Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
111 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 8
Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and grievance handling at Birch Pointe Health and Rehabilitation.
Findings
The facility failed to promote resident self-determination in shower scheduling for six residents, failed to document and resolve grievances for two residents, failed to ensure residents received scheduled showers, failed to ensure residents were free from unnecessary medications including opioids and psychotropics without proper monitoring and documentation, failed to remove expired medications and supplies from medication carts and storage rooms, failed to ensure food items were stored properly with expired items found, and failed to maintain effective infection control by not cleaning patient care equipment between resident use.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to promote resident self-determination and provide scheduled showers as preferred for six residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide documented evidence of grievance documentation and resolution for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents received scheduled showers and document refusals or re-offers of bathing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from unnecessary medications; opioid pain medication was administered without proper pain assessment, documentation of non-pharmacological interventions, or monitoring for side effects. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer psychotropic drugs only when medically necessary; failed to educate residents or representatives on risks and benefits, monitor target behaviors, offer nonpharmacological interventions, and monitor adverse side effects for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove expired medications and supplies from medication carts and storage rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food items were stored in accordance with professional standards; expired food items were found in kitchen storage areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective infection control program; patient care equipment was not cleaned and disinfected between resident use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Norco administrations with no or mild pain: 53
Norco administrations with no or mild pain: 22
Norco administrations with no or mild pain: 11
Expired Assure Prism blood glucose control solution: 3
Expired evaporated milk cans: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 1 | CNA | Primary job as shower aide, reported being pulled to floor affecting shower schedule |
| Registered Nurse 1 | RN | Reported shower aides notify if residents refuse showers and staffing affects shower schedule |
| Director of Nursing | DON | Reviewed bathing records, confirmed lack of documentation for re-offering baths, and discussed medication monitoring deficiencies |
| Assistant Director of Nursing | ADON | Reported residents have two scheduled showers a week and shower aide notifies refusals |
| Social Service Director | SSD | Discussed grievances and family concerns about missing clothes |
| Clinical Pharmacist | Pharm D | Unaware of PRN monitoring for psychotropic medications and expected daily monitoring |
| Certified Medication Technician 1 | CMT | Observed not cleaning patient care equipment between residents |
| Certified Medication Technician 5 | CMT | Observed not cleaning patient care equipment between residents |
| Infection Preventionist | IP | Stated patient care equipment should be cleaned between residents and staff are trained |
| Certified Director of Food Service | CDFS | Confirmed expired food items in kitchen storage |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Aug 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate care and treatment for a resident's surgical incision following cervical spine surgery.
Findings
The facility failed to assess, monitor, care plan, and provide treatment for a resident's cervical spine surgical incision, resulting in the incision dehiscing with greenish-white drainage. Staff did not follow hospital discharge instructions, failed to document or obtain physician orders for wound care, and did not properly assess or treat the wound. The resident's care plan lacked specifics related to the surgical incision, and staff did not remove the resident's cervical collar for wound assessment due to resident refusal.
Complaint Details
The investigation was complaint-driven, focusing on the failure to provide appropriate wound care for Resident #1's cervical spine surgical incision. The complaint was substantiated as the facility did not follow hospital discharge instructions, did not obtain or document physician orders for wound care, and failed to monitor or treat the wound properly, leading to wound dehiscence and infection.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care per standards of practice for surgical incision resulting in dehiscence and drainage. | Level of Harm - Actual harm |
Report Facts
Facility census: 111
Wound size length: 4.5
Wound size width: 2.5
Wound size depth: 0.3
Wound tunneling at 1 o'clock: 1.3
Wound tunneling at 7 o'clock: 1.1
Wound bed slough percentage: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Assisted with admission and provided statements about wound care and resident refusal to remove C-collar |
| LPN B | Licensed Practical Nurse | Provided statements about wound care orders and resident refusal to remove C-collar |
| CNA C | Certified Nurse Assistant | Reported resident wore neck collar at all times and was unaware of incision |
| CMT D | Certified Medication Technician | Reported resident frequently requested pain medication assumed for neck |
| LPN E | Licensed Practical Nurse | Described admission procedures for skin assessment and wound care orders |
| Wound Nurse | Responsible for weekly wound assessments and treatments; provided statements on wound care practices | |
| OT F | Occupational Therapist | Assisted resident with shower and collar care; unaware of resident's neck incision |
| DON | Director of Nursing | Provided statements on wound care responsibilities, care plans, and facility policies |
| LPN G | Medicare Manager | Provided statements on admission orders and documentation |
| LPN H | Licensed Practical Nurse | Responsible for care plans; provided statements on care plan documentation |
| Administrator | Provided statements on facility policies regarding wound care and physician orders | |
| Neurosurgeon's Nurse Practitioner | Nurse Practitioner | Provided expert statements on wound care standards and resident's wound condition |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Jul 12, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility staff's failure to prevent further abuse and protect resident safety after resident-to-resident altercations involving Resident #1 and five other residents.
