Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
92 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Routine
Census: 92
Deficiencies: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with skin care and foot care standards, specifically focusing on one resident's foot care and skin assessments.
Findings
The facility failed to ensure that one resident's feet were free from dry skin and that skin assessments were accurate. The resident's foot care needs were not properly addressed in the care plan, and documentation of dry skin was incomplete. Observations revealed a large blister and dry, flaky skin on the resident's feet.
Deficiencies (1)
Failed to ensure one resident's feet were free from dry skin and skin assessments were accurate; foot care needs not addressed in care plan.
Report Facts
Census: 92
Sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant B | Certified Nursing Assistant (CNA) | Interviewed regarding awareness of resident's foot wound and skin assessments |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding awareness of resident's foot wound and skin assessments |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding awareness of resident's dry skin and wound care follow-up |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Sep 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately report an allegation of injury of unknown origin involving Resident #1, who was found wandering with injuries and a cord tied around the waist.
Complaint Details
The complaint investigation found that the facility did not report an injury of unknown origin involving Resident #1 to the Department of Health of Senior Services within the required two-hour timeframe. The resident was found with bruising and blood on the face, unsteady gait, and a cord tied around the waist. Staff assumed the injuries were due to a fall, but no fall was witnessed and no injury of unknown origin report was made. The assisted living Director of Nursing was not notified timely, and the Administrator did not instruct staff to report to DHSS.
Findings
The facility failed to report the injury of unknown origin to the Department of Health of Senior Services within the required two-hour timeframe. The resident sustained bruising and bleeding likely due to a fall, but the incident was treated as a fall rather than an injury of unknown origin. Staff interviews and documentation reviews revealed delays and gaps in reporting and investigation.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or injury of unknown origin to proper authorities within required timeframes.
Report Facts
Census: 74
Fall risk score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Noted resident's bruising and blood, contacted physician and family, reported incident to RN D |
| CMT A | Certified Medication Technician | Observed resident with injuries, notified LPN B, provided statements |
| CNA C | Certified Nurse Assistant | Assigned to resident, found resident with injuries, transported resident, provided statements |
| RN D | Registered Nurse | On call nurse who received reports, instructed notifications, reviewed incident |
| Administrator | Facility Administrator | Oversaw investigation, did not instruct staff to report to DHSS |
| Director of Nursing | Assisted Living Director of Nursing | Notified late, unaware of fall details, interviewed during investigation |
Inspection Report
Census: 128
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to the facility's failure to have a licensed Administrator responsible for establishing and implementing policies regarding the management and operation of the facility.
Findings
The facility failed to have a licensed Administrator from an unspecified period, which had the potential to affect all residents. The Director of Business Operations filed and received a Temporary Emergency License to serve as the Administrator, correcting the deficiency.
Deficiencies (1)
Failure to have a licensed Administrator legally responsible for establishing and implementing policies for managing and operating the facility.
Report Facts
Census: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Administrator whose license expired and was on leave during the deficiency period |
| Director of Business Operations | Director of Business Operations (DBO) | Filed and received Temporary Emergency License and served as temporary Administrator |
| Interim Administrator | Interim Administrator | Interviewed regarding the Administrator situation and facility management |
Inspection Report
Routine
Census: 88
Deficiencies: 1
Date: Jun 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the use of psychotropic medications, specifically focusing on the requirement for stop dates on as needed (PRN) psychotropic medications.
Findings
The facility failed to obtain a stop date of 14 days or less on an as needed (PRN) psychotropic medication for one resident (Resident #76). The resident's medical records showed PRN Lorazepam was administered without a stop date, contrary to facility policy and regulatory requirements.
Deficiencies (1)
Failure to obtain a stop date of 14 days or less on an as needed (PRN) psychotropic medication for one resident.
Report Facts
Sample size: 19
Census: 88
PRN Lorazepam administrations: 6
PRN Lorazepam administrations: 0
PRN Lorazepam administrations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding PRN medication stop dates | |
| Administrator | Interviewed regarding PRN medication stop dates |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 8
Date: Jun 26, 2024
Visit Reason
The inspection was conducted based on complaint investigations and observations related to regulatory compliance in a nursing home facility.
Complaint Details
The complaint investigation included issues related to failure to post survey results, failure to notify physicians timely, employee screening deficiencies, medication errors, failure to send resident to hospital timely, inadequate snack provision, and infection control breaches.
