Inspection Reports for
Baptist Homes of Independence
17451 Medical Center Pkwy, Independence, MO 64057, United States, MO, 64057
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
23.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
331% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
47% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 2
Date: May 14, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to quality of care and free of accident hazards, and to review the facility's plan of correction for cited deficiencies.
Findings
The facility failed to provide adequate care and services to meet the needs of a hospice resident, including medication administration and pain management. Additionally, the facility failed to ensure safety during resident transfers using mechanical lifts, resulting in injury.
Deficiencies (2)
F684 Quality of care deficiency related to failure to provide appropriate hospice care and medication management for a sampled resident. The facility census was 55 residents.
F689 Free of accident hazards deficiency due to failure to properly inspect and maintain mechanical lift sling, resulting in resident injury from sling strap breaking during transfer.
Report Facts
Facility census: 55
Sampled residents: 5
Sampled residents: 5
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: May 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide appropriate hospice care to a resident and failure to follow facility policy for mechanical lift use resulting in a resident fall.
Complaint Details
The complaint investigation found that the facility failed to provide appropriate hospice care to Resident #29, including medication order management and administration. Additionally, the facility failed to inspect mechanical lift slings properly, leading to a fall of Resident #24 when a sling strap broke during transfer, causing head injury. Both incidents involved minimal harm and affected few residents.
Findings
The facility failed to provide adequate hospice care to a resident on hospice, including failure to timely enter and administer hospice medication orders. Additionally, the facility failed to properly inspect mechanical lift slings, resulting in a sling strap breaking and a resident falling and hitting their head. Staff training and procedures related to sling inspection and medication administration were found deficient.
Deficiencies (2)
Failure to provide care and services to meet the needs of a resident on hospice, including failure to timely enter and administer hospice medication orders.
Failure to follow facility policy for mechanical lifts, including failure to inspect lift sling for safety, resulting in sling strap breaking and resident fall with head injury.
Report Facts
Residents affected: 1
Residents affected: 1
Facility census: 55
Date of incident: May 10, 2025
Date of hospice admission: May 9, 2025
Date of medication order: May 12, 2025
Date of medication administration: May 14, 2025
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 12
Date: Feb 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's family of a change in condition and other related concerns.
Complaint Details
Complaint investigation focused on failure to notify family of change in condition, injury reporting, infection control, bathing and hygiene care, wound care, fall investigation, staffing adequacy, medication administration, diet orders, and infection prevention practices.
Findings
The facility failed to notify the family timely about a resident's arm fracture, failed to maintain cleanliness and odor control in certain areas, failed to report an injury of unknown origin timely, failed to investigate injuries and bruises, failed to provide adequate bathing and hygiene care to several residents, failed to complete wound care assessments and treatments, failed to ensure follow-up appointments, failed to investigate a resident fall properly, failed to provide sufficient nursing staff during a winter storm, failed to ensure proper medication administration, failed to follow infection prevention protocols including Enhanced Barrier Precautions, and failed to ensure proper diet orders and discontinuations.
Deficiencies (12)
Failure to notify resident's family of a change in condition and arm fracture in a timely manner.
Failure to maintain cleanliness and odor control in facility areas including ceiling vents and hallways.
Failure to timely report injury of unknown origin to physician and State Agency.
Failure to investigate injury of unknown origin and skin tears/bruises.
Failure to provide adequate bathing and hygiene care to dependent residents.
Failure to complete and document wound assessments and treatments as ordered, and failure to keep resident clean from wound drainage.
Failure to ensure follow-up surgical appointment for staple removal after hip surgery.
Failure to investigate resident fall, assess resident post-fall, and implement new interventions.
Failure to provide sufficient nursing staff during a winter storm causing overworked staff and missed medication administration.
Failure to administer medications as ordered to multiple residents.
Failure to ensure diet orders were correct and followed, and failure to discontinue conflicting diet orders.
Failure to implement infection prevention and control program including Enhanced Barrier Precautions, hand hygiene, and TB testing.
Report Facts
Facility census: 55
Medication doses not received: 9
Medication doses not received: 4
Medication doses not received: 1
Medication doses not received: 3
Medication doses not received: 4
Medication doses not received: 7
Medication doses not received: 4
Medication doses not received: 15
Medication doses not received: 5
Medication doses not received: 9
Staff hours worked: 49
Staff hours worked: 16.5
Staff hours worked: 21.25
Staff hours worked: 49
Staff hours worked: 13
Staff hours worked: 13
Staff hours worked: 14.75
Staff hours worked: 13.5
Staff hours worked: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Worked extended shifts during winter storm, responsible for medication administration and wound care |
| LPN A | Licensed Practical Nurse | Worked extended shifts during winter storm, involved in staffing and wound care |
| Assistant Director | Responsible for staffing, communicated with nursing staff during winter storm | |
| DON | Director of Nursing | Responsible for nursing operations, wound care oversight, staffing, and infection control |
| CMT C | Certified Medication Technician | Administered medications, did not use gloves for eye drops, unaware of EBP |
| CNA E | Certified Nursing Assistant | Assisted with wound care, did not use PPE, unaware of EBP |
| CNA F | Certified Nursing Assistant | Assisted with wound care, did not use PPE, unaware of EBP |
| LPN C | Licensed Practical Nurse | Provided wound care, forgot hand hygiene, unaware of EBP |
| Physician A | Physician | Commented on failure to investigate injury and follow policies |
Inspection Report
Routine
Census: 55
Capacity: 118
Deficiencies: 33
Date: Feb 19, 2025
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements across multiple areas including resident rights, financial management, care planning, medication administration, infection control, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain authorization forms for resident trust funds, incomplete and untimely financial reconciliations, inconsistent documentation of advanced directives and code status, failure to notify family of resident condition changes, poor environmental cleanliness and odor control, incomplete and inaccurate resident care plans and assessments, inadequate wound care and pain management, medication administration errors, insufficient staffing during inclement weather, lack of infection preventionist and antibiotic stewardship program, failure to provide immunizations, and unsafe emergency equipment maintenance.
