Inspection Reports for
Belleview Care Center
1616 WEISENBORN RD, SAINT JOSEPH, MO, 64507-2527
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
28 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
409% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
44% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 84
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with proper management and accounting of residents' personal money deposited with the nursing home.
Findings
The facility failed to maintain a system to assure that accurate quarterly accounting statements of resident trust fund accounts were sent to residents or their representatives, affecting four sampled residents. The Business Office Manager had not been sending these quarterly reports as required.
Deficiencies (1)
Failure to send quarterly accounting statements of resident trust fund accounts to residents or their representatives.
Report Facts
Residents affected: 4
Facility census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Responsible for sending resident trust fund accounting reports; acknowledged failure to send quarterly reports | |
| Facility Regional Consultant | Confirmed responsibility of Business Office Manager for sending quarterly reports |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Nov 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #1 physically abused Resident #2 by pushing him/her to the floor.
Complaint Details
The complaint investigation found that Resident #1 pushed Resident #2 to the ground, constituting physical abuse. Resident #1 has a history of aggression and was experiencing a urinary tract infection at the time. Both residents were separated and sent for psychological evaluation. Staff were retrained on abuse prevention.
Findings
The facility failed to protect Resident #2 from physical abuse when Resident #1 pushed Resident #2 to the ground. The facility responded by separating the residents, conducting an investigation, retraining staff on abuse prevention, and updating care plans. Resident #2 had no injuries and the noncompliance was corrected promptly.
Deficiencies (1)
Failed to protect a resident from physical abuse when another resident pushed him/her to the floor.
Report Facts
Staff trained on abuse prevention: 39
Inspection Report
Plan of Correction
Census: 10
Deficiencies: 3
Date: Apr 22, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding community based assessments, resident condition/medication reviews, and resident rights in an assisted living facility.
Findings
The facility failed to complete Community Based Assessments within five calendar days of admission for two of three sampled residents. The facility also failed to maintain monthly reviews of resident conditions and medication for four sampled residents and failed to review resident rights annually for two of three sampled residents. Policies regarding these areas were not provided.
Deficiencies (3)
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day. The facility failed to complete a Community Based Assessment within five calendar days of admission for two of three sampled residents. The facility census was 10.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to maintain a monthly review of each resident's general condition, needs, and significant incidents for four of four sampled residents. The facility census was 10.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review. The facility failed to review resident rights annually with each resident or their designee for two of three sampled residents. The facility census was 10.
Report Facts
Facility census: 10
Sampled residents: 3
Sampled residents: 4
Sampled residents: 3
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to protect residents from abuse, specifically incidents involving Resident #1 physically assaulting Residents #2, #3, and #4.
Complaint Details
The complaint investigation found substantiated incidents where Resident #1 physically assaulted Residents #2, #3, and #4. The facility failed to immediately intervene despite 1:1 monitoring. Resident #1 was sent for psychiatric evaluation and discharged from the facility.
Findings
The facility failed to protect residents from abuse when Resident #1 punched and hit other residents multiple times. Staff did not immediately intervene despite 1:1 monitoring. Resident #1 was transferred to a psychiatric hospital and the facility implemented staff education on abuse prevention.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical abuse by another resident.
Report Facts
Residents affected: 3
Census: 82
Date of incidents: Mar 13, 2025
Date of correction: Mar 18, 2025
Inspection Report
Plan of Correction
Census: 82
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The visit was conducted to address a past noncompliance related to abuse and neglect at Belleview Care Center, specifically involving resident-to-resident physical altercations. The facility was notified of the noncompliance and implemented corrective actions.
Findings
The facility failed to protect residents from abuse, neglect, and exploitation as evidenced by Resident #1 physically assaulting Residents #2, #3, and #4. The facility conducted investigations and staff education on abuse prevention and monitoring aggressive residents. The noncompliance was corrected by 03/18/25.
Deficiencies (1)
F 600: The facility failed to protect residents from abuse and neglect as Resident #1 punched Resident #4 with a closed fist and hit Residents #2 and #3 with an open hand. The facility conducted an investigation and implemented corrective actions.
Report Facts
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #1's behavior and staff education on abuse prevention |
| Administrator | Administrator | Notified of past noncompliance and interviewed about incidents and corrective actions |
| Activities Aide A | Provided statement about Resident #1 punching Resident #4 | |
| CNA B | Certified Nurses Aide | Interviewed about Resident #1's aggressive behavior and facility investigations |
Inspection Report
Routine
Census: 82
Deficiencies: 2
Date: Feb 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to food palatability and call light accessibility for residents at Belleview Care Center.
Findings
The facility failed to ensure food served was palatable and attractive for two of 18 sampled residents, and failed to assure two residents had access to a call light while lying in bed, potentially risking resident safety. Both deficiencies were noted with minimal harm or potential for actual harm.
Deficiencies (2)
Failed to ensure staff served food that was palatable and attractive for two of 18 sampled residents.
Failed to assure two residents had access to a working call system in their bathroom and bathing area to summon staff as needed.
Report Facts
Residents sampled: 18
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding expectations for food temperature, appearance, seasoning, and texture. | |
| Dietician | Interviewed regarding expectations for food temperature, appearance, seasoning, and texture. | |
| Senior Administrator | Interviewed regarding expectations for food temperature, appearance, seasoning, and texture. | |
| CNA-B | Interviewed regarding call light placement and accessibility. | |
| LPN-B | Interviewed regarding call light placement and accessibility. | |
| Maintenance Director | Interviewed regarding call light placement and accessibility. | |
| Director of Nursing | Interviewed regarding call light placement and accessibility. |
Inspection Report
Routine
Census: 82
Deficiencies: 12
Date: Feb 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, safety, medication administration, environment, food service, and equipment maintenance at Belleview Care Center.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' rights and dignity during ADL care, inconsistent code status documentation, unsafe and unclean environment, medication administration errors, inadequate personal hygiene care, improper respiratory care, food service issues, unsafe kitchen practices, malfunctioning freezer, and inaccessible call lights for residents.
Deficiencies (12)
Failure to ensure staff maintained residents' rights and dignity during ADL care, including failure to remove facial hair and honor bathing preferences.
Failure to clarify and maintain consistent Do Not Resuscitate (DNR) orders for Resident #10.
Failure to maintain a safe, clean, comfortable, and homelike environment including peeling wallpaper, water stains, broken furniture, and unclean medical equipment.
Failure to record administration of medications on the Medication Administration Record (MAR) for Resident #13.
Failure to provide complete peri care to dependent residents, not separating and cleaning all perineal folds.
Failure to provide care and services to attain or maintain highest practicable well-being, including improper medication administration by another resident and failure to respect shower preferences.
Failure to provide safe and appropriate respiratory care, including failure to follow physician orders for continuous oxygen therapy and failure to provide clean oxygen equipment.
Medication administration errors observed with eye drop technique, including touching eye dropper tip to resident's eye.
Failure to ensure food served was palatable, attractive, and at safe temperature; residents reported cold, bland, and unappetizing food.
Failure to prepare and serve food in accordance with professional standards including unlabeled and expired foods, missing temperature logs, improper storage, unclean kitchen environment, and poor hand hygiene.
Failure to maintain essential equipment safely and operably, specifically the walk-in freezer with ice buildup and elevated temperatures affecting food safety.
Failure to ensure residents had access to working call lights within reach in their rooms and bathrooms.
Report Facts
Census: 82
Medication errors: 2
Medication opportunities: 26
Oxygen flow rate: 2
Freezer temperature: 28
Freezer temperature: 12
Medication administration missing documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Observed administering eye drops incorrectly and interviewed about proper technique |
| CNA D | Certified Nurses Aide | Observed providing incomplete peri care to Resident #10 |
| NA B | Nurses Aide | Interviewed about peri care procedures |
| LPN A | Licensed Practical Nurse | Interviewed about grooming and equipment storage |
| RN B | Registered Nurse | Interviewed about medication administration and oxygen orders |
| DON | Director of Nursing | Interviewed about expectations for resident care, medication administration, and call light accessibility |
| Administrator | Administrator | Interviewed about facility policies on showers, medication administration, and food service |
| Dietary Manager | Dietary Manager | Interviewed about food service standards and kitchen hygiene |
| Dietary Aid A | Dietary Aide | Observed and interviewed about kitchen practices and freezer maintenance |
| Maintenance Director | Maintenance Director | Interviewed about freezer maintenance and call light accessibility |
| CNA B | Certified Nurses Aide | Interviewed about call light accessibility and peri care |
Inspection Report
Annual Inspection
Census: 82
Capacity: 83
Deficiencies: 12
Date: Feb 12, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations at Belleview Care Center.