Findings
The facility failed to post survey results accessibly, timely notify physicians of resident condition changes, properly screen new employees for abuse indicators, clarify medication orders, send residents to hospital timely, provide snacks at bedtime, and follow infection control protocols including PPE use and equipment disinfection.
Deficiencies (8)
Failed to post survey results in a place accessible to residents and visitors.
Failed to notify resident's physician timely of changes in surgical wound drainage and blood pressure.
Failed to screen newly hired employees for federal abuse indicators via Nurse Aide Registry checks.
Failed to clarify duplicate medication orders and failed to send resident to hospital timely.
Failed to obtain a stop date of 14 days or less on a PRN psychotropic medication order.
Failed to discard expired medication, date opened medication, and maintain refrigerator temperature logs.
Failed to follow infection control practices including cleaning treatment carts between rooms, hand hygiene, disinfecting equipment, and wearing appropriate PPE.
Failed to provide snacks at bedtime; snacks only offered mid-day.
Report Facts
Census: 88
Sample size: 19
New employees hired: 57
PRN Lorazepam administrations: 6
PRN Lorazepam administrations: 2
Expired medication date: 2024
Wound size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in failure to timely notify physician of resident condition changes |
| LPN E | Licensed Practical Nurse | Named in failure to timely send resident to hospital and infection control breaches |
| LPN F | Licensed Practical Nurse | Named in medication administration and infection control breaches |
| LPN D | Licensed Practical Nurse | Named in failure to timely send resident to hospital and infection control breaches |
| DON | Director of Nursing | Named in oversight of infection control and medication administration |
| Administrator | Facility Administrator | Named in oversight of employee screening and infection control |
| Medical Director | Physician | Named in medication order clarification and resident care expectations |
| PA | Physician Assistant | Named in resident wound care and communication with facility |
Inspection Report
Routine
Census: 80
Deficiencies: 6
Date: Dec 29, 2023
Visit Reason
The inspection was conducted to evaluate compliance with nursing home regulations related to resident safety, specifically focusing on fall evaluations and supervision on the memory care unit, as well as medication administration practices.
Findings
The facility failed to evaluate and assess one resident after falls and did not provide adequate supervision on the memory care unit. Staff failed to document two falls for one resident and left unsupervised medications next to another resident in the dementia/memory care dining room. Policies on neurological assessments after falls and medication self-administration were incomplete or not followed.
Deficiencies (6)
Failure to evaluate and assess one resident after falls and failure to provide adequate supervision on the memory care unit.
Staff did not complete documentation of two falls for one resident (Resident #4).
Left unsupervised medications next to one resident (Resident #5) in the dementia/memory care dining room.
Facility's policy did not address neurological assessments related to witnessed or unwitnessed falls.
Failure to document fall follow-up notes and notify physician and family after witnessed fall.
Medications were left unsupervised with a cognitively impaired resident without physician order or self-administration assessment.
Report Facts
Census: 80
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Mentioned in relation to fall documentation and medication supervision deficiencies |
| Licensed Practical Nurse B | LPN | Mentioned regarding fall follow-up note requirements |
| Licensed Practical Nurse C | LPN | Witnessed a fall but failed to document or notify others |
| Registered Nurse D | RN | Provided information on neuro check procedures after falls |
| Licensed Practical Nurse E | LPN | Discussed medication self-administration assessment and physician order requirements |
| Administrator | New to company, unfamiliar with fall and medication self-administration policies | |
| Quality Control Nurse | New to company, unfamiliar with fall and medication self-administration policies |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Date: Aug 31, 2023
Visit Reason
The inspection was conducted following a complaint alleging that two Certified Nurse Aides (CNAs) physically forced a resident to get into bed against his/her expressed wishes, causing pain and injury concerns.
Complaint Details
The complaint alleged abuse by two CNAs who forcibly transferred a resident to bed against his/her wishes. The resident reported pain and requested emergency care and police involvement. The facility investigated, suspended the CNAs, and involved police, who found no evidence of abuse. The resident's statements and staff interviews were inconsistent.
Findings
The facility failed to reasonably accommodate the resident's preferences and needs during transfers, resulting in physical force used by staff. The resident was transported to the hospital with complaints of pain but no visible injuries were found. Additionally, medication storage and administrator licensing deficiencies were identified.