Deficiencies (33)
Failed to maintain authorization forms for resident trust funds for sampled residents.
Failed to maintain reconciled bank statements, monthly petty cash records, and timely posting of deposits and withdrawals for resident trust funds.
Failed to document and maintain consistent code status for sampled residents.
Failed to notify resident's family timely of change in condition and failed to investigate fall and notify family.
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) to residents discharged from Medicare Part A.
Failed to maintain a clean, odor-free, and safe environment including urine odor control, dust and debris removal, and hot water temperature maintenance.
Failed to timely report injury of unknown origin to physician and State Agency and failed to investigate injury and skin tears.
Failed to notify Ombudsman of resident transfer and failed to notify resident/family of bed-hold policy.
Failed to complete accurate and timely Minimum Data Set (MDS) assessments and care plans for sampled residents.
Failed to develop and implement comprehensive care plans that reflect resident needs and current conditions.
Failed to provide adequate bathing and hygiene care to residents, resulting in poor hygiene and resident complaints.
Activities program was not directed by a qualified professional and failed to meet resident interests and needs.
Failed to complete and document wound assessments, provide ordered wound treatments, and manage pain during wound care for sampled residents.
Failed to provide sufficient nursing staff during a winter storm, resulting in staff exhaustion and missed medication administration for multiple residents.
Failed to post nurse staffing information daily at all nursing stations in a visible location for residents, visitors, and staff.
Failed to provide timely assistance to Medicaid pending residents in procuring Medicaid benefits.
Failed to ensure narcotic medications were counted and signed by two nurses at shift changes and failed to document narcotic administration correctly.
Failed to ensure proper feeding tube care including placement checks, residual checks, documentation, and staff education.
Failed to ensure oxygen and nebulizer equipment was stored in a sanitary condition and tubing was not left on the floor.
Failed to identify and implement pain management interventions during wound care for a resident expressing pain.
Failed to provide adequate staffing during inclement weather and failed to ensure medication administration and resident care were safely completed.
Failed to ensure a Registered Nurse was on duty at least eight hours per day, seven days per week.
Failed to post nurse staffing information in locations easily accessible to residents, visitors, and staff.
Failed to provide medically-related social services to assist residents with Medicaid applications and renewals.
Failed to ensure safe storage of medications including refrigeration of medications, absence of loose pills, daily temperature checks of medication refrigerators, and cleanliness of medication room.
Failed to provide continuity of care by not following up on pharmacist medication regimen review recommendations and physician responses.
Failed to provide appropriate pressure ulcer care including weekly wound assessments, treatment as ordered, and pressure reducing devices for residents at risk.
Failed to investigate a resident fall, assess the resident post-fall, and implement interventions to prevent further falls.
Failed to ensure residents with feeding tubes had proper placement and residual checks, documentation, and staff education on tube feeding care.
Failed to ensure oxygen and nebulizer equipment was stored properly and tubing changed regularly.
Failed to provide infection prevention and control program including Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, staff education on EBP, hand hygiene, and PPE use.
Failed to provide pneumococcal and influenza vaccinations to eligible residents and failed to maintain vaccine consent documentation.
Failed to ensure Automated External Defibrillators (AED) were maintained in working condition with batteries and pads, and crash cart checklists included AED checks.
Report Facts
Facility census: 55
Total licensed capacity: 118
Missed medication doses: 63
Missed medication doses: 70
Missed medication doses: 82
Narcotic card count missed: 27
Medication refrigerator temperature checks missed: 11
Medication refrigerator temperature checks missed: 15
Medication refrigerator temperature checks missed: 20
Narcotic card count missed: 106
Narcotic card count missed: 53
Narcotic card count missed: 9
Narcotic card count missed: 27
Narcotic card count missed: 10
Narcotic card count missed: 15
Narcotic card count missed: 18
Narcotic card count missed: 12
Narcotic card count missed: 7
Narcotic card count missed: 28
Narcotic card count missed: 9
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Narcotic card count missed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in medication administration errors, wound care pain management, narcotic count, oxygen equipment, and feeding tube care |
| DON | Director of Nursing | Named in staffing, medication administration oversight, wound care oversight, infection prevention, and narcotic count oversight |
| Assistant Director | Named in staffing coordination, medication administration oversight, infection prevention, and narcotic count oversight | |
| Certified Nursing Assistant A | CNA | Named in observations of resident care, bathing, wound care, and resident activities |
| Certified Nursing Assistant B | CNA | Named in observations of resident care, bathing, wound care, and resident activities |
| Certified Medication Technician C | CMT | Named in medication administration, wound care, oxygen equipment, and infection prevention |
| Licensed Practical Nurse A | LPN | Named in medication administration, wound care, infection prevention, and resident care |
| Licensed Practical Nurse B | LPN | Named in medication administration, wound care, and staffing |
| Licensed Practical Nurse F | LPN | Named in staffing |
| Certified Medication Technician E | CMT | Named in staffing and infection prevention |
| Certified Medication Technician F | CMT | Named in staffing and infection prevention |
| Certified Nursing Assistant G | CNA | Named in observations of resident care and meal delivery |
| Certified Nursing Assistant H | CNA | Named in staffing |
| Certified Nursing Assistant M | CNA | Named in staffing |
| Certified Nursing Assistant N | CNA | Named in staffing |
| Certified Nursing Assistant P | CNA | Named in staffing |
| Certified Nursing Assistant Q | CNA | Named in staffing |
| Certified Nursing Assistant R | CNA | Named in staffing |
| Certified Nursing Assistant S | CNA | Named in staffing |
| Licensed Practical Nurse G | LPN | Named in resident pain assessment and medication administration |
| Certified Nursing Assistant T | CNA | Named in resident pain assessment |
| Social Services Director | Named in Medicaid application assistance and Ombudsman notification | |
| Dietary Manager | Named in food temperature monitoring and dietary concerns | |
| Registered Dietitian | RD | Named in dietary assessment and care plan |
| Life Enrichment Coordinator | Named in activities program direction and certification | |
| Executive Director | Named in staffing, infection prevention, Medicaid assistance, and dietary oversight |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly account for and return resident funds within 30 days of a resident's death, and allegations of misappropriation of resident funds by a Business Office Manager.