Findings
The facility was found to have multiple deficiencies related to resident rights, safe environment, medication administration, quality of care, and other regulatory requirements. The facility census was 82 with a total capacity of 83 beds.
Deficiencies (12)
F550 Resident Rights: Facility staff failed to ensure residents' rights were maintained, including failure to remove facial hair and honor bathing preferences for sampled residents.
F578 Request/Refuse/Discontinue Treatment: Facility failed to clarify and maintain accurate Do Not Resuscitate (DNR) orders for a sampled resident.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility failed to maintain a safe, clean, and comfortable environment, including unclean equipment, damaged furniture, and peeling wallpaper.
F658 Services Provided Meet Professional Standards: Facility failed to provide services meeting professional standards, including medication administration errors for a sampled resident.
F677 ADL Care Provided for Dependent Residents: Facility failed to ensure dependent residents received necessary personal hygiene care, affecting three sampled residents.
F684 Quality of Care: Facility failed to ensure residents received care consistent with professional standards, including proper medication administration and respect for resident choice.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility failed to provide respiratory care consistent with professional standards for two sampled residents.
F759 Free of Medication Error Rates 5 Percent or More: Facility medication error rate exceeded five percent, affecting two sampled residents.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: Facility failed to provide palatable and appropriately prepared food to sampled residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to maintain sanitary food storage and preparation areas, including expired foods and unclean equipment.
F908 Essential Equipment, Safe Operating Condition: Facility failed to maintain kitchen equipment in safe operating condition, including freezer temperature issues and ice buildup.
F919 Resident Call System: Facility failed to ensure call lights were accessible and functional for sampled residents.
Report Facts
Facility census: 82
Total capacity: 83
Number of sampled residents: 18
Medication error rate: 7
Medication error opportunities: 26
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 4
Date: Nov 12, 2024
Visit Reason
The inspection was conducted due to complaints regarding facility conditions and resident abuse allegations.
Complaint Details
The complaint involved a resident (Resident #2) who reported being forcibly fed by a Certified Nurse Aide (CNA A) despite expressing refusal. The resident was emotionally upset and tearful. The facility did not report the abuse allegation to the State Agency within the required two-hour timeframe and failed to conduct a full investigation including obtaining staff statements. The Administrator considered the issue customer service rather than abuse and did not report it. The CNA was later severed from the work environment.
Findings
The facility failed to maintain a safe environment due to water leaks and mold in a resident room and adjacent utility room. Additionally, the facility failed to prevent a staff member from forcibly feeding a resident against their wishes and did not properly investigate or report the abuse allegation in a timely manner.
Deficiencies (4)
Failed to maintain a safe, clean, and homelike environment due to water leaks and mold in resident and utility rooms.
Failed to protect a resident from abuse when a staff member forcibly fed the resident against their will.
Failed to timely report suspected abuse to proper authorities within required timeframes.
Failed to conduct a thorough investigation and maintain documentation regarding the abuse allegation.
Report Facts
Facility census: 82
Date of incident: Oct 27, 2024
Date of grievance report: Oct 28, 2024
Date of investigation summary: Oct 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in abuse finding for forcibly feeding Resident #2 |
| PTA A | Physical Therapy Assistant | Reported the resident's complaint of being forcibly fed |
| LPN B | Licensed Practical Nurse | Received report from Resident #2 about abuse and notified Administrator |
| Administrator | Facility Administrator | Interviewed regarding abuse complaint and investigation; did not report to State Agency |
| Social Service Director | Social Service Director | Interviewed resident and other residents regarding abuse complaint |
Inspection Report
Plan of Correction
Census: 82
Deficiencies: 6
Date: Nov 12, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to the safety, environment, abuse prevention, and reporting requirements at Belleview Care Center.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to water leaks and mold. The facility also failed to prevent abuse and neglect, including force feeding a resident, and did not report alleged violations promptly as required.
Deficiencies (6)
F584 Safe Environment: The facility failed to maintain a safe, clean, and homelike environment due to water leaks, mold, and lack of adequate maintenance and safety policies.
F600 Freedom from Abuse and Neglect: The facility failed to ensure a resident was free from abuse when a staff member forcibly fed the resident against their will.
F609 Reporting of Alleged Violations: The facility failed to report an alleged violation of potential physical abuse immediately and did not conduct a thorough investigation within required timeframes.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This deficiency is uncorrected and referred to F600.
A8023 Develop/Implement Abuse/Neglect Policies: The facility failed to develop and implement written policies prohibiting abuse, neglect, and misappropriation of resident property and to report such incidents as required.
A8024 Staff Trained on Reporting Abuse/Neglect: The facility failed to ensure all staff were trained on laws and rules regarding reporting suspected abuse and neglect of residents.
Report Facts
Facility census: 82
Sampled residents: 6
Plan of correction completion dates: Multiple corrective actions with completion dates of 2024-11-13
Inspection Report
Routine
Census: 80
Deficiencies: 1
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and notification practices at Belleview Care Center.
Findings
The facility failed to ensure staff notified the physician when Resident #4 refused to take prescribed tacrolimus medication, an antirejection drug, and also refused food and liquids, leading to a hospital transfer. Documentation and communication deficiencies were noted regarding the resident's condition and medication refusal.
Deficiencies (1)
Failure to notify the physician when Resident #4 refused prescribed tacrolimus medication and food intake.
Report Facts
Medication refusal instances: 4
Medication dosage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide B | Certified Nurse Aide (CNA) | Interviewed regarding Resident #4's refusal of food and medication and notification practices. |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed about medication refusal notification procedures. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about usual resident behavior and notification expectations. |
| Primary Care Physician | Primary Care Physician | Interviewed regarding notification about Resident #4's medication refusal and condition. |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 2
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding medication administration and notification practices related to a resident's refusal of prescribed antirejection medication.
Findings
The facility failed to ensure staff followed acceptable standards of practice when Resident #4 did not take prescribed tacrolimus medication and the physician was not notified. The resident refused medication and food, and staff did not promptly notify the physician, posing a risk to the resident's health.
Deficiencies (2)
F658 Services Provided Meet Professional Standards. The facility failed to assure staff followed acceptable standards of practice when Resident #4 did not take prescribed tacrolimus medication and the physician was not notified.
A4075 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the issues noted in F658.
Report Facts
Facility census: 80
Inspection Report
Routine
Census: 10
Deficiencies: 9
Date: May 16, 2024
Visit Reason
Routine inspection to assess compliance with regulations including tuberculosis (TB) screening, personnel records, community based assessments, resident condition/medication reviews, kitchen waste container coverage, and food safety.
Findings
The facility was found deficient in multiple areas including failure to provide TB screening policies and tests for residents, incomplete personnel records without physician statements, missing community based assessments, incomplete monthly resident reviews, uncovered kitchen waste containers, and improper food labeling and storage. The facility census was consistently noted as 10 during the inspection.
Deficiencies (9)
A4724: The facility failed to provide a policy regarding TB screenings and did not have current TB tests for residents. Three sampled residents lacked required TB testing for 2023 or 2024.
A4733: The facility failed to maintain personnel records with written physician statements for employees. Three sampled employees lacked such documentation.
A4750: The facility failed to ensure community based assessments were completed at least semiannually for three sampled residents. No policy regarding CBAs was provided.
A4837: The facility failed to ensure monthly reviews of residents' general condition and needs were completed for three sampled residents. Several months of reviews were missing.
A6031: Waste containers in food-preparation and utensil-washing areas were not kept covered when not in use. Several trash cans lacked lids or had broken lids.
A7013: The facility failed to ensure food was labeled and dated when opened. Multiple prepared foods in refrigerators were unlabeled and undated.
A7016: Food not being prepped or served was stored in uncovered containers. Several food items in the kitchen were uncovered or improperly stored.
A7019: Bulk food items were not stored in containers labeled with the food's common name. Several bulk containers were unlabeled.
A7067: Nonfood-contact surfaces of equipment were not cleaned or sanitized adequately. Stove surfaces and refrigerator backsplashes had dust, food build-up, and debris.
Report Facts
Facility census: 10
Deficiencies cited: 9
Inspection Report
Routine
Census: 82
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment, specifically focusing on the condition of the ceilings in the memory care unit.