Deficiencies (3)
Failed to reasonably accommodate the needs and preferences of a resident during transfer to bed, resulting in physical force and pain.
Failed to ensure all medications were stored in locked compartments; insulin vials found in an unlocked refrigerator.
Failed to employ a licensed administrator as required by state regulations.
Report Facts
Census: 70
Unopened Basaglar KwikPen: 4
Inspection completion date: Aug 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Documented resident complaints and coordinated emergency response |
| CNA B | Certified Nurse Aide | Involved in resident transfer and alleged abuse |
| CNA C | Certified Nurse Aide | Assisted in resident transfer and alleged abuse |
| Regional Executive Director | Regional Executive Director | Interviewed regarding facility administration and licensing |
| Director of Clinical Services | Director of Clinical Services | Interviewed regarding medication storage |
| Administrator | Administrator | Interviewed regarding resident rights and facility policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding resident condition and care |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: Apr 25, 2023
Visit Reason
The inspection was conducted due to an allegation of sexual abuse by a Certified Nurse Aide (CNA) against a resident, which triggered a complaint investigation.
Complaint Details
The complaint involved an allegation by Resident #1 that an African American male CNA molested him/her about a month prior. The resident reported a miscarriage and possible drugging. The investigation included interviews with the resident, social service director, assistant director of nursing, and family members. The resident later did not recall the allegation and showed moderate cognitive impairment. No witnesses or known perpetrator were identified. The facility did not interview African American male CNAs despite their presence on staff.
Findings
The facility failed to thoroughly investigate the allegation of sexual abuse and did not document the resident's physical assessment in a timely manner. The investigation lacked interviews with African American male CNAs despite their presence on staff. The resident's cognitive status declined during the investigation period, and no conclusive evidence or known perpetrator was identified.
Deficiencies (2)
Failure to thoroughly investigate an allegation of sexual abuse, including not interviewing African American male CNAs.
Failure to document the resident's physical assessment in a timely manner.
Report Facts
Census: 76
Brief Interview Mental Status (BIMS) score: 11
Brief Interview Mental Status (BIMS) score: 13
Number of African American male CNAs: 5
Number of shifts worked by Agency CNA A: 20
Inspection Report
Routine
Census: 93
Deficiencies: 13
Date: Oct 27, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with healthcare facility regulations, including medication administration, infection control, resident care, and staffing.
Findings
The facility failed to ensure proper medication administration on admission, timely physician notification of missed medications, adequate chest tube care training, proper oxygen administration, infection control including COVID-19 containment, accurate nurse staffing postings, and effective quality assurance participation. Immediate Jeopardy was identified related to COVID-19 infection control but was removed after corrective actions.
Deficiencies (13)
Failed to ensure one resident had a physician's order and was assessed and care planned for self-administration of medications prior to self-administration.
Failed to notify physician when medications were not administered for multiple residents and failed to administer medications on day of admission.
Failed to timely report suspected abuse to the State Survey Agency for one resident and failed to maintain documented evidence of investigation.
Failed to provide treatments as ordered and failed to update medical record with skin integrity changes for one resident.
Failed to ensure urinary catheter was secured with a leg strap (stat lock) to reduce friction and movement, resulting in injury.
Failed to provide appropriate respiratory care including oxygen administration per physician orders and respiratory treatments for two residents.
Failed to ensure clinical staff had chest tube skills and knowledge to provide chest tube care effectively and safely.
Failed to post complete and accurate nurse staffing information daily in a prominent place.
Failed to provide pharmaceutical services to meet resident needs including timely administration of medications on admission and availability of emergency stock.
Failed to implement gradual dose reductions and monitor behaviors for residents on psychotropic medications.
Failed to have Medical Director or designee attend Quality Assessment and Assurance meetings.
Failed to properly contain COVID-19 resulting in Immediate Jeopardy when a COVID-19 positive resident was unmasked in a communal area and EMTs entered without source control.
Failed to inform residents and families when three residents tested positive for COVID-19.