Findings
The facility failed to implement consistent and effective care plan interventions to prevent ongoing resident-to-resident altercations involving Resident #1. Multiple incidents of physical and verbal aggression were documented, including hitting, slapping, and threatening behaviors. Despite interventions such as 15-minute monitoring and medication adjustments, Resident #1 continued aggressive behaviors leading to an emergency discharge. The facility did not update care plans adequately to address these behaviors or protect other residents.
Complaint Details
The complaint investigation found substantiated evidence that Resident #1 engaged in multiple aggressive incidents against other residents and staff, including hitting, slapping, striking with a walker, verbal threats, and pushing. The facility's response included 15-minute monitoring, medication changes, and ultimately an emergency discharge due to safety concerns.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to take steps to prevent further abuse and protect resident safety when staff failed to implement and care plan consistent and effective interventions for one resident after resident-to-resident altercations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 99
15-minute checks: 15
Medication dosage: 50
Medication dosage: 25
Medication dosage: 25
Medication dosage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Struck on right arm by Resident #1 during incident in Resident #2's room |
| Director of Nursing | Director of Nursing | Spoke with Resident #1's responsible party regarding violent behavior and emergency discharge |
| Social Services Director | Social Services Director | Documented Resident #1's family appeal of emergency discharge decision |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Dec 1, 2023
Visit Reason
The inspection was conducted due to allegations of possible abuse involving five residents, to investigate the facility's failure to report and thoroughly investigate these allegations in a timely manner.
Findings
The facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency. The facility also failed to thoroughly document investigations of alleged abuse involving five residents. Multiple staff interviews and record reviews revealed inconsistent reporting and follow-up on abuse allegations, with some residents recanting statements and staff not reporting or investigating incidents as required.
Complaint Details
The complaint involved allegations of abuse by Resident #3 toward Residents #25, #50, #66, and #82, including inappropriate touching and physical contact. The facility failed to report these allegations timely and did not document investigations properly. The facility census was 93 residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all allegations of possible abuse were thoroughly and timely investigated and documented. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Sample size: 24
Facility census: 93
Dates of admission: Admission dates for residents involved (various dates from 2019 to 2023)
Dates of MDS assessments: Various dates for Minimum Data Set assessments for residents involved
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Reported abuse allegation to Director of Nursing and educated resident on communication |
| CMT L | Certified Medication Technician | Reported multiple abuse incidents and considered allegations of sexual abuse |
| RN M | Registered Nurse | Heard about abuse allegations during shift and reported to administration |
| DON | Director of Nursing | Reviewed facility cameras, investigated allegations, and provided statements on reporting failures |
| Administrator | Facility Administrator | Oversaw investigation process and acknowledged failure to report allegations timely |
| CNA O | Certified Nurse Aide | Reported resident behaviors and abuse allegations |
| CNA P | Certified Nurse Aide | Reported resident inappropriate touching and abuse incidents |
| LPN K | Licensed Practical Nurse | Heard abuse allegations during nursing report |
| LPN Q | Licensed Practical Nurse | Reported hearing about resident undressing and abuse incidents |
| CMT D | Certified Medication Technician | Reported resident found undressed in another resident's bed |
| Staff Person U | Reported resident touching another resident's breast | |
| CNA F | Certified Nurse Aide | Reported resident found naked in another resident's bed |
Inspection Report
Routine
Census: 93
Deficiencies: 7
Dec 1, 2023
Visit Reason
The inspection was conducted to assess compliance with resident care, abuse reporting, infection control, dialysis care, and emergency procedures.