Complaint Details
The complaint investigation revealed that the Business Office Manager wrote and cashed a check for $7,279.74 from a deceased resident's account to himself, after altering the payee name and forging a signature. The resident's family had not received the refund within 30 days as required. The manager admitted to the act and was terminated and arrested. The facility failed to follow policies for resident funds and check signing.
Findings
The facility failed to return funds owed to the family of a deceased resident within the required 30 days and allowed a Business Office Manager to write a check to himself from the resident trust account, which was cashed improperly. The check was altered and forged, leading to police involvement and termination of the employee. The facility's policies on resident funds and check signing were not followed, and oversight was inadequate.
Deficiencies (2)
Failed to account for and return resident funds within 30 days of death.
Misappropriation of resident funds by Business Office Manager who wrote a check to self and cashed it.
Report Facts
Resident census: 55
Refund amount: 7279.74
Days funds held: 30
Days funds remained in account: 270
Check number: 2139
Days spent teaching BOM A: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BOM A | Business Office Manager | Named in findings related to misappropriation of resident funds and failure to return funds |
| Administrator | Administrator | Supervisor of BOM A, involved in investigation and oversight |
| AIT | Administrator-In-Training | Direct supervisor of BOM A during the incident |
| President of Health Care Administration | President of Health Care Administration | Corporate officer involved in financial oversight and investigation |
| Retired Vice President | Retired Vice President | Signature on check was forged; denied signing the check |
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 6
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to the management of resident personal funds and prevention of misappropriation, including abuse, neglect, and exploitation concerns.
Findings
The facility failed to properly account for and return resident funds within required timeframes, resulting in misappropriation by the Business Office Manager. Policies and procedures related to resident funds and abuse prevention were not adequately implemented.
Deficiencies (6)
F569 Notice and conveyance of personal funds: The facility failed to account for one resident's funds within 30 days of death and return funds to designated family members. The resident trust policy and procedures were not fully followed.
F602 Free from misappropriation/exploitation: The facility failed to prevent misappropriation of one resident's funds when the Business Office Manager wrote a check to herself and cashed it without authorization.
A8023 Develop/implement abuse, neglect, exploitation policies: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents as required by regulation.
A9013 Deceased resident fund use requirements: The facility failed to comply with requirements for handling deceased resident funds, including contacting the Department of Social Services and proper accounting.
A9016 Resident funds to DSS within 60 days: The facility failed to pay DSS any remaining personal funds within 60 working days after demand for payment following a resident's death.
A9020 Unclaimed funds more than $150: The facility failed to notify the Department of Health and Senior Services about unclaimed resident funds and return abandoned property as required.
Report Facts
Resident census: 55
Refund amount: 7279.74
Plan of correction completion date: Jan 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BOM A | Business Office Manager | Named in findings related to misappropriation of resident funds and check forgery |
| Administrator | Administrator involved in investigation and oversight of plan of correction |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Apr 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where a Certified Nursing Assistant (CNA) was observed to have forcefully pushed Resident #1 into his/her recliner, potentially violating the resident's right to be treated with respect and dignity.
Complaint Details
The complaint investigation was substantiated by video evidence showing CNA A physically aggressive with Resident #1 by pushing him/her into a recliner with too much force. The local police department was notified. The family chose not to press charges. The Administrator plans to terminate the CNA regardless of the investigation outcome.
Findings
The facility failed to provide care in a respectful and dignified manner when CNA A forcefully pushed Resident #1 into a recliner. The incident was confirmed by video evidence and family observation. The facility administration conducted staff in-service training on abuse, neglect, and resident rights, and planned to terminate the CNA involved.
Deficiencies (1)
Failed to provide care in a respectful and dignified manner when CNA forcefully pushed Resident #1 into recliner.
Report Facts
Residents present: 55
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in the finding for forcefully pushing Resident #1 into recliner |
| Administrator | Interviewed regarding the incident and plans to terminate CNA A |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Apr 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident involving a Certified Nursing Assistant (CNA) forcefully pushing a resident into a recliner.