Report Facts
Residents: 93
Missed medication administrations: 3
Chest tube drainage: 600
Blood in urinary collection bag: 800
Days delayed for dose reduction: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN7 | Licensed Practical Nurse | Verified missed treatments and medication administration for Resident R65 and R294 |
| RN1 | Registered Nurse | Discussed medication availability and emergency stock access issues |
| Medical Director | Provided statements on medication administration expectations and chest tube training | |
| Director of Nursing | Confirmed multiple findings including medication administration, oxygen care, chest tube training, and infection control | |
| Social Worker | Discussed behavior monitoring and pharmacy recommendations | |
| Infection Preventionist | Confirmed infection control deficiencies and QAPI concerns | |
| Administrator | Discussed staffing posting issues, COVID-19 notification, and abuse reporting | |
| Nurse Manager | Confirmed oxygen administration and wound care findings | |
| MDS Coordinator | Licensed Practical Nurse | Performed chest tube drainage without training or supervision |
| Certified Medication Technician 3 | Discussed medication availability and emergency stock access | |
| Certified Nurse Aide 6 | Confirmed lack of chest tube care training | |
| Licensed Practical Nurse 3 | Confirmed lack of chest tube care training |
Inspection Report
Routine
Census: 125
Deficiencies: 12
Date: Aug 16, 2019
Visit Reason
The inspection was a routine survey of Sherbrooke Village nursing home to assess compliance with resident rights, care, and safety standards.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination, failure to notify physicians of significant changes in resident condition, inaccurate resident assessments, incomplete care plans, delayed follow-up after resident falls, inadequate pressure ulcer care and documentation, improper catheter care, failure to follow respiratory care orders, insufficient nursing staff coverage, unsafe food handling practices, improper medication storage and labeling, and failure to follow infection prevention protocols.
Deficiencies (12)
Failed to promote and facilitate resident self-determination by locking the dining room outside scheduled meal times, preventing resident choice.
Failed to notify resident's physician of significant change in condition when resident returned from hospital with new symptoms and oxygen use.
Failed to assure accurate resident assessments reflective of resident status, including pressure ulcer risk and hospice status.
Failed to develop and implement complete, accurate, and individualized care plans addressing transfer status, pressure ulcers, CPAP use, catheters, dialysis, and oxygen use.
Failed to provide timely follow-up and appropriate care after resident fall resulting in fractured femur; failed to assess and follow up on resident's change in condition after hospital return; failed to appropriately assess and document wound.
Failed to provide appropriate pressure ulcer care including treatment per orders, thorough assessments, documentation, and updating physicians for new or deteriorating ulcers.
Failed to provide appropriate care for residents with indwelling urinary catheters including maintaining proper catheter placement and drainage bag positioning to prevent infection.
Failed to provide appropriate perineal care and hand hygiene during care; failed to properly handle catheter tubing and store oxygen equipment per infection control standards.
Failed to provide sufficient nursing staff on a 24-hour basis to meet resident care needs and ensure resident supervision, resulting in residents being unattended and wandering.
Failed to store, prepare, distribute and serve food in accordance with professional standards including failure to label and date food, failure to ensure food items were closed and sealed, and failure to follow proper handwashing techniques during food temperature testing.
Failed to ensure drugs and biologicals were labeled with appropriate instructions and expiration dates and stored in locked compartments.
Failed to follow physician orders for oxygen administration including ensuring oxygen tanks contained oxygen, oxygen flow rates were followed, and CPAP orders and equipment were properly managed.
Report Facts
Sample size: 25
Census: 125
Pressure ulcer measurements: 3
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 3
Pressure ulcer measurements: 4
Pressure ulcer measurements: 0
Pressure ulcer measurements: 3
Pressure ulcer measurements: 4
Pressure ulcer measurements: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse K | Nurse | Named in fall follow-up and pain management deficiency |
| Nurse E | Nurse | Named in oxygen therapy and wound care deficiencies |
| Nurse C | Nurse | Named in wound care and competency deficiency |
| Nurse S | Nurse | Named in fall follow-up deficiency |
| Nurse R | Nurse | Named in fall follow-up deficiency |
| Nurse Z | Nurse | Named in oxygen therapy deficiency |
| Nurse X | Nurse | Named in staffing deficiency |
| Nurse Y | Nurse | Named in staffing deficiency |
| Nurse BB | Certified Nursing Assistant | Named in staffing and supervision deficiency |
| Nurse CC | Nurse | Named in staffing and supervision deficiency |
| Nurse F | Nurse | Named in medication storage deficiency |
| Nurse V | Certified Nursing Assistant | Named in oxygen therapy deficiency |
| Nurse B | Certified Nursing Assistant | Named in infection control deficiency |
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