Deficiencies (last 8 years)
Deficiencies (over 8 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
92% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 8
Date: 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.
Deficiencies (8)
Failed to promote resident self-determination and provide scheduled showers as preferred for six residents.
Failed to provide documented evidence of grievance documentation and resolution for two residents.
Failed to ensure residents received scheduled showers and document refusals or re-offers of bathing.
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.
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.
Failed to remove expired medications and supplies from medication carts and storage rooms.
Failed to ensure food items were stored in accordance with professional standards; expired food items were found in kitchen storage areas.
Failed to maintain an effective infection control program; patient care equipment was not cleaned and disinfected between resident use.
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
Life Safety
Census: 110
Capacity: 120
Deficiencies: 2
Date: Feb 12, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness regulations for participation in Medicare/Medicaid.
Findings
The facility was found to be noncompliant with Life Safety Code requirements related to egress door signage and emergency generator testing. Deficiencies affected all 110 residents present during the inspection.
Deficiencies (2)
K222 Egress Doors: The facility failed to ensure exit doors with delayed egress had signage stating 'Push until alarm sounds door can be opened in 15 seconds.' Nine of 11 exit doors lacked this signage.
K918 Electrical Systems: The facility failed to ensure the emergency generator was tested monthly as required. Records showed no documented monthly battery tests for 2024, confirmed by the Maintenance Director.
Report Facts
Residents present: 110
Total licensed beds: 120
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to provide care per standards of practice for surgical incision resulting in dehiscence and drainage.
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
Plan of Correction
Census: 111
Deficiencies: 2
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to investigate and document deficiencies related to quality of care at Birch Pointe Health and Rehabilitation, specifically regarding the treatment and care of a resident's surgical incision.
Findings
The facility failed to provide care per standards of practice by not assessing, monitoring, or treating a resident's surgical incision properly. Staff did not document wound care orders, and the resident's refusal of treatment was not adequately addressed or communicated.
Deficiencies (2)
F684 Quality of care deficiency: Facility staff failed to assess, monitor, care plan, and provide treatment for a resident's surgical incision, resulting in incision dehiscence and drainage. Staff did not document wound care orders or notify supervisors appropriately.
A4075 Nursing care per resident condition deficiency: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as referenced by F684.
Report Facts
Facility census: 111
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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: 99
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving resident-to-resident altercations at Birch Pointe Health and Rehabilitation.
Complaint Details
The complaint investigation substantiated allegations of resident-to-resident abuse involving Resident #1 and multiple other residents. The facility failed to prevent and properly manage aggressive behaviors and altercations despite documented incidents and care plan revisions. Resident #1 was discharged during the investigation period.
Findings
The facility failed to prevent further abuse and protect resident safety by not implementing an effective care plan for a resident involved in multiple altercations with other residents. The investigation revealed inadequate monitoring and intervention despite documented aggressive behaviors and incidents.
Deficiencies (2)
F610: The facility failed to investigate, prevent, and correct alleged violations of abuse, neglect, exploitation, or mistreatment. Staff did not implement an effective care plan to prevent resident-to-resident altercations involving Resident #1 and five other residents.
A4074: The facility failed to provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, as required by regulation.
Report Facts
Resident census: 99
Completion date: Plan of correction completion date is 2024-08-26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Spoke about Resident #1's behavior and emergency discharge |
| Certified Medication Tech | Certified Medication Tech (CMT) H | Interviewed regarding monitoring of Resident #1 |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) A | Interviewed regarding monitoring of Resident #1 |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) C | Interviewed regarding one-on-one monitoring |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) G | Interviewed regarding 15-minute checks and incident reports |
| Registered Nurse | Registered Nurse (RN) B | Responsible for updating resident care plans and interviewed about interventions |
| Certified Nurse Aide | Certified Nurse Aide (CNA) | Reported incidents and interviewed about resident altercations |
| Administrator | Administrator | Signed investigation and plan of correction documents |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to ensure all allegations of possible abuse were thoroughly and timely investigated and documented.
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
Date: 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)
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
Life Safety
Census: 93
Capacity: 120
Deficiencies: 3
Date: Dec 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 fire safety regulations.
Findings
The facility failed to maintain the electrical system properly by allowing improper use of power taps and outlet extenders, which posed a fire and electrical injury risk. Additionally, the facility did not have an annual consultation and review of fire and evacuation plans with the local fire department as required.