Complaint Details
The complaint investigation was substantiated based on video evidence, interviews with the resident, family, local police, and staff. The CNA was observed pushing the resident roughly into a recliner, causing a hard landing. The facility plans to terminate the CNA regardless of the State Agency investigation outcome.
Findings
The facility failed to provide care in a respectful and dignified manner as evidenced by a CNA pushing a resident into a recliner with excessive force. The incident was documented through observation, interviews, and video evidence, and the facility administration took corrective actions including staff in-service training and plans to terminate the CNA involved.
Deficiencies (1)
F 557 Respect, Dignity/Right to have Personal Property. The facility failed to treat a resident with respect and dignity when a CNA forcefully pushed the resident into a recliner. The facility census was 55 residents.
Report Facts
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in the finding for forcefully pushing a resident into a recliner |
Inspection Report
Routine
Census: 59
Deficiencies: 2
Date: Feb 13, 2024
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program and antibiotic stewardship program compliance.
Findings
The facility failed to maintain an effective infection control program including proper hand hygiene and perineal care, and failed to implement an antibiotic stewardship program. Observations and interviews revealed improper handling of soiled linen and inadequate infection monitoring and training.
Deficiencies (2)
Failed to maintain an effective infection control program including tracking infections and proper hand hygiene between glove changes; improper perineal care and placing soiled linen on the floor.
Failed to implement a program that monitors antibiotic use and lacked documentation of an antibiotic stewardship program.
Report Facts
Facility census: 59
Dates of infection surveillance review: 2/1/23 to 2/1/24
Resident admission date: Resident #7 admitted on undisclosed date
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding perineal care and infection control practices |
| Certified Nursing Assistant (CNA) A | Certified Nursing Assistant | Observed performing perineal care and handling soiled linen improperly |
| Director of Nursing (DON) | Director of Nursing | Interviewed about infection monitoring, training, and expectations for staff practices |
| Administrator | Administrator | Interviewed regarding antibiotic stewardship program documentation and staffing |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 3
Date: Feb 13, 2024
Visit Reason
The inspection was an annual survey conducted to evaluate the facility's infection prevention and control program and antibiotic stewardship program compliance.
Findings
The facility failed to maintain an effective infection control program including proper hand hygiene and handling of soiled linen, and lacked an antibiotic stewardship program to monitor antibiotic use. These deficiencies had the potential to affect all 59 residents.
Deficiencies (3)
F880 Infection Prevention & Control: The facility failed to maintain an effective infection control program including tracking and trending resident infections, proper hand hygiene between glove changes, and preventing placement of soiled linen on the floor for one sampled resident.
F881 Antibiotic Stewardship Program: The facility failed to have an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use.
A4086 Infection Control/Communicable Disease: The facility failed to report communicable diseases to the state within seven days as required by Missouri regulations.
Report Facts
Facility census: 59
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in interviews regarding infection control and antibiotic stewardship program deficiencies |
| Administrator | Administrator | Named as signing official and involved in antibiotic stewardship program implementation |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 4
Date: Jun 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to complete a thorough investigation of a resident's bruise of unknown origin and a left arm fracture to rule out abuse and neglect, as well as concerns about staff competencies with mechanical lifts, infection control practices, and COVID-19 outbreak management.
Complaint Details
The complaint investigation focused on the facility's failure to thoroughly investigate a resident's injury of unknown origin, potential abuse and neglect, inadequate staff training on mechanical lifts, infection control deficiencies during a COVID-19 outbreak, and failure to notify families of COVID-19 positive residents.
Findings
The facility failed to properly investigate a resident injury, ensure staff competency in mechanical lift use, follow infection prevention and control protocols including proper hand hygiene and COVID-19 testing procedures, prevent cross-contamination, and notify families of COVID-19 positive residents. Deficiencies were noted in investigation completeness, staff training, infection control practices, and communication with families.
Deficiencies (4)
Failed to complete a thorough investigation of a resident's bruise and fracture to rule out abuse and neglect.
Failed to ensure nursing staff had appropriate competencies and skills to use a mechanical lift prior to use.
Failed to provide and implement an infection prevention and control program, including proper hand hygiene and wound care.
Failed to follow COVID-19 infection control measures including improper COVID-19 testing technique, shared bathrooms between COVID-positive and negative residents, improper PPE handling, and failure to notify families of COVID-19 positive residents.
Report Facts
Residents affected by bruise/fracture investigation deficiency: 1
Residents affected by mechanical lift competency deficiency: 2
Residents affected by infection prevention and control deficiency: 1
Residents affected by COVID-19 related deficiencies: 7
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Notified physician, DON, and family about resident injury; interviewed multiple times regarding injury and investigation; stated expectations for staff training and investigation. |
| CNA C | Certified Nursing Assistant | Found bruise and skin tear on resident; assisted with mechanical lift transfer. |
| MDS Coordinator | Notified of injury, collected some staff statements, delegated further statement collection, but did not receive all statements. | |
| DON | Director of Nursing | Believed injury was due to mechanical lift transfer; responsible for investigation and staff training; acknowledged deficiencies in investigation and training; responsible for family notification of COVID-19 status. |
| HRD | Human Resources Director | Performed COVID-19 testing improperly, including improper glove use and hand hygiene. |
| CNA B | Certified Nursing Assistant | Observed performing wound care with poor hand hygiene; responsible for reminding resident not to use shared bathroom; did not offer commode to resident. |
| LPN C | Licensed Practical Nurse | Observed performing wound care with improper hand hygiene. |
| CNA D | Certified Nursing Assistant | Assisted with mechanical lift transfer; unaware of mechanical lift in-service. |
| CNA A | Certified Nursing Assistant | Had not been trained on mechanical lift use; unaware of resident's broken arm. |
| CNA F | Certified Nursing Assistant | Shown how to use lift once by bath aide; not asked to demonstrate proper use. |
| Agency CNA A | Certified Nursing Assistant | Had not been educated on Hoyer lifts; never demonstrated competency. |
Inspection Report
Routine
Census: 55
Deficiencies: 18
Date: Jun 5, 2023
Visit Reason
Routine inspection of Abode Health and Wellness Center to assess compliance with healthcare regulations including resident rights, care, safety, and infection control.