Findings
The facility was found deficient in promoting resident self-determination related to bathing and oral care, timely reporting and investigating allegations of abuse, providing written bed-hold policy at hospital transfer, verifying code status and providing timely CPR, communicating dialysis care information, and maintaining an effective infection control program including proper PPE use and source control during a COVID-19 outbreak.
Deficiencies (7)
| Description |
|---|
| Failed to promote resident self-determination by not providing routine baths/showers and oral care assistance consistently for sampled residents. |
| Failed to timely report allegations of possible abuse to management and State Survey Agency for five residents. |
| Failed to thoroughly and timely investigate allegations of abuse involving five residents. |
| Failed to provide written bed-hold policy to resident or representative upon hospital transfer. |
| Failed to verify resident's code status and provide timely CPR for a resident found unresponsive. |
| Failed to communicate and collaborate with dialysis center regarding resident's dialysis sessions and assessments. |
| Failed to maintain an effective infection control program including improper disposal and donning of PPE, failure to implement source control during COVID-19 outbreak, and improper handling of hall trays and cleaning supplies from isolation rooms. |
Report Facts
Residents affected by abuse reporting deficiency: 5
Residents affected by infection control deficiency: 5
Facility census: 93
Dialysis communication missing dates: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Reported abuse allegation involving Resident #82 and Resident #3 |
| CMT L | Certified Medication Technician | Reported multiple abuse incidents involving residents and described abuse reporting procedures |
| DON | Director of Nursing | Responsible for abuse investigations and infection control oversight |
| Administrator | Facility Administrator | Oversight of abuse reporting, infection control, and bed-hold policy |
| BOM | Business Office Manager | Responsible for sending bed-hold policy to residents |
| IP | Infection Preventionist | Provided infection control education and guidance on PPE and COVID-19 protocols |
| LPN C | Licensed Practical Nurse | Described proper PPE use and infection control procedures |
Inspection Report
Routine
Census: 94
Deficiencies: 3
Aug 1, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, catheter care, and timely imaging services at Birch Pointe Health and Rehabilitation.
Findings
The facility failed to ensure proper documentation and care related to bathing and personal hygiene for dependent residents, timely catheter care and adherence to physician orders for catheter size and frequency, and timely performance and notification of stat ultrasound imaging for a resident with abdominal tenderness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to document routine offers of bathing or showering and failed to address resident's preferences for shower/baths in the care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain timely catheter care orders, failed to document catheter changes, failed to obtain timely urine specimens, and failed to follow physician's orders for catheter size. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain a timely ultrasound and notify the physician when a stat ultrasound imaging was delayed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 94
Bathing frequency: 2
Catheter size: 16
Catheter balloon size: 10
Catheter balloon size observed: 5
Urine culture colony forming units: 100000
Catheter change order date: 24
Ultrasound delay days: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant A | CNA | Interviewed regarding bathing schedule and catheter care training |
| Licensed Practical Nurse B | LPN | Interviewed regarding bathing schedule and urine specimen collection |
| Director of Nursing | DON | Interviewed regarding bathing schedule, catheter care, and imaging delays |
| Assistant Director of Nursing, Long-Term Care | ADON-LTC | Interviewed regarding catheter care and imaging orders |
| Administrator | Interviewed regarding documentation and adherence to physician orders |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 11
Jun 2, 2021
Visit Reason
The inspection was conducted due to complaints regarding failure to treat residents with dignity and respect related to COVID-19 quarantine procedures, missing controlled medications, inadequate care for contractured hand and edema, delayed treatment for pressure ulcers, improper respiratory care, medication errors, improper food preparation, and infection control deficiencies.