Findings
The facility failed to maintain the ceilings in the memory care unit, with multiple holes observed in various locations. The Director of Maintenance and Administrator acknowledged the issues and stated that contractors would be returning to repair the ceilings, but no repair date was known.
Deficiencies (1)
Facility failed to maintain a safe, clean, comfortable homelike environment by not maintaining the ceilings in the memory care unit, including multiple open and covered holes.
Report Facts
Residents affected: 22
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding the ceiling holes and maintenance issues | |
| Administrator | Interviewed regarding awareness of ceiling holes and repair expectations |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 2
Date: Mar 20, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Belleview Care Center.
Findings
The facility failed to maintain a safe, clean, and comfortable homelike environment, specifically in the memory care unit where multiple holes were found in the ceiling. The building was also found not to be substantially constructed and maintained in good repair as required by regulations.
Deficiencies (2)
F584 Safe Environment: The facility failed to maintain a safe, clean, and comfortable homelike environment by not repairing multiple holes in the memory care unit ceiling affecting 22 residents. The facility also lacked a policy regarding maintaining the environment.
A3001 Substantially Constructed/Maintained: The building was not maintained in good repair as required by 19 CSR 30-85.032(2), evidenced by the deficiencies noted in F584.
Report Facts
Facility census: 82
Residents affected: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding ceiling holes and repairs | |
| Administrator | Interviewed about ceiling holes and repair expectations |
Inspection Report
Routine
Census: 82
Deficiencies: 2
Date: Jan 4, 2024
Visit Reason
The inspection was conducted to assess compliance with resident dignity and care standards, including hygiene and medication administration, at Belleview Care Center.
Findings
The facility failed to ensure residents were treated with dignity, as evidenced by poor hygiene and lack of showers for several residents. Additionally, licensed nurse staff failed to carry out physician's medication orders properly, leaving blanks in medication and treatment administration records for multiple residents.
Deficiencies (2)
Facility staff failed to ensure residents were treated in a dignified manner, with four residents having greasy, disheveled hair, body odor, and wearing hospital gowns mid-morning on 12/25/23.
Licensed nurse staff failed to ensure physician's orders were carried out for four residents when blanks were left in the medication administration record (MAR) and treatment administration record (TAR).
Report Facts
Residents affected: 4
Residents affected: 4
Census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide A | Certified Nurses Aide | Reported insufficient staff and time to provide showers |
| Certified Nurses Aide B | Certified Nurses Aide | Reported staff did not have time to give showers consistently |
| Director of Nursing | Director of Nursing | Acknowledged complaints about showers and staffing shortages |
| Administrator | Administrator | Discussed expectations for shower frequency and staffing |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed expectations regarding medication administration and documentation |
| Certified Medication Technician A | Certified Medication Technician | Discussed medication administration documentation and emergency kit access |
| Certified Medication Technician B | Certified Medication Technician | Discussed medication documentation and reasons for missed doses |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 6
Date: Jan 4, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and professional standards at Belleview Care Center.
Findings
The facility was found deficient in ensuring residents' rights to dignity and personal care, including failure to provide adequate bathing and grooming. Additionally, the facility failed to meet professional standards in medication administration and documentation for multiple residents.
Deficiencies (6)
F550 Resident Rights: The facility failed to ensure residents were treated with dignity and provided adequate bathing and grooming, as evidenced by residents with greasy hair, body odor, and hospital gowns worn mid-morning. Staff did not document showers for the past 14 days for several residents.
F658 Services Provided Meet Professional Standards: Licensed nursing staff failed to follow physician orders for medication administration and treatment for four residents, with multiple omissions and incomplete documentation in medication administration records and treatment administration records.
A4055 Safe/Effective Medication System: The facility did not maintain a safe and effective medication system, as referenced to F658 deficiencies.
A4076 Clean, Dry, Odor Free: Residents were not consistently clean, dry, and free of offensive body and mouth odor, as referenced to F550 deficiencies.
A4077 Residents Groomed/Dressed Appropriately: Residents were not well-groomed or dressed appropriately, with issues related to hygiene and clothing, as referenced to F550 deficiencies.
A8030 Dignity/Privacy: Residents were not treated with full recognition of dignity and privacy, as referenced to F550 deficiencies.
Report Facts
Facility census: 82
Residents affected: 8
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide (CNA) A | Certified Nurses Aide | Reported insufficient staff and time to provide showers |
| Certified Nurses Aide (CNA) B | Certified Nurses Aide | Reported staff did not have time to give showers consistently |
| Director of Nursing (DON) | Director of Nursing | Acknowledged insufficient staff to provide showers and care |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Reported medication administration record issues and staff expectations |
| Certified Medication Technician (CMT) A | Certified Medication Technician | Reported medication documentation issues |
| Certified Medication Technician (CMT) B | Certified Medication Technician | Reported medication documentation issues |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Dec 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide necessary care and medication to a resident, specifically the failure to administer Levemir insulin as ordered, resulting in harm to the resident.
Complaint Details
The complaint investigation found that the facility staff failed to administer the ordered Levemir insulin to Resident #3, did not notify the physician of the missed doses, and the resident was hospitalized with critically high blood glucose and complications including diabetic ketoacidosis and kidney failure.
Findings
The facility failed to administer Levemir insulin to Resident #3 on 11/28/23 and 11/29/23, leading to critically elevated blood glucose levels and hospitalization with diabetic ketoacidosis and kidney failure. Staff did not notify the physician or properly manage medication delivery and administration despite the medication being available in the emergency kit.
Deficiencies (1)
Failure to administer Levemir insulin as ordered on 11/28/23 and 11/29/23, resulting in harm to the resident.
Report Facts
Blood glucose level: 755
Blood glucose level in ED: 1000
Blood urea nitrogen (BUN): 107
Creatinine: 3.45
Medication dose: 10
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Documented failure to administer Levemir insulin on 11/28/23 and 11/29/23 due to time constraints and not checking medication availability |
| LPN C | Licensed Practical Nurse | Documented resident condition and reported resident complaints on 11/29/23 |
| LPN B | Licensed Practical Nurse | Signed for pharmacy delivery of Levemir insulin on 11/28/23 and delivered medications to nurses stations |
| Director of Nursing | Director of Nursing | Interviewed and stated expectation that nurses administer medications as ordered |
| Administrator | Administrator | Interviewed and stated expectation that nurses administer medications and use E-Kit if pharmacy delivery delayed |
| Pharmacy representative A | Pharmacy representative | Confirmed delivery of Levemir insulin on 11/28/23 |
| Primary Care Physician | Primary Care Physician (PCP) | Interviewed and stated facility staff did not notify him of missed medication and that it was not acceptable to miss doses due to time constraints |
Inspection Report
Plan of Correction
Census: 82
Deficiencies: 2
Date: Dec 1, 2023
Visit Reason
The inspection was conducted to assess compliance with quality of care regulations, specifically related to medication administration and treatment of residents, including a review of a resident's insulin administration and related care.
Findings
The facility failed to provide necessary care and services to maintain a resident's health, including failure to monitor blood glucose and administer insulin as ordered, resulting in the resident being sent to the hospital with critically high blood glucose levels. The facility also lacked a medication administration policy and had deficiencies in medication delivery and documentation.
Deficiencies (2)
F684 Quality of care: The facility failed to ensure staff provided necessary care and services to maintain a resident's health, including monitoring blood glucose and administering insulin as ordered, resulting in hospitalization. The facility did not provide a medication administration policy.
A4075 Nursing care per resident condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiencies cited under F684.
Report Facts
Facility census: 82
Glucose level: 755
Blood glucose level in ED: 1000
Creatinine level: 3.45
Blood urea nitrogen (BUN): 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Documented failure to administer insulin as ordered and medication delivery issues |
| LPN C | Licensed Practical Nurse | Documented resident condition and medication administration observations |
| Director of Nursing | Director of Nursing | Interviewed regarding awareness of insulin order and medication administration |
| Administrator | Administrator | Interviewed regarding expectations for medication administration and staff duties |
| Primary Care Physician | Primary Care Physician | Interviewed regarding facility notification and medication orders |
Inspection Report
Plan of Correction
Census: 14
Deficiencies: 2
Date: Sep 14, 2023
Visit Reason
The inspection was conducted to assess compliance with proper care per individualized service plans and appropriate action and notification requirements, focusing on a resident with diabetes who experienced low blood sugar and related care issues.