Complaint Details
Complaint MO00219381 related to infection prevention and control deficiencies including COVID-19 outbreak management, testing, PPE use, and family notification.
Findings
The facility had multiple deficiencies including failure to maintain proper resident fund authorization and ledger accuracy, inadequate assessment and monitoring of physical restraints, incomplete investigations of alleged abuse, failure to notify residents of bed hold policies, incomplete significant change assessments, incomplete care plans, inadequate assistance with activities of daily living, improper catheter care, unsafe medication storage, improper food temperature control, incomplete staff training on mechanical lifts, failure to submit payroll based journal data, and lapses in infection prevention and control practices including COVID-19 protocols.
Deficiencies (18)
Failed to have authorization form signed by Public Administrator for resident funds and legible authorization for another resident.
Failed to list transactions for May 2023 on resident ledger sheet.
Failed to notify resident or responsible parties of resident fund balances exceeding notification limits.
Failed to provide adequate assessment and monitoring for use of physical restraints (seatbelt) for a resident.
Failed to complete thorough investigation of resident's bruise and fracture to rule out abuse and neglect.
Failed to inform resident and/or responsible party of bed hold policy and obtain signed acknowledgment.
Failed to accurately complete significant change MDS assessments when residents started hospice services.
Failed to ensure comprehensive care plans reflecting hospice services, oxygen therapy, and dementia care.
Failed to provide bathing per resident preference and care plan, with missed baths and incomplete documentation.
Failed to ensure low air loss mattress remained inflated and in working order, and mattress settings documented.
Failed to complete thorough fall investigations and update care plans with fall interventions.
Failed to ensure infection control practices during catheter care including proper placement of drainage bags and obtaining physician orders for catheter care.
Failed to ensure respiratory equipment was kept covered when not in use and care plans updated for respiratory treatments.
Failed to ensure mechanical lift training and competency demonstration for staff prior to use.
Failed to submit Payroll Based Journal staffing data for three quarters.
Failed to maintain safe storage of medications including unlocked medication room and refrigerator with undated controlled substances.
Failed to maintain cold food at safe temperature and serve hot food at appropriate temperature during meal service.
Failed to follow infection prevention and control policies including improper COVID-19 testing technique, used PPE left outside positive resident rooms, failure to notify families of COVID-19 positive residents, and inadequate hand hygiene during wound care.
Report Facts
Facility census: 55
Resident sample size: 16
Supplemental resident sample size: 8
Temperature of cucumber tomato salad: 66
Temperature of meatball sandwich: 105
Fall risk score: 18
Number of missing monthly medication reviews: 5
Number of missing monthly medication reviews: 7
Number of missing monthly medication reviews: 5
Number of missing monthly medication reviews: 8
Number of opened Ativan bottles undated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Mentioned in relation to catheter care, fall investigations, infection control, medication storage, and COVID-19 family notification |
| CNA B | Certified Nursing Assistant | Mentioned in relation to wound care, bathing, catheter care, fall prevention, and COVID-19 bathroom sharing |
| DON | Director of Nursing | Mentioned in relation to oversight of care plans, fall investigations, medication reviews, infection control, and staff training |
| HRD | Human Resources Director | Performed COVID-19 testing with improper technique |
| CNA A | Certified Nursing Assistant | Mentioned in relation to catheter care, respiratory equipment, fall prevention, and COVID-19 bathroom sharing |
| CNA D | Certified Nursing Assistant | Mentioned in relation to catheter care and bathing |
| CNA F | Certified Nursing Assistant | Mentioned in relation to bathing and respiratory equipment |
| CNA G | Certified Nursing Assistant | Mentioned in relation to mechanical lift use |
| CNA H | Certified Nursing Assistant | Mentioned in relation to mechanical lift use |
| LPN B | Licensed Practical Nurse | Mentioned in relation to catheter care and mechanical lift use |
| LPN C | Licensed Practical Nurse | Mentioned in relation to wound care and infection control |
| CMT A | Certified Medication Technician | Mentioned in relation to medication storage |
| DA A | Dietary Aide | Mentioned in relation to food temperature control |
| DM | Dietary Manager | Mentioned in relation to food temperature control and kitchen maintenance |
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 5
Date: Aug 9, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including catheter care, staffing posting, medication regimen reviews, infection control, and equipment maintenance.
Findings
The facility was found deficient in multiple areas including improper catheter care practices risking infection, failure to post daily nurse staffing information visibly, missing pharmacist medication regimen review documentation, incomplete annual tuberculosis screenings for several residents, and inadequate maintenance and monitoring of AED machines.