Deficiencies (3)
K920 Electrical Equipment - Power cords and extension cords were improperly used as power strips and outlet extenders in multiple areas, posing fire and electrical injury risks. The facility lacked a policy on the use of power taps or outlet extenders.
A2058 Fire Drill/Emergency Preparedness - The facility failed to have the local fire department complete an annual consultation and review of facility fire and evacuation plans.
A3037 Extension Cords/Duplex Receptacles - Extension cords were not used according to safety standards, referencing the K920 deficiency for details.
Report Facts
Facility capacity: 120
Census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding use of outlet extenders and fire consultation requirements | |
| Administrator | Interviewed regarding outlet extender use and fire consultation requirements |
Inspection Report
Routine
Census: 94
Deficiencies: 3
Date: 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.
Deficiencies (3)
Failed to document routine offers of bathing or showering and failed to address resident's preferences for shower/baths in the care plan.
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.
Failed to obtain a timely ultrasound and notify the physician when a stat ultrasound imaging was delayed.
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
Plan of Correction
Census: 94
Deficiencies: 5
Date: Aug 1, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding care for dependent residents, catheter care, and diagnostic services at Birch Pointe Health and Rehabilitation.
Findings
The facility failed to provide necessary ADL care for dependent residents, timely catheter care and physician orders, and timely diagnostic services such as ultrasounds. Documentation and adherence to care plans and physician orders were inconsistent.
Deficiencies (5)
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure staff provided necessary grooming and personal hygiene services and did not document bathing frequency or resident preferences for one resident. The facility census was 94.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to obtain timely catheter care orders, document catheter changes, obtain timely urine specimens, and follow physician orders for catheter size and care for multiple residents. The facility census was 94.
F776 Radiology/Other Diagnostic Services: The facility failed to obtain timely ultrasounds and notify the physician when emergent imaging was delayed for one resident with abdominal tenderness. The facility census was 94.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with their condition. This regulation was not met as evidenced by deficiencies F690 and F776.
A4077 Residents Groomed/Dressed Appropriately: Residents shall be well-groomed and dressed appropriately. This regulation was not met as evidenced by deficiency F677.
Report Facts
Facility census: 94
Inspection Report
Plan of Correction
Census: 104
Deficiencies: 1
Date: Apr 7, 2023
Visit Reason
The inspection was conducted following a fire incident in the facility's laundry room to assess compliance with fire watch monitoring requirements.
Findings
The facility failed to complete documented hourly visual checks for 24 hours after a fire occurred in a laundry room. The fire watch policies did not address monitoring the fire area for 24 hours, and staff left the fire area unsupervised for approximately seven hours overnight.
Deficiencies (1)
19 CSR 30-85.022(2)(G) Fire-24hr Monitor, Hourly Checks. The facility failed to complete documented hourly visual checks for 24 hours after a fire occurred in the laundry room. The fire watch policies did not require monitoring the fire area for 24 hours.
Report Facts
Facility census: 104
Fire incident date: Apr 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding fire incident and staffing | |
| Director of Nursing | Interviewed regarding staffing and fire incident | |
| Laundry Assistant A | Interviewed about fire occurrence in laundry room | |
| Maintenance Director | Responsible for reviewing Emergency Manual and fire drill oversight |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Date: Jan 10, 2023
Visit Reason
The inspection was conducted in response to allegations of abuse involving two residents at Birch Pointe Health and Rehabilitation.
Complaint Details
The complaint involved allegations of abuse between two residents. The facility was found to have failed to report the abuse within the required timeframe, resulting in a substantiated deficiency.
Findings
The facility failed to report allegations of abuse involving two residents within the required two-hour timeframe. The noncompliance was corrected on 12/21/2022 after investigation and implementation of daily chart checks.
Deficiencies (1)
F 609: The facility failed to report allegations of abuse involving two residents to the Department of Health and Senior Services within two hours of staff becoming aware of the allegation.
Report Facts
Facility census: 104
Time delay in reporting: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam M. Yandow | Surveyor | Signed the inspection report |
Inspection Report
Routine
Census: 113
Deficiencies: 2
Date: Dec 1, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with water temperature safety regulations and resident environment safety.
Findings
The facility failed to maintain water temperatures between 105 and 120 degrees Fahrenheit in resident rooms, increasing the risk of burns. Multiple resident records and water temperature logs showed temperatures exceeding the safe range.
Deficiencies (2)
F 689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2). The facility failed to ensure the resident environment was free of accident hazards as water temperatures exceeded safe limits, putting residents at risk of burns.