Findings
The facility failed to provide proper care for a resident with diabetes, including inadequate assessment and failure to notify the physician of critical blood sugar levels. The resident was found unresponsive and required emergency medical services. The facility also failed to notify the resident's physician when blood sugar levels were below the ordered threshold.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to adequately assess a resident with diabetes after low blood sugar episodes, resulting in unresponsiveness and emergency medical intervention. The resident's individualized service plan was not properly followed.
19 CSR 30-86.047(37) Appropriate Action & Notification: The facility failed to notify the resident's physician when blood sugar levels fell below 60, contrary to physician orders. This failure delayed appropriate medical response.
Report Facts
Census: 14
Blood sugar levels: 40
Blood sugar levels: 25
Blood sugar levels: 53
Blood sugar levels: 41
Plan of Correction Completion Date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed and stated staff should have rechecked resident's blood sugar after lunch and notified physicians |
| Administrator | Administrator | Interviewed and stated staff should have rechecked resident's blood sugar after lunch and notified physicians |
| Level One Medication Aide A | Medication Aide | Interviewed about resident's condition and care on 9/13/23 |
| Level One Medication Aide B | Medication Aide | Interviewed about resident's blood sugar checks and care on 9/13/23 |
Inspection Report
Routine
Census: 56
Deficiencies: 3
Date: Sep 1, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in nursing care, activities of daily living assistance, and staffing adequacy at Belleview Care Center.
Findings
The facility failed to ensure nursing staff followed physician orders for treatment and oxygen therapy, provide adequate assistance with activities of daily living including bathing and incontinent care, maintain timely response to call lights, and provide sufficient staffing to meet resident needs. Several residents did not receive scheduled showers, experienced delayed call light responses, and one resident was left on a bedpan for an extended period.
Deficiencies (3)
Failure to follow physician orders for applying tubi grips and obtaining oxygen therapy orders for residents.
Failure to provide adequate assistance with activities of daily living including bathing, incontinent care, and showering for multiple residents.
Failure to provide sufficient nursing staff to meet resident needs, resulting in missed showers, delayed call light responses, and prolonged time on bedpan for a resident.
Report Facts
Facility census: 56
Number of sampled residents: 14
Number of documented showers for Resident #11: 12
Scheduled shower days for Resident #8: 2
Call light response time: 5
Extended time on bedpan for Resident #25: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Interviewed regarding failure to follow physician orders and shower completion |
| CNA B | Certified Nursing Assistant | Interviewed regarding staffing shortages and call light response delays |
| LPN A | Licensed Practical Nurse | Interviewed regarding physician orders and shower policies |
| LPN B | Licensed Practical Nurse | Interviewed regarding call light response and resident complaints |
| Director of Nursing | Director of Nursing | Interviewed regarding compliance with physician orders, shower schedules, and staffing adequacy |
Inspection Report
Routine
Census: 56
Deficiencies: 17
Date: Sep 1, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with resident rights, care and services, infection control, medication management, staffing, and other regulatory requirements at Belleview Care Center.
Findings
The facility was found deficient in multiple areas including failure to answer call lights timely, inadequate monitoring of residents, failure to accommodate resident needs, lack of communication with resident council, financial management issues, inconsistent notification of resident rights, conflicting advance directive documentation, unsafe and unclean environment in memory care unit, incomplete care plans, medication administration errors, inadequate respiratory care, insufficient assistance with activities of daily living, inadequate staffing levels, and infection control lapses including improper linen handling and hand hygiene.
Deficiencies (17)
Failed to answer call lights in a timely manner affecting multiple residents.
Failed to monitor resident to prevent disrobing in public areas.
Failed to accommodate resident needs including providing appropriate furniture.
Failed to communicate and respond to resident council grievances.
Failed to ensure residents had access to their funds and proper financial management.
Failed to inform residents of their rights periodically during their stay.
Conflicting and unclear documentation of residents' advance directives and code status.
Failed to provide a safe, clean, comfortable, and homelike environment in the memory care unit.
Failed to provide timely notification of transfer or discharge to residents or their representatives.
Failed to develop and implement comprehensive care plans addressing all resident needs including PTSD and oxygen therapy.
Failed to provide care and treatment in accordance with professional standards including medication administration and oxygen therapy.
Failed to provide adequate assistance with activities of daily living including bathing, perineal care, and incontinent care.
Failed to provide an ongoing program of activities to meet the interests and well-being of residents in the memory care unit.
Failed to ensure medication error rate was less than 5%, including errors in insulin pen use.
Failed to ensure proper medication storage including discarding expired medications, no food in medication refrigerator, and proper labeling and dating of insulin pens and oxygen equipment.
Failed to provide sufficient nursing staff to meet resident needs and ensure timely response to call lights.
Failed to establish and maintain an infection prevention and control program including proper hand hygiene, linen handling, and availability of incontinent supplies.
Report Facts
Medication errors: 3
Medication error rate: 11
Resident showers scheduled: 26
Resident showers documented: 12
Resident showers refused: 1
Resident census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed medication administration errors and oxygen therapy practices |
| CNA A | Certified Nursing Assistant | Observed providing inadequate perineal care and bathing assistance |
| CNA B | Certified Nursing Assistant | Observed providing inadequate perineal care and bathing assistance |
| Director of Nursing | Director of Nursing | Provided interviews on care plans, staffing, infection control, and medication management |
| Administrator | Facility Administrator | Provided interviews on facility operations and responses to deficiencies |
| Regional Director of Business Office | Regional Director of Business Office | Provided interviews on resident funds and payment processing |
| Activities Director | Activities Director | Provided interviews on activity programming in memory care unit |
Inspection Report
Life Safety
Census: 57
Capacity: 90
Deficiencies: 8
Date: Sep 1, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain the one-hour fire rating of ceilings and walls due to unsealed holes and penetrations. Additional deficiencies included failure to provide emergency lighting controlled by light switches, lack of proper exit signage, failure to test fire alarm systems, incomplete sprinkler system inspections, and unsafe suspended unit heaters.
Deficiencies (8)
K161: The facility failed to maintain the one-hour fire rating of ceilings and walls due to unsealed holes and penetrations in multiple areas including the assisted living facility and nursing facility sides.
K291: The facility failed to provide emergency lighting controlled by light switches in medication rooms, potentially affecting all residents.
K293: The facility failed to provide proper exit signage including a NO EXIT sign on the courtyard door, affecting all residents and staff.
K345: The facility failed to test and maintain the fire alarm system, including lack of records for range hood connection testing and weekly smoke detector testing.
K353: The facility failed to inspect and maintain the wet sprinkler system per NFPA 25 standards, including missing inspections of the Post Indicator Valve (PIV).
K523: The facility failed to provide suspended unit heaters in an accessible location, with one heater unreachable and potentially hazardous.
K918: The facility failed to provide current, comprehensive documentation and testing of electrical systems including the emergency power generator and circuit breakers.
K920: The facility failed to ensure safe use of power strips and extension cords in patient care areas, including use of unapproved power strips and extension cords.
Report Facts
Facility capacity: 90
Resident census: 57
Deficiency counts: 8
Inspection Report
Plan of Correction
Census: 14
Deficiencies: 1
Date: Jun 21, 2023
Visit Reason
The visit was conducted to assess compliance with resident condition and medication review regulations and to address deficiencies related to monthly summaries and medication reviews.
Findings
The facility failed to ensure monthly summaries and medication reviews were completed for four sampled residents. The facility census was 14 at the time of inspection.
Deficiencies (1)
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to ensure monthly summaries and medication reviews were completed for four sampled residents. The facility did not provide a monthly summary policy or medication review policy.
Report Facts
Facility census: 14
Sampled residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding monthly summaries and medication reviews |
Inspection Report
Routine
Census: 60
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan development and revision requirements, specifically regarding updating care plans for residents using side rails or bolsters on their beds.
Findings
The facility failed to update and revise the care plans for four residents who used side rails or bolsters on their beds, despite assessments and observations indicating their use. The care plans did not reflect the current use of these devices, and staff interviews confirmed inconsistent care planning practices.
Deficiencies (1)
Failure to develop and revise comprehensive care plans within 7 days of assessment for residents using side rails or bolsters.
Report Facts
Residents affected: 4
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Provided information about resident use of side rails |
| Director of Nursing | Director of Nursing | Provided information about resident transfer needs and care plan expectations |
| CNA A | Certified Nursing Assistant | Provided information about resident use of side rails and bolsters |
| CNA B | Certified Nursing Assistant | Provided information about resident use of side rails and bolsters |
| Social Services Director | Social Services Director | Discussed side rail assessment and care planning process |
| MDS Coordinator | MDS Coordinator | Discussed care plan completion responsibilities and staffing changes |
| Administrator | Administrator | Discussed expectations for care plan updates after meetings |
Inspection Report
Follow-Up
Census: 60
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies related to care plan timing and revision at Belleview Care Center.