Findings
The facility failed to verify COVID-19 vaccination status prior to quarantine placement, protect residents from misappropriation of controlled medications, provide appropriate care for contractured hand and edema, timely treat pressure ulcers, obtain physician orders for oxygen use, maintain medication error rates below 5%, prepare pureed diets according to recipes, and implement effective infection prevention and control measures including proper PPE use and environmental cleaning.
Complaint Details
The complaint investigation included issues related to COVID-19 quarantine procedures, medication misappropriation, care deficiencies, infection control, and other regulatory concerns as detailed in the findings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to verify COVID-19 vaccination status prior to placing a fully vaccinated resident in quarantine. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from misappropriation of controlled medications with missing narcotics for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care and treatment for a resident's contractured hand including failure to follow therapy recommendations and obtain physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to identify, develop, and implement interventions for care of a resident's edematous left leg. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete timely assessment and treatment of new pressure ulcers including failure to obtain treatment orders and document treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain physician orders for oxygen use and update care plan accordingly for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration errors with two missed medications out of 27 opportunities for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow approved recipes and measure ingredients when preparing pureed diets. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection prevention and control program including improper PPE use, failure to sanitize equipment, improper disposal of contaminated materials, and lack of Legionella prevention program. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately assess and address dental needs of a resident including failure to document dental issues and coordinate dental care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure all controlled drugs were reconciled periodically with multiple instances of nurses failing to sign narcotic count sheets during shift changes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 104
Medication error rate: 7.4
Missing oxycodone tablets: 15
Missing morphine sulfate tablets: 5
Missing oxycodone tablets: 15
Missing OxyContin ER tablets: 19
Missing lorazepam tablets: 22
Pressure ulcer size: 0.7
Pressure ulcer size: 1.8
Pressure ulcer size: 1.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Notified DON of missing narcotics and described narcotic count procedures |
| DON | Director of Nursing | Investigated narcotic discrepancies, discussed COVID-19 quarantine procedures, and infection control |
| ADON | Assistant Director of Nursing | Discussed vaccination verification and quarantine procedures |
| Therapy Aide FF | Therapy Aide | Described therapy staff actions related to quarantine hall residents |
| Speech Therapist S | Speech Therapist | Described quarantine hall admission procedures |
| Pharmacist | Verified resident vaccination and medication deliveries | |
| CNA G | Certified Nurse Aide | Described infection control lapses and PPE use on quarantine hall |
| LPN Z | Licensed Practical Nurse | Described care for resident's contractured hand and infection control practices |
| Dietary Manager | Discussed pureed diet preparation expectations | |
| LPN EE | Licensed Practical Nurse | Described narcotic count procedures and oxygen order process |
| CMT C | Certified Medication Technician | Described medication refill and administration procedures |
| RN F | Registered Nurse | Described pressure ulcer evaluation process |
| LPN N | Licensed Practical Nurse | Described vital sign cart sanitization and quarantine hall equipment |
| CNA FF | Certified Nursing Assistant | Described oxygen use and communication of oxygen orders |
| CNA GG | Certified Nursing Assistant | Described oxygen use and communication of oxygen orders |
| LPN A | Licensed Practical Nurse | Described medication administration errors and oxygen order process |
| CNA X | Certified Nursing Assistant | Described oxygen use and care plan communication |
| RN I | Registered Nurse | Described dental assessment and referral process |
| SLP S | Speech Language Pathologist | Described dental assessment and referral process |
| CNA O | Certified Nurse Aide | Described dental assessment and reporting |
| LPN E | Licensed Practical Nurse | Described dental assessment and care plan process |
| OT HH | Occupational Therapist | Described therapy for contractured hand and communication with nursing |
| DOR | Director of Rehabilitation | Described therapy services and communication with nursing |
| CMT C | Certified Medication Technician | Described attempts to place orthotic device and medication administration |
| CNA CC | Certified Nurse Aide | Described orthotic device placement and resident tolerance |
| LPN N | Licensed Practical Nurse | Described infection control and equipment sanitization |
| Maintenance Director | Unaware of Legionella prevention policy and procedures | |
| Administrator | Discussed expectations for narcotic counts and Legionella prevention |
Loading inspection reports...