A3023 19 CSR 30-85.032(24) Hot Water 105-120 Degrees F. The facility did not ensure plumbing fixtures supplying hot water were thermostatically controlled to maintain water temperatures within 105-120 degrees Fahrenheit.
Report Facts
Facility census: 113
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Date: Nov 2, 2021
Visit Reason
The inspection was conducted to investigate complaints related to resident self-determination rights and bathing/showering care deficiencies at Birch Pointe Health and Rehabilitation.
Complaint Details
The complaint investigation substantiated that residents were not receiving the preferred frequency of showers, with staff shortages and removal of the shower aide contributing to the issue. Residents and staff reported concerns about hygiene and shower availability.
Findings
The facility failed to maintain sufficient staff to provide preferred bathing and showering for six residents. Multiple residents reported not receiving the expected number of showers per week, and staff documented inconsistent bathing care. The facility also failed to meet regulations regarding resident grooming and dressing appropriately.
Deficiencies (2)
F561 Self-determination: The facility failed to provide sufficient staff to support resident bathing/showers as preferred for six residents, violating residents' rights to choose activities and care consistent with their interests.
A4076 Resident Groomed/Dressed Appropriately: The facility did not ensure residents were well-groomed and dressed appropriately, as evidenced by poor hygiene and grooming issues related to the bathing deficiencies.
Report Facts
Facility census: 105
Number of residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician (CMT) A | Certified Medication Technician | Reported facility pulled shower aide to the floor and inability to complete showers |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Reported need for shower aide and issues with residents not receiving two showers per week |
| Certified Nursing Assistant (CNA) C | Certified Nursing Assistant | Reported residents not receiving two showers per week and communication with charge nurse and Director of Nursing |
| Certified Nursing Assistant (CNA) E | Certified Nursing Assistant | Reported shower aide pulled to floor and residents' hygiene concerns |
| Certified Nursing Assistant (CNA) F | Certified Nursing Assistant | Reported shower aide pulled to floor and shower sheet documentation process |
| Quality Assurance (QA) nurse | Quality Assurance nurse | Reported staff should notify charge nurse if residents refuse showers |
| Director of Nursing (DON) | Director of Nursing | Reported no designated shower aide and residents not receiving two showers per week |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 11
Date: 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.
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.
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.
Deficiencies (11)
Failure to verify COVID-19 vaccination status prior to placing a fully vaccinated resident in quarantine.
Failure to protect residents from misappropriation of controlled medications with missing narcotics for three residents.
Failure to provide appropriate care and treatment for a resident's contractured hand including failure to follow therapy recommendations and obtain physician orders.
Failure to identify, develop, and implement interventions for care of a resident's edematous left leg.
Failure to complete timely assessment and treatment of new pressure ulcers including failure to obtain treatment orders and document treatments.
Failure to obtain physician orders for oxygen use and update care plan accordingly for a resident.
Medication administration errors with two missed medications out of 27 opportunities for one resident.
Failure to follow approved recipes and measure ingredients when preparing pureed diets.
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.
Failure to accurately assess and address dental needs of a resident including failure to document dental issues and coordinate dental care.
Failure to ensure all controlled drugs were reconciled periodically with multiple instances of nurses failing to sign narcotic count sheets during shift changes.
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 |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Date: Dec 22, 2020
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted due to concerns about infection control and a staff member testing positive for COVID-19 while working.
Complaint Details
The complaint investigation was substantiated as the facility allowed a registered nurse who tested positive for COVID-19 to work, exposing residents to infection. The facility census was 84 at the time.
Findings
The facility failed to maintain an infection control program during the COVID-19 pandemic, specifically allowing a registered nurse who tested positive for COVID-19 to continue working, exposing residents to infection risk.
Deficiencies (2)
F880 Infection Control: The facility failed to maintain an infection prevention and control program during the COVID-19 pandemic by allowing a registered nurse who tested positive for COVID-19 to continue working, exposing residents to infection risk.
A4085 19 CSR 30-85.042(78) Infection Control/Communicable Disease: The facility did not meet infection control regulations requiring reporting of communicable diseases and use of acceptable infection control procedures.
Report Facts
Facility census: 84
Residents on Memory Care Unit: 36
COVID-19 positive residents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John A. Miller | Administrator | Signed plan of correction and interviewed regarding staffing and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
This was a complaint investigation related to COVID-19 focused infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 3
Date: Oct 1, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse involving resident-to-resident altercation and concerns about staffing and food service.