Findings
The facility failed to update and revise care plans for four residents as required. Observations and interviews confirmed issues with side rail use and care plan documentation. A plan of correction was submitted addressing these deficiencies.
Deficiencies (2)
F657 Care Plan Timing and Revision: The facility failed to update and revise the care plan for four residents, including issues with side rails and bolsters not being properly assessed or documented.
A4107 Clinical Records - assessment/interventions: The clinical record did not contain sufficient information to reflect initial and ongoing assessments and interventions by each discipline involved in resident care.
Report Facts
Facility census: 60
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan and side rail use |
| Administrator | Administrator | Interviewed and signed plan of correction |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding resident care and side rail use |
| Certified Nursing Assistant A | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and side rail use |
| Certified Nursing Assistant B | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and side rail use |
| Social Services Director | Social Services Director | Interviewed regarding side rail assessment and care planning |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plans and side rail assessments |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to refund resident funds within 30 days of discharge for one resident.
Complaint Details
The complaint was substantiated. The resident's daughter reported multiple bounced reimbursement checks totaling $2,016.00 and additional banking fees of $30.00. The facility eventually paid the owed amount plus fees in cash after over three months.
Findings
The facility failed to refund resident funds within 30 days of discharge for one resident, resulting in multiple bounced reimbursement checks and delayed payment. The issue was eventually resolved with a cash payment to the resident's daughter after over three months.
Deficiencies (1)
Failed to refund resident funds within 30 days of discharge for one resident.
Report Facts
Resident census: 58
Reimbursement amount: 2016
Banking fees: 30
Number of bounced checks: 2
Final cash payment: 2046
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Accounting Manager | Interviewed regarding issues with bounced reimbursement checks and payment resolution | |
| Administrator | Interviewed about facility's expectations for refunding resident funds within 30 days of discharge |
Inspection Report
Routine
Census: 66
Deficiencies: 4
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including criminal background checks, discharge planning, staffing adequacy, and facility maintenance.
Findings
The facility failed to complete criminal background checks for three CNAs prior to resident contact, did not develop appropriate discharge plans for two residents, had insufficient nursing staff leading to missed showers and restorative aide services, and failed to maintain hot water in two resident rooms affecting three residents.
Deficiencies (4)
Failed to ensure criminal background checks were completed for three CNAs prior to resident contact.
Failed to develop appropriate discharge plans for two residents, including lack of safe housing and physician orders.
Failed to provide sufficient nursing staff to meet resident needs, resulting in missed showers and restorative aide services.
Failed to maintain functional hot water in two resident rooms affecting three residents.
Report Facts
Facility census: 66
Residents affected by CBC deficiency: 3
Residents affected by discharge planning deficiency: 2
Residents affected by staffing deficiency: 4
Residents affected by hot water deficiency: 3
Resident debt amount: 1941.5
Resident payment: 300
Number of aides scheduled on certain days: 2
Number of showers scheduled on Sundays: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | LPN | Documented resident falls and care notes related to discharge planning |
| Social Services Director | SSD | Issued discharge notices and failed to secure safe housing for residents |
| Assistant Administrator | AA | Discussed discharge notices and staffing issues |
| Business Office Manager | BOM | Provided financial details on resident debt and payment |
| Certified Medication Technician A | CMT | Reported staffing shortages and missed resident care |
| Assistant Director of Nursing | ADON | Discussed shower completion and staffing |
| Maintenance Supervisor | Unaware of hot water issues due to lack of work order reports | |
| Administrator | Expected compliance with CBC, discharge planning, and maintenance reporting |
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 4
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to abuse/neglect policies, discharge planning process, sufficient nursing staff, and environmental conditions at Riverside Place.
Findings
The facility failed to complete criminal background checks for certain Certified Nurse Aides prior to resident contact, did not develop appropriate discharge plans for some residents, lacked sufficient nursing staff to meet resident needs, and failed to maintain a functional hot water system affecting resident hygiene.
Deficiencies (4)
F607 The facility failed to ensure criminal background checks were completed for three Certified Nurse Aides prior to resident contact.
F660 The facility failed to develop appropriate discharge plans for two of eight sampled residents, including failure to secure housing and provide detailed discharge explanations.
F725 The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in incomplete showers and care for multiple residents.
F921 The facility failed to maintain a functional and sanitary environment when the hot water did not function in two resident rooms, affecting three residents.
Report Facts
Facility census: 66
Residents sampled for discharge planning: 8
Residents with incomplete discharge plans: 2
Residents affected by hot water issue: 3
Inspection Report
Life Safety
Census: 66
Capacity: 90
Deficiencies: 3
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with life safety code requirements, specifically related to battery-operated smoke alarms in resident rooms and fire alarm system maintenance.
Findings
The facility failed to ensure proper monitoring and maintenance of battery-operated smoke alarms in resident rooms, resulting in alarms beeping and maintenance requests being canceled rather than completed. The facility also did not provide requested fire alarm inspections or monitoring documentation.
Deficiencies (3)
K300 Protection - Other: The facility failed to monitor and maintain battery-operated smoke alarms in resident rooms as required by the City of St. Joseph's fire department and the 2018 International Building Code. Maintenance requests for smoke alarms were canceled instead of completed, and alarms were reported beeping for months without resolution.
A2019 Fire Alarm System-Test/Maintain: The facility did not meet requirements to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. This deficiency is classified as Class II.
A4003 Operator/Administrator Responsibilities: The administrator failed to assure compliance with laws and rules, including oversight to ensure residents receive appropriate nursing and medical care. This deficiency is classified as Class II.
Report Facts
Facility capacity: 90
Census: 66
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 4
Date: Dec 22, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding facility administration, medical director responsibilities, and operator/administrator compliance.
Complaint Details
The complaint investigation found the facility did not have a medical director since the current management company took over in October 2022. The facility census was 75 at the time of the investigation.
Findings
The facility failed to have a designated medical director and did not meet administration requirements for effective resource use. The operator/administrator was not fully authorized and responsible for ensuring compliance with laws and rules.
Deficiencies (4)
F835 Administration: The facility failed to ensure resources were used effectively and efficiently to attain or maintain the highest well-being of each resident.
F841 Responsibilities of Medical Director: The facility failed to designate a physician to serve as medical director and ensure oversight of medical care.
A4003 Operator/Administrator Responsibilities: The operator was not fully authorized or responsible for ensuring compliance with laws and rules.
A4012 Supervising Physician: A supervising physician was not available to assist in coordinating the overall medical care program.
Report Facts
Facility census: 75
Staff Contract Company A payment: 39799.53
Staff Contract Company B payment: 42060.41
Staff Contract Company C payment: 65456.98
Inspection Report
Plan of Correction
Census: 78
Deficiencies: 2
Date: Nov 18, 2022
Visit Reason
The inspection was conducted to evaluate compliance with notice requirements before transfer or discharge of residents, specifically regarding a 30-day notice prior to discharge.
Findings
The facility failed to provide a resident with a 30-day notice prior to discharge as required by regulation. The resident was discharged without proper notice due to insurance issues and misunderstanding of Medicare coverage options.
Deficiencies (2)
F623 Notice Requirements Before Transfer/Discharge. The facility failed to provide a resident a 30-day notice prior to discharge as required by regulation. The resident was discharged without proper notice due to insurance and Medicare coverage issues.
A8015 30 Day Notice-Transfer/Discharge. No resident shall be transferred or discharged except in emergencies or with proper 30-day notice. This regulation was not met as evidenced by the F623 deficiency.
Report Facts
Facility census: 78
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Cotten Adam | Laboratory Director or Provider/Supplier Representative | Signed the statement of deficiencies and plan of correction |
| Social Services Designee | Interviewed regarding resident discharge and notice | |
| Director of Care Coordination | Provided information on Medicare Non-Coverage Notice and resident appeal | |
| Therapy Director | Interviewed about resident therapy needs and discharge | |
| Director of Nursing | Interviewed about resident discharge options and insurance coverage | |
| Home Health Nurse A | Interviewed about resident admission to home health services |
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 3
Date: Aug 17, 2022
Visit Reason
This inspection was conducted as a re-inspection following prior deficiencies related to resident safety and care at Riverside Place.