Deficiencies (5)
Failure to ensure urinary catheter tubing and drainage bags were kept off the floor, risking infection for two residents.
Failure to properly post daily nurse staffing information in a visible area for staff, residents, and visitors.
Failure to ensure pharmacy Medication Regimen Reviews with pharmacist recommendations were documented monthly in residents' medical records for two residents.
Failure to complete annual tuberculosis screening for one sampled resident and three supplemental residents.
Failure to maintain two AED machines by not ensuring monthly checks, expired and opened battery/pads packs, and lack of staff knowledge of AED locations.
Report Facts
Residents affected: 2
Residents affected: 30
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding catheter care, staffing posting, medication regimen reviews, tuberculosis screening, and AED maintenance |
| Administrator | Administrator | Interviewed regarding staffing posting and AED maintenance responsibilities |
| Certified Nursing Assistant A | Certified Nursing Assistant | Observed placing urinary drainage bag on floor |
| Certified Nursing Assistant B | Certified Nursing Assistant | Interviewed regarding catheter bag placement |
| LPN B | Licensed Practical Nurse | Interviewed regarding staffing sheet location |
| Certified Nursing Assistant C | Certified Nursing Assistant | Interviewed regarding AED knowledge |
| Certified Nursing Assistant D | Certified Nursing Assistant | Interviewed regarding AED knowledge |
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 9
Date: Aug 9, 2021
Visit Reason
The inspection was the annual survey of Truman Gardens nursing facility to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including catheter care, nurse staffing information posting, drug regimen review, infection prevention and control, and employee tuberculosis screening. Several residents were directly affected by poor practices and documentation was incomplete or missing in key areas.
Deficiencies (9)
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to ensure staff kept urinary catheter tubing, drainage bag, and privacy bag off the floor, risking infection for sampled residents.
F732 Posted Nurse Staffing Information: Facility failed to properly post daily staffing data in a visible area for staff, residents, and visitors, affecting all residents and staff.
F756 Drug Regimen Review: Facility failed to ensure pharmacy medication regimen reviews with pharmacist recommendations were documented in residents' medical records.
F880 Infection Prevention & Control: Facility failed to ensure staff completed annual tuberculosis screening for residents and maintain infection control procedures, affecting multiple residents.
F908 Essential Equipment, Safe Operating Condition: Facility failed to maintain two Automatic External Defibrillators (AEDs) by not ensuring monthly checks and proper maintenance documentation.
A4029 Communicable Disease-Employees: Facility failed to properly screen new employees for tuberculosis and maintain documentation, affecting all residents and staff.
A4060 Drug Regimen Review-Monthly: Facility failed to ensure monthly pharmacist or nurse review of drug regimens and proper documentation of irregularities.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice.
A4085 Infection Control/Communicable Disease: Facility failed to provide acceptable infection control procedures to prevent spread of infection and timely reporting.
Report Facts
Deficiencies cited: 9
Facility census: 30
Inspection Report
Routine
Deficiencies: 0
Date: Jan 11, 2021
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 practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with related 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 practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 10, 2020
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 for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 41
Capacity: 118
Deficiencies: 11
Date: Oct 30, 2019
Visit Reason
The inspection was conducted to investigate complaints related to regulatory compliance in a nursing facility, including criminal background check requests, notice requirements before transfer/discharge, bed hold policies, baseline care planning, medication administration, infection control, and other care standards.
Complaint Details
The visit was complaint-related, investigating allegations of noncompliance with criminal background checks, transfer/discharge notices, bed hold policies, care planning, medication administration, infection control, and dental services. The deficiencies were substantiated as evidenced by interviews, record reviews, and observations.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks prior to hiring, failure to provide written notice of transfer or discharge to residents or their representatives, failure to notify residents of bed hold policies, incomplete baseline care plans, untimely medication administration, inadequate infection prevention and control, and failure to provide routine dental services. The facility census was 41 residents with a licensed capacity of 118 beds.
Deficiencies (11)
F607: The facility failed to request Criminal Background Checks for two sampled employees prior to hire as required by regulation.
F623: The facility failed to provide written notice of transfer or discharge to residents or their representatives for sampled residents.
F625: The facility failed to notify residents and their representatives of the bed hold policy before transferring residents to the hospital.
F655: The facility failed to develop and provide baseline care plans for sampled residents within 48 hours of admission.
F658: The facility failed to administer medications timely and document administration for three sampled residents.
F688: The facility failed to provide restorative nursing services according to residents' care plans for one sampled resident.
F730: The facility failed to complete performance reviews and provide regular in-service education for certified nursing assistants annually.
F791: The facility failed to provide routine and emergency dental services to residents as required.
F812: The facility failed to store, prepare, distribute, and serve food in a sanitary manner, including food residue and cutting board issues.
F880: The facility failed to establish and maintain an infection prevention and control program, including hand hygiene and wound care practices.
F883: The facility failed to ensure residents were offered influenza and pneumococcal immunizations and document refusals or contraindications.
Report Facts
Facility census: 41
Licensed capacity: 118
Deficiency count: 11
Medication pass times late: 45
Water Management Inspection Checklist points: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Named in criminal background check deficiency | |
| Employee C | Named in criminal background check deficiency | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding CBC process and transfer notices |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication pass and nursing duties |
| Certified Medication Technician | Certified Medication Technician (CMT) | Observed administering medications |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed regarding staff training and infection control |
| Social Services Director | Social Services Director | Interviewed regarding transfer notices and dental care documentation |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and kitchen sanitation |
Inspection Report
Life Safety
Census: 41
Capacity: 118
Deficiencies: 8
Date: Oct 30, 2019
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and life safety code provisions.
