establishment of the Emergency Program (EP): Based on record review and interview, the facility failed to establish and maintain a comprehensive emergency preparedness program including required elements.
E009 Local, State, Tribal Collaboration Process: The facility failed to include correct phone numbers for local FEMA/CMS/State Emergency Management Agency contacts in its Emergency Contact Directory.
E015 Subsistence Needs for Staff and Patients: The facility failed to fully develop a plan for continuity of sewage services and other subsistence provisions in the event of a water outage or other emergency.
E022 Policies/Procedures for Sheltering in Place: The facility failed to include a backup plan for communication/phone system failure in its disaster preparedness plan.
E024 Policies/Procedures-Volunteers and Staffing: The facility failed to include contact information for all current employees in the disaster plan's Emergency Staff Contact page.
E025 Arrangement with Other Facilities: The facility failed to include contact information for transportation entities and arrangements with other providers to receive patients in the event of evacuation.
E026 Roles Under a Waiver Declared by Secretary: The facility failed to include policy/procedures regarding use of an 1135 waiver and its role under federal emergency waivers in its disaster manual.
E036 EP Training and Testing: The facility failed to document procedures and records for initial and annual training/testing for Emergency Preparedness for all staff.
Report Facts
residents potentially affected: 22
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