Findings
The facility failed to ensure a safe environment free of accident hazards for residents, including improper use and maintenance of low air loss mattresses and bed rails. Multiple deficiencies were identified related to resident falls, injury, and inadequate staff knowledge and policies.
Deficiencies (3)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure two sampled residents' environments were free of accident hazards, resulting in falls and injuries. Staff failed to ensure proper mattress settings, bed rails, and adequate assistance for bed mobility.
A4074 Protective Oversight, Voluntary Leave: The facility did not provide 24-hour protective oversight and supervision for residents on voluntary leave as required.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions.
Report Facts
Facility census: 81
Inspection Report
Routine
Deficiencies: 0
Date: Feb 16, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with relevant federal regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and COVID-19 protocols.
Inspection Report
Routine
Census: 67
Deficiencies: 10
Date: Jan 12, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including background checks, resident transfer and discharge notifications, care planning, pressure ulcer care, fall evaluations, nutrition monitoring, respiratory care, RN staffing, dental services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to complete timely criminal background checks for staff, failure to provide written transfer/discharge notices and bed-hold policy to residents and representatives, incomplete and outdated care plans, inadequate pressure ulcer care and documentation, inconsistent post-fall evaluations, failure to monitor weight loss adequately, failure to provide ordered respiratory care and maintain oxygen equipment properly, failure to maintain required RN coverage separate from the DON role, failure to assist a resident in obtaining dental care, and lapses in infection control practices including catheter bag placement, hand hygiene during peri-care, and COVID-19 screening of staff.
Deficiencies (10)
Failure to complete Criminal Background Checks and CNA registry checks for multiple staff prior to hire.
Failure to provide timely written notice of transfer or discharge and bed-hold policy to residents and their representatives.
Incomplete care plans that did not address key resident needs such as depression, anticoagulant use, oxygen therapy, and urinary catheters.
Failure to provide appropriate pressure ulcer care and documentation for residents with pressure ulcers and failure to prevent new ulcers.
Failure to consistently document post-fall evaluations for a resident who suffered multiple falls.
Failure to maintain a system to monitor weight loss for a resident, including failure to follow up on missed weights and dental care needs.
Failure to provide respiratory care as ordered and failure to maintain clean oxygen tubing in resident rooms.
Failure to provide RN coverage separate from the Director of Nursing for eight consecutive hours per day as required.
Failure to assist a resident in obtaining dental care despite physician orders and resident requests.
Failure to maintain infection control practices including catheter bags touching the floor, inadequate hand hygiene during peri-care, and failure to screen agency staff for COVID symptoms upon entry.
Report Facts
Facility census: 67
Resident census: 67
Number of days RN coverage missing: 6
Resident #12 BIMS score: 12
Resident #30 BIMS score: 0
Resident #58 BIMS score: 6
Resident #50 weight: 274
Resident #50 previous weights: 330
Resident #50 previous weights: 312
Resident #50 weight: 262.8
Pressure ulcer size: 4.3
Pressure ulcer size: 4.8
Pressure ulcer depth: 2.5
Pressure ulcer size: 6
Pressure ulcer size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide B | Named in failure to complete background check finding | |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding care plan updates and fall evaluations |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding wound care and oxygen titration |
| Certified Nurse Aide F | Certified Nurse Aide | Failed to complete COVID screening upon entry |
| Certified Nurse Aide G | Certified Nurse Aide | Failed to complete COVID screening upon entry |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including background checks, transfer notices, care plans, RN coverage, infection control, and COVID screening |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding wound care and RN coverage |
| Certified Nurse Aide H | Certified Nurse Aide | Observed failing to perform hand hygiene during peri-care |
| Certified Nurse Aide I | Certified Nurse Aide | Observed failing to perform hand hygiene during peri-care |
| Social Services | Interviewed regarding transfer and bed hold notices, dental appointment scheduling | |
| Transport/Front Office staff member | Interviewed regarding dental appointment scheduling and COVID screening | |
| Infection Preventionist | Interviewed regarding COVID screening signage and procedures |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 11
Date: Jan 12, 2022
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for Riverside Place nursing facility.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks for staff, inadequate notice requirements before resident transfer or discharge, incomplete comprehensive care plans, failure to prevent pressure ulcers, inadequate infection control, and insufficient staffing coverage by registered nurses.
Deficiencies (11)
F607: The facility failed to ensure criminal background checks and nurse aide registry verifications were completed for all staff members prior to employment. This affected eight sampled staff members. Facility census was 67.
F623: The facility failed to provide written notice of transfer or discharge to residents and their representatives in a language they understood. This affected three of seventeen sampled residents. Facility census was 67.
F625: The facility failed to inform residents and their representatives of the bed hold policy at the time of transfer or discharge. This affected three of seventeen sampled residents. Facility census was 67.
F656: The facility failed to develop and update comprehensive care plans for residents, including measurable objectives and discharge plans. This affected three residents. Facility census was 67.
F686: The facility failed to ensure residents with pressure ulcers received necessary treatment and care to promote healing. This affected three residents. Facility census was 67.
F689: The facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in multiple falls for one resident. Facility census was 67.
F692: The facility failed to maintain acceptable nutritional and hydration status for residents, including failure to monitor weight loss and provide adequate interventions. Facility census was 67.
F695: The facility failed to provide adequate respiratory and tracheostomy care to residents, including failure to maintain clean oxygen concentrator tubing. Facility census was 67.
F727: The facility failed to provide registered nurse coverage for eight consecutive hours per day, seven days a week, when census exceeded 60 residents. Facility census was 67.
F791: The facility failed to assist residents in obtaining routine and emergency dental services. Facility census was 67.
F880: The facility failed to establish and maintain an infection prevention and control program, including failure to educate staff on COVID-19 screening and infection control policies. Facility census was 67.
Report Facts
Facility census: 67
Deficiencies cited: 11
Inspection Report
Plan of Correction
Census: 18
Deficiencies: 5
Date: Jan 12, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for an assisted living facility, including tuberculosis screening, community based assessments, individualized service plans, physician orders, and medication review.
Findings
The facility failed to meet multiple regulatory requirements including tuberculosis screening for residents and staff, completion of community based assessments, timely updates of individualized service plans, adherence to physician orders for medication administration, and completion of monthly medication summaries and weights for residents.
Deficiencies (5)
19 CSR 30-86.047(19) TB Screen Residents & Staff. The facility failed to ensure required two-step tuberculosis screening tests were administered annually for sampled residents. The facility census was 18.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually. The facility failed to ensure community based assessments were completed semi-annually for sampled residents. The facility census was 18.
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements. The facility failed to ensure individualized service plans were completed at least yearly for sampled residents. The facility census was 18.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to ensure staff followed physician orders for medication administration for sampled residents. The facility census was 18.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to ensure monthly medication summaries and weights were completed for sampled residents. The facility census was 18.
Report Facts
Facility census: 18
Sampled residents: 5
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 29, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted on 11/29/21 and 11/30/21 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 for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 7/28/21 through 8/6/21 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 during the survey period.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 22, 2021
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from 1/14/21 through 1/22/21 to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 29, 2020
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted from October 21 to October 29, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 2
Date: Sep 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess infection prevention and control practices related to COVID-19 in the facility.
Findings
The facility was found to be in compliance with certain infection control regulations but failed to maintain proper infection control practices including screening healthcare providers, use of PPE, isolation procedures, and signage. Several residents were affected by these deficiencies.
Deficiencies (2)
F880 Infection Prevention & Control - The facility failed to maintain proper infection control practices including screening healthcare providers, implementing PPE protocols, isolation procedures, and posting appropriate signage, affecting multiple residents.
A4085 Infection Control/Communicable Disease - The facility failed to make a report to the division within seven days after a resident was diagnosed with a communicable disease as required by Missouri state regulations.
Report Facts
Facility census: 84
Number of pages: 37
Inspection Report
Routine
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from June 9 to June 17, 2020 to assess compliance with CMS and CDC recommended practices and federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Date: Dec 4, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to medication labeling, environmental conditions, and abuse/neglect allegations at Riverside Place.
Complaint Details
The complaint investigation was substantiated as the facility failed to properly investigate and report abuse and neglect allegations involving a resident. The facility also failed to maintain safe medication practices and environmental conditions.
Findings
The facility failed to properly label and store medications, maintain a safe and functional environment, and follow abuse and neglect policies. Multiple deficiencies were identified including expired medication use, broken bathroom thresholds, and failure to investigate abuse allegations.