Findings
The facility failed to establish and maintain a comprehensive emergency preparedness program meeting federal requirements. Deficiencies were found in the fire alarm system notification devices, fire watch policy, fire door inspections, electrical system maintenance, and emergency generator annunciator visibility.
Deficiencies (8)
E001: The facility failed to establish and maintain a comprehensive emergency preparedness program that meets all federal, state, and local requirements, including communication methods and contact information for emergency agencies.
K343: The fire alarm system failed to ensure all audio and visual notification devices were properly installed in critical areas including laundry rooms and the enclosed courtyard.
K346: The facility lacked a comprehensive fire watch policy and failed to provide an achievable fire watch plan when the fire alarm system was out of service for more than four hours.
K761: Fire doors and frames lacked proper Fire Resistance Rating (FRR) labels, and some labels were illegible or painted over, compromising fire safety compliance.
K914: The facility failed to maintain complete, itemized annual records for bedside electrical receptacles in resident rooms, affecting 14 smoke zones.
K916: The emergency generator remote annunciator was not readily observable or audible, risking delayed emergency response.
K918: The facility failed to maintain two sets of generator manuals on-site, ensure breaker panel clearance, and provide proper training and documentation for generator maintenance.
K920: Surge protectors were not properly secured, and multi-plex outlet adapters were used in patient care areas contrary to NFPA standards.
Report Facts
Facility census: 41
Total capacity: 118
Facility smoke zones: 14
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 2
Date: Feb 22, 2019
Visit Reason
The inspection was conducted to evaluate compliance with professional standards related to medication administration and comprehensive care plans, specifically addressing transcription of chemotherapy medication orders.
Findings
The facility failed to transcribe a chemotherapy medication order correctly from a telephone order to the Medication Administration Record, resulting in medication administration errors for a sampled resident. The facility submitted a plan of correction to address transcription procedures and staff training.
Deficiencies (2)
F658: The facility failed to transcribe a chemotherapy medication order correctly from a telephone order to the Medication Administration Record, resulting in medication errors for a sampled resident receiving chemotherapy.
A4053: No medication, treatment, or diet shall be given without a written order from a lawful prescriber. This requirement was not met as referenced in F658.
Report Facts
Resident census: 50
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Nurse A | Clinical Nurse | Named in relation to medication order transcription and administration errors |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed and wrote a statement regarding medication order |
| Director of Nursing | Director of Nursing | Interviewed regarding medication order and facility procedures |
| Certified Medication Technician B | Certified Medication Technician | Interviewed about medication administration procedures |
Inspection Report
Life Safety
Census: 54
Capacity: 118
Deficiencies: 9
Date: Jan 29, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Life Safety Code and related fire safety regulations at Truman Gardens.
Findings
The facility was found deficient in multiple areas related to fire safety including sprinkler system impairments, blocked egress routes, combustible storage in attic areas, and inadequate fire drills. The facility census was 54 residents with a licensed capacity of 118 beds.
Deficiencies (9)
K161: The facility failed to ensure the foyer ceiling resisted smoke passage due to absence of ductwork over a grate, potentially affecting 20 residents.
K211: The facility failed to prevent accumulation of items obstructing the service hall egress route, potentially affecting 16 residents.
K271: The facility failed to maintain all-weather exit surfaces free of damage and ice, potentially affecting 20 residents.
K300: The facility failed to keep attic areas free of combustible materials and animal nests, potentially affecting 30 residents.
K354: The sprinkler system was out of service for more than 10 hours without a complete fire watch policy, affecting all residents and staff.
K363: The door to the dry goods storage room was held open improperly, compromising smoke barrier integrity and affecting at least 20 residents.
K372: The facility failed to ensure a safe route to inspect the smoke barrier wall in the attic, affecting at least 34 residents.
K712: The facility failed to conduct fire drills at varying times and shifts as required, potentially affecting all residents.
K919: The facility failed to maintain electrical equipment safety in the attic, including uncovered voltage boxes and improper storage near electrical panels, affecting at least 15 residents.
Report Facts
Facility census: 54
Licensed capacity: 118
Fire drills conducted: 8
Fire drills missed: 4
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 18
Date: Jan 29, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain residents' dignity and to ensure self-administration of medications was clinically appropriate.
Complaint Details
The complaint investigation was substantiated. The facility failed to maintain residents' dignity, failed to ensure proper medication self-administration orders, and failed to investigate abuse allegations. Multiple other deficiencies were identified during the investigation.
Findings
The facility failed to maintain dignity for sampled residents, including improper handling of catheter bags and privacy issues. The facility also failed to ensure a physician's order for self-administration of medications was obtained and followed. Additional deficiencies were noted in resident care, abuse prevention, safe environment, quality of care, wound care, nutrition, medication management, infection control, and pest control.
Deficiencies (18)
F550 Resident Rights: The facility failed to ensure residents' dignity was maintained, including improper handling of catheter bags and lack of privacy during care.
F554 Resident Self-Admin Meds-Clinically Approp: The facility failed to ensure a physician's order was obtained and followed for residents self-administering medications.
F567 Protection/Management of Personal Funds: The facility failed to obtain authorization to hold and manage a resident's personal funds.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a safe, clean, and comfortable environment, including adequate lighting, temperature control, and housekeeping.