Deficiencies (3)
F761 Labeling of Drugs and Biologicals: The facility failed to follow policy and discard prescription eye medication that was over 30 days old and improperly labeled.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to repair the threshold in the unisex bathroom on the Special Care Unit, creating difficulty for a resident using a wheelchair.
F943 Abuse, Neglect, and Exploitation Training: The facility failed to follow its abuse and neglect policy when investigating a report of possible abuse and neglect of a resident.
Report Facts
Facility census: 92
Facility census: 93
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 5
Date: Nov 19, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the protection and management of residents' personal funds, including proper accounting and notification procedures.
Findings
The facility failed to ensure residents and their responsible parties were informed about managing residents' personal funds held in the facility's operating account. The facility did not provide a policy on management of resident funds and failed to provide final accounting of individual trust fund balances within 30 days of discharge or death.
Deficiencies (5)
F567 Protection/Management of Personal Funds: The facility failed to ensure residents and responsible parties were informed about managing residents' personal funds held in the facility operating account. The facility did not provide a policy on management of resident funds.
F569 Notice and Conveyance of Personal Funds: The facility failed to provide a final accounting of individual trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate after discharge, eviction, or death.
A8044 Resident Funds-Itemized Bill: The facility failed to provide an itemized bill for all goods and services rendered within 30 days after discharge or death of a resident.
A9011 Death of Resident, Contact DSS: The facility failed to contact the Department of Social Services upon the death of a resident as required.
A9017 Provide Account of Funds to Fiduciary: The facility failed to provide a complete account of all the resident's personal funds and possessions to the fiduciary or resident's estate upon death when DSS had not expended funds on the resident's behalf.
Report Facts
Facility census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beverly Bellayles | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Oct 3, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to quality of care concerns at Riverside Place.
Complaint Details
The visit was complaint-related, focusing on quality of care issues including failure to provide proper emergency care and medication management. Specific substantiation status is not stated.
Findings
The facility failed to provide proper emergency care for two residents, did not perform post-fall vital sign and neurological checks, and failed to notify a resident's physician of abnormal blood pressure. Additionally, the facility failed to order timely narcotic medication for adequate pain relief.
Deficiencies (1)
F684 Quality of care deficiency: The facility failed to ensure staff provided proper emergency care for two residents, including post-fall vital sign and neurological checks, and failed to notify a resident's physician of abnormal blood pressure. The facility also failed to order narcotic medication timely to ensure adequate pain relief.
Report Facts
Facility census: 67
Inspection Report
Plan of Correction
Census: 18
Deficiencies: 1
Date: Aug 27, 2019
Visit Reason
The inspection was conducted to investigate a deficiency related to medication orders and administration following a complaint or routine survey.
Findings
The facility failed to follow physician's orders for administering post-operative antibiotics in a timely manner for one resident. Staff did not start the resident's antibiotic medication on the correct date and delayed administration due to pharmacy delivery issues.
Deficiencies (1)
19 CSR 30-86.047(47)(A) Physicians Orders Followed: The facility failed to administer antibiotics according to physician's orders for one resident, delaying the start of medication due to pharmacy delivery issues.
Report Facts
Facility census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding medication administration | |
| Director of Nursing (DON) | Interviewed regarding antibiotic administration policy |
Inspection Report
Follow-Up
Census: 70
Deficiencies: 21
Date: Apr 5, 2019
Visit Reason
Follow-up visit to verify correction of previous deficiencies at Riverside Place nursing facility.
Findings
The facility was found to have multiple deficiencies related to resident dignity, self-determination, staff employment practices, transfer and discharge documentation, care planning, ADL care, infection control, medication storage, and behavioral health services. The facility submitted a plan of correction addressing these issues.
Deficiencies (21)
F557 Respect, Dignity/Right to have Personal Property. Staff did not treat Resident #34 with dignity, including inappropriate communication and treatment during meals.
F561 Self-Determination. Facility failed to promote resident self-determination by not offering evening snacks to all residents and not updating care plans for residents #213, #55, and #215.
F606 Not Employ/Engage Staff with Adverse Actions. Facility failed to check Nurse Assistant Registry for all newly hired employees, affecting six of eight sampled staff.
F622 Transfer and Discharge Requirements. Facility failed to ensure proper documentation and communication for resident transfers and discharges, including Resident #215.
F657 Care Plan Timing and Revision. Facility failed to develop and update comprehensive care plans for residents #213, #55, and #215 consistent with assessments and changes in condition.
F677 ADL Care Provided for Dependent Residents. Facility failed to provide adequate perineal care for residents #4 and #58 dependent on staff assistance.
F684 Quality of Care. Facility failed to respond timely to resident condition changes and prevent decline for Resident #14, including falls and incontinence care.
F689 Free of Accident Hazards/Supervision/Devices. Facility failed to provide adequate supervision and assistance to prevent falls and injuries for Resident #49 and others.
F690 Bowel/Bladder Incontinence, Catheter, UTI. Facility failed to provide proper catheter and perineal care for residents #56 and #213, resulting in incontinence and infection risks.
F732 Posted Nurse Staffing Information. Facility failed to post nurse staffing data daily in a clear and accessible manner for residents and visitors.
F740 Behavioral Health Services. Facility failed to provide necessary behavioral health care and services for Resident #55 and others, including care plan updates and interventions.
F761 Label/Store Drugs and Biologicals. Facility failed to properly store and label medications, including expired insulin pens and other drugs, affecting resident safety.
F804 Nutritive Value/Appear, Palatable/Prefer Temp. Facility failed to provide palatable and properly prepared food, including cold and overcooked meals, affecting resident satisfaction.
F880 Infection Prevention & Control. Facility failed to maintain an effective infection control program, including hand hygiene and cleaning practices, affecting resident safety.
A4063 Medication Storage. Facility failed to store medications at appropriate temperatures and secure discontinued medications separately.
A4074 Nursing Care per Resident Condition. Facility failed to provide personal attention and nursing care consistent with resident conditions.
A4079 Mealtime Assistance/Supervision. Facility failed to provide adequate assistance during meals for residents requiring help.
A4085 Infection Control/Communicable Disease. Facility failed to use acceptable infection control procedures to prevent disease spread.
A4086 Dr Notification-Change in Condition. Facility failed to notify physician timely of significant changes in resident condition.
A8030 Dignity/Privacy. Facility failed to treat residents with dignity and respect, including privacy in care and treatment.
A8042 Resident Lives Not Regulated/Controlled. Facility failed to regulate or control residents' personal lives beyond reasonable adherence to policies.
Report Facts
Facility census: 70
Number of sampled residents: 16
Number of sampled employees: 8
Number of residents affected: 6
Number of residents affected: 3
Number of residents affected: 2
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 1
Inspection Report
Life Safety
Census: 70
Capacity: 90
Deficiencies: 6
Date: Apr 5, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations for the facility.
Findings
The facility failed to maintain the one-hour fire rating of the ceiling, did not conduct monthly fire alarm system tests, and failed to maintain corridor doors and smoke barriers to resist smoke passage. Additionally, the facility did not perform required electrical receptacle testing and failed to maintain the emergency power generator load testing.
Deficiencies (6)
K161: The facility failed to maintain the one-hour fire rating of the ceiling due to holes from a sprinkler break and other ceiling penetrations. Rooms 204, 211, the Business Manager's office, and the assisted living laundry room had ceiling holes.
K345: The facility failed to conduct monthly fire alarm system tests as required by NFPA 72, potentially affecting all residents.
K363: Corridor doors did not resist smoke passage properly; several doors would not latch and had gaps, and no system was in place to monitor door status.
K372: The facility failed to provide monitoring, maintenance, and access for smoke dampers in the attic, affecting three of six smoke compartments.
K914: The facility failed to perform and document annual inspection and testing of resident room electrical receptacles, affecting all residents.
K918: The facility failed to conduct monthly load tests and inspections of the emergency power generator, affecting all occupants in case of power outage.
Report Facts
Facility capacity: 90
Resident census: 70
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 19
Capacity: 90
Deficiencies: 4
Date: Apr 5, 2019
Visit Reason
Annual inspection conducted to evaluate compliance with fire alarm system testing, emergency lighting and power source maintenance, building construction and maintenance, and food preparation and services.
Findings
The facility failed to conduct monthly fire alarm tests and emergency generator load tests, maintain the one-hour fire rating of ceilings, and provide dietary services meeting resident preferences. Several deficiencies were identified related to fire safety, emergency power, building maintenance, and food service quality.
Deficiencies (4)
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to sound test the fire alarm system monthly as required, with no evidence of tests in 6/2018, 7/2018, and 12/2018.
19 CSR 30-86.022(12)(B) Emergency Lighting - Power Source. Staff failed to conduct monthly load tests and inspections of the emergency power generator in 11/2018, 12/2018, and 1/2019.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to maintain the one-hour fire rating of ceilings, with holes in multiple areas including therapy department corridor and laundry room.
19 CSR 30-86.052(1) Food Prep & Services, As Ordered. The facility failed to provide dietary services meeting resident preferences, including serving cold food items, tough chicken, insufficient assistance with meals, and inadequate drink service.
Report Facts
Facility capacity: 90
Resident census: 19
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #34 | Reported dissatisfaction with food temperature and drink service | |
| Resident #163 | Reported issues with tough chicken and requested assistance with meals | |
| Resident #136 | Reported needing help cutting chicken and lack of staff assistance | |
| Cook B | Reported insufficient staff in kitchen and dining room causing food to become cold | |
| Dietary Manager | Dietary Manager | Acknowledged serving cold food and drink service issues |
| Licensed Practical Nurse D | Licensed Practical Nurse | Reported chicken served was tough |
| Director of Nursing | Director of Nursing | Reported staff availability for resident assistance in dining room |
| Maintenance Director | Maintenance Director | Responsible for fire alarm testing and generator load test corrective actions |
| Administrator | Administrator | Involved in corrective action plans and monitoring |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 4
Date: Mar 7, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate care related to showering and activities provided to residents in the Special Care Unit (SCU) at Riverside Place.
Complaint Details
The visit was complaint-related, investigating allegations that residents were not receiving showers as scheduled and were not provided meaningful activities. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure residents received showers as scheduled and did not provide meaningful activities for residents in the SCU. Staff did not follow shower schedules, and the facility lacked policies on showers and activities.
Deficiencies (4)
F677: The facility failed to ensure staff followed the shower schedule for residents in the SCU. Shower sheets were incomplete and staff did not provide showers as required, including for residents receiving hospice care.
F679: The facility did not provide meaningful activities for residents in the SCU. There was no policy on activities, and staff failed to assist residents with activities of choice or provide scheduled activities.
A4074: The facility failed to provide personal attention and nursing care in accordance with acceptable nursing practice, as evidenced by deficiencies referenced in F677.
A4100: The facility failed to designate an employee responsible for the activity program and did not provide planned activities as required, as evidenced by deficiencies referenced in F679.
Report Facts
Facility census: 88
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Wiley | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing (DON) | Interviewed regarding shower issues and facility expectations | |
| Certified Nurse Assistant (CNA) A | Interviewed about shower provision and unit conditions | |
| Certified Nurse Assistant (CNA) B | Interviewed about shower provision and hospice care | |
| Licensed Practical Nurse (LPN) A | Interviewed about shower monitoring and activity provision | |
| Activity Director (AD) | Interviewed regarding resident activities and scheduling |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 19
Date: Jun 22, 2018
Visit Reason
Annual state survey conducted to assess compliance with federal and state regulations for Riverside Place nursing facility.
Findings
The facility was found noncompliant with multiple requirements including resident rights, participation in care planning, abuse/neglect policies, ADL care, restorative nursing, medication administration, accident prevention, infection control, and other regulatory standards. Deficiencies affected multiple residents and staff practices.
Deficiencies (19)
F550 Resident Rights: The facility failed to ensure residents were cared for in a dignified manner, affecting two sampled residents. Privacy curtains were not functioning properly and residents were undressed in view of others.
F553 Right to Participate in Planning Care: The facility failed to ensure residents or their representatives were invited to care plan meetings, missing invitations for three sampled residents. Resident council members were unaware of care plan meetings.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to check the Nurse Aide registry and employee disqualification list prior to employment for six of eight sampled employees.
F677 ADL Care Provided: The facility failed to provide complete perineal care to three incontinent residents, resulting in poor hygiene and skin issues.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide restorative nursing services to maintain range of motion for four sampled residents, lacking documentation of therapy and training.
F689 Free of Accident Hazards: The facility failed to ensure proper use of transfer belts and supervision to prevent accidents for two sampled residents.
F759 Free of Medication Error Rates 5 Percent or More: The facility had a medication error rate of 10.34%, with three errors out of 29 opportunities affecting two residents.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure proper storage and labeling of medications, including expired drugs and lack of temperature monitoring for refrigerated medications.
F809 Frequency of Meals/Snacks at Bedtime: The facility failed to provide evening snacks to all residents, with four of eight residents reporting no snacks offered.
F880 Infection Prevention & Control: The facility failed to follow infection control protocols, including hand hygiene, isolation precautions, and cleaning, affecting multiple residents with infections.
A4029 Communicable Disease-Employees: The facility failed to ensure new employees were screened for tuberculosis with required testing prior to contact with residents.
A4054 Safe/Effective Medication System: Refer to F759 for medication administration deficiencies.
A4063 Medication Storage: The facility failed to store medications securely and in an orderly manner, including refrigerated medications.
A4074 Nursing Care per Resident Condition: Residents did not consistently receive personal attention and nursing care consistent with their condition.
A4075 Clean, Dry, Odor Free: Residents were not consistently clean, dry, and free of offensive odors.
A4080 Restorative Nursing; Residents Out of Bed: Residents were not provided restorative nursing to encourage independence and mobility as appropriate.
A4085 Infection Control/Communicable Disease: Refer to F880 for infection control deficiencies.
A5007 Bedtime Snacks, Offered/Nourishing: Refer to F809 for bedtime snack deficiencies.
A8030 Dignity/Privacy: Refer to F550 for dignity and privacy deficiencies.
Report Facts
Facility census: 76
Medication error rate: 10.34
Medication errors: 3
Medication opportunities: 29
Residents sampled: 15
Inspection Report
Life Safety
Census: 94
Capacity: 190
Deficiencies: 4
Date: Jun 22, 2018
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, including emergency preparedness training and fire drills, as part of a life safety code survey.
Findings
The facility failed to maintain an adequate emergency preparedness training program for all staff and volunteers, and did not conduct fire drills in accordance with NFPA 101 standards. The facility also failed to acquire a fire consultation from the local fire department within the last twelve months.
Deficiencies (4)
E036 Emergency Preparedness Training and Testing. The facility failed to have a training and testing program ensuring all staff and volunteers know emergency policies and procedures. Several staff reported no emergency training and drills did not involve frontline staff.
K712 Fire Drills. The facility failed to conduct fire drills as required by NFPA 101, 2012 edition, including drills at unexpected times and under varying conditions. The drills did not involve all shifts or staff as required.
A2058 Fire Drill/Emergency Preparedness Plans. The facility failed to obtain a fire consultation from the local fire department within the last twelve months to review fire and evacuation plans.
A2061 Fire Drill Requirements, Evacuation. The facility failed to conduct a minimum of twelve fire drills annually with at least one every three months on each shift, including unannounced drills and simulated resident evacuations.
Report Facts
Facility census: 94
Facility capacity: 190
Fire drills conducted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Grand | RN, LPNHA | Signed the inspection report and plan of correction |
Inspection Report
Annual Inspection
Census: 94
Capacity: 190
Deficiencies: 4
Date: Jun 21, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with fire drill requirements, tuberculosis screening, and community-based assessments for an assisted living facility.
Findings
The facility failed to acquire a fire consultation from the local fire department, did not conduct the required number of fire drills, failed to screen residents for tuberculosis as required, and did not complete community-based assessments semiannually for sampled residents.
Deficiencies (4)
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan was not met as the facility failed to acquire a fire consultation from the local fire department within the last twelve months. The facility capacity was 190 and the census was 94.
19 CSR 30-86.022(5)(D) Fire Drill Requirements were not met as the facility failed to conduct the minimum twelve fire drills annually with required frequency and conditions. The facility capacity was 190 and the census was 94.
19 CSR 30-86.047(19) TB Screen Residents & Staff was not met as the facility failed to screen three sampled residents for tuberculosis as required by regulations. The facility census was 18.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually was not met as the facility failed to complete community-based assessments upon admission and semiannually for three sampled residents. The facility census was 18.
Report Facts
Facility capacity: 190
Facility census: 94
Facility census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Quail | RN, LPN | Signed the statement of deficiencies on 7/14/2018 |
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