F610 Initiate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate allegations of abuse and neglect involving residents.
F625 Notice of Hold Policy Before/Upon Transfer: The facility failed to provide required notice of bed-hold policy to residents upon transfer or discharge.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide adequate activity programs and documentation for residents.
F684 Quality of Care: The facility failed to provide adequate care for wounds, including assessment, treatment, and documentation.
F692 Nutrition/Hydration Status Maintained: The facility failed to ensure residents received adequate nutrition and hydration, including monitoring and documentation.
F755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to ensure medications were properly stored, labeled, and administered.
F760 Label/Storage Drugs and Biologicals: The facility failed to properly store and label medications and supplies.
F761 Label/Storage Drugs and Biologicals: The facility failed to maintain medication storage areas free of expired items and properly secured.
F800 Food and Nutrition Services: The facility failed to provide safe and properly prepared food meeting residents' dietary needs.
F805 Food in Form to Meet Individual Needs: The facility failed to provide food in appropriate form for residents with chewing difficulties.
F812 Food Safety Requirements: The facility failed to maintain proper food safety standards including cleanliness and temperature control.
F880 Infection Prevention and Control: The facility failed to maintain an effective infection control program, including proper cleaning and handling of supplies.
F923 Ventilation: The facility failed to provide adequate ventilation in the laundry room.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, allowing animal nests and mud dauber nests.
Report Facts
Facility census: 54
Deficiencies cited: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Named in findings related to catheter bag handling and resident care |
| Certified Medication Technician (CMT) D | Certified Medication Technician | Named in findings related to medication administration |
| Director of Nursing (DON) | Director of Nursing | Named in findings related to oversight of resident care and investigations |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in findings related to facility cleanliness and environment |
| Maintenance Supervisor | Maintenance Supervisor | Named in findings related to facility environment and pest control |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Named in findings related to wound care and medication administration |
| Certified Nursing Assistant (CNA) A and CNA F | Certified Nursing Assistants | Named in findings related to resident care and dignity |
| Social Services Director | Social Services Director | Named in findings related to abuse investigation and resident care |
| Activity Director | Activity Director | Named in findings related to resident activities and care planning |
| Dietary Manager | Dietary Manager | Named in findings related to food service and nutrition |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 12
Date: Jan 23, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and to evaluate the quality of care and services provided at Truman Gardens nursing facility.
Findings
The facility was found to have multiple deficiencies related to resident care, medication management, nursing staff compliance, and documentation. Several residents' care plans and assessments were incomplete or not updated, and there were issues with medication errors and infection control practices.
Deficiencies (12)
F 558: The facility failed to ensure reasonable accommodation for residents, including proper positioning of foot rests on Broda chairs, affecting resident comfort and safety.
F 606: The facility failed to check the Nurse Aide Registry prior to hiring new employees, risking employment of individuals with abuse or neglect history.
F 656: The facility failed to develop and implement comprehensive care plans for residents, including pain management and oxygen use.
F 684: The facility failed to provide adequate treatment and care for residents, including wound care, fall prevention, and behavioral management.
F 689: The facility failed to ensure adequate supervision and assistance to prevent accidents and falls, and failed to properly investigate and document falls.
F 690: The facility failed to provide appropriate incontinence care and bowel and bladder management for residents.
F 692: The facility failed to ensure adequate nutrition and hydration for residents, including monitoring and documentation of intake.
F 755: The facility failed to provide proper pharmacy services, including medication administration and documentation.
F 759: The facility failed to maintain medication error rates below 5%, with multiple errors in medication administration and documentation.
F 760: The facility failed to ensure residents were free from significant medication errors, including improper dosing and documentation.
F 761: The facility failed to ensure proper storage and handling of drugs and controlled substances, including narcotic counts and medication disposal.
F 880: The facility failed to maintain an effective infection prevention and control program, including hand hygiene and use of personal protective equipment.
Report Facts
Deficiencies cited: 12
Resident census: 54
Inspection Report
Life Safety
Census: 54
Capacity: 118
Deficiencies: 6
Date: Jan 23, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain continuous illumination of exit signage, did not have documentation for a required five-year sprinkler system obstruction inspection, lacked documentation for lubrication of fusible links on smoke and fire dampers, failed to conduct quarterly fire drills on all shifts, and did not properly assess electrical receptacles at resident bed locations. The facility census was 54 residents with a licensed capacity of 118 beds.
Deficiencies (6)
K293 Exit Signage: The facility failed to maintain lighting power sources for 27 of 31 internally illuminated exit signs, affecting 54 residents and staff.
K353 Sprinkler System - Maintenance and Testing: The facility lacked documentation of a required five-year sprinkler system obstruction inspection.
K521 HVAC: The facility failed to provide documentation of lubrication of fusible links on smoke and fire dampers for the past four years, affecting all residents in 14 smoke compartments.
K712 Fire Drills: Facility staff failed to conduct quarterly fire drills on all shifts, with missing drills on multiple months and shifts.
K781 Portable Space Heaters: The facility used portable space heaters in staff and employee areas without required documentation of heating elements.
K914 Electrical Systems - Maintenance and Testing: The facility did not assess electrical receptacles at resident bed locations for integrity, grounding, polarity, and retention force in 62 resident rooms.
Report Facts
Facility census: 54
Licensed capacity: 118
Deficiencies cited: 6
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