Complaint Details
The complaint involved an alleged resident-to-resident abuse incident where Resident #34 shoved Resident #25. The allegation was not reported within the required two-hour timeframe. The complaint was substantiated as the facility failed to report timely.
Findings
The facility failed to report an allegation of abuse within the required two-hour timeframe and failed to provide sufficient staff to serve residents meals in a timely manner. Additionally, the facility did not ensure foods were held at appropriate temperatures to inhibit foodborne illness.
Deficiencies (3)
F609: The facility failed to report an allegation of abuse to the Department of Health and Senior Services within the required two-hour timeframe after a resident-to-resident altercation.
F802: The facility failed to provide sufficient staff to serve residents meals in a timely manner, affecting all residents in the long-term care dining room.
F812: The facility failed to ensure foods were held at appropriate temperatures to inhibit the growth of pathogens that can cause foodborne illness.
Report Facts
Facility census: 105
Deficiencies cited: 3
Inspection Report
Annual Inspection
Census: 105
Capacity: 120
Deficiencies: 2
Date: Oct 1, 2019
Visit Reason
The inspection was an annual recertification survey to assess compliance with emergency preparedness and life safety code requirements.
Findings
No emergency preparedness deficiencies were cited. The facility failed to meet the 2012 Life Safety Code provisions related to delayed egress locking arrangements on two smoke barrier doors, which could affect residents and visitors.
Deficiencies (2)
K222: The facility failed to ensure two smoke barrier doors equipped with delayed egress locking hardware released with activation of the fire alarm. Observations showed the doors did not close when the alarm was activated.
A2055: The facility did not meet the regulation requiring self-closing devices on all doors providing separation between floors, with a higher classification due to the extent of the violation.
Report Facts
Facility capacity: 120
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding smoke barrier door checks | |
| Maintenance Director | Responsible for reporting findings to QA committee |
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 1
Date: Jul 19, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse involving two residents at Birch Pointe Health and Rehabilitation.
Complaint Details
The complaint involved allegations of abuse between Resident #1 and Resident #2. The allegation was substantiated as Resident #1 was observed slapping Resident #2. The facility did not report the incident within the required timeframe.
Findings
The facility failed to report an allegation of abuse involving two residents within the required two-hour timeframe. The investigation confirmed that Resident #1 slapped Resident #2, and the facility did not meet the reporting requirements to the Department of Health and Senior Services (DHSS).
Deficiencies (1)
F 609: The facility failed to report an allegation of abuse involving two residents to the Department of Health and Senior Services within the required two-hour timeframe.
Report Facts
Facility census: 17
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 6, 2018
Visit Reason
The inspection was conducted as an annual recertification survey and licensure inspection of Birch Pointe Health and Rehabilitation.
Findings
No Emergency Preparedness deficiencies were cited during the annual recertification survey. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Plan of Correction
Census: 70
Deficiencies: 2
Date: Nov 5, 2018
Visit Reason
The inspection was conducted to assess compliance with psychotropic medication regulations, specifically regarding the use of antipsychotic medications and PRN orders for psychotropic drugs.
Findings
The facility failed to ensure a medication regimen free from unnecessary antipsychotic medications and did not provide adequate indications or appropriate diagnoses for one resident's antipsychotic medication. The facility also lacked documentation addressing the resident's psychotropic medication use in the care plan.
Deficiencies (2)
F758 Psychotropic Drugs. The facility failed to ensure residents did not receive psychotropic drugs without appropriate diagnoses or indications and did not properly document PRN orders for psychotropic drugs beyond 14 days.
A4074 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with the resident's condition as evidenced by the issues noted in F758.
Report Facts
Facility census: 70
Sample size: 19
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 4
Date: Aug 30, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse involving Resident #1 exhibiting sexually inappropriate behaviors toward other residents, and the facility's failure to protect residents from abuse.
Complaint Details
The complaint investigation was substantiated. The facility failed to protect residents from abuse by Resident #1 and failed to report alleged abuse within required timeframes.
Findings
The facility failed to protect four residents from abuse by Resident #1, who exhibited inappropriate sexual behaviors. The facility also failed to report alleged abuse within required timeframes and did not update care plans or interventions to address the behaviors.
Deficiencies (4)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to protect four residents from abuse by Resident #1, who engaged in inappropriate sexual contact with residents. Staff did not implement new interventions or update care plans to address these behaviors.
F609 Reporting of Alleged Violations: The facility failed to report one resident's documented sexual inappropriate behaviors within two hours to the state licensing agency. The facility also failed to ensure all allegations of possible abuse were reported timely.
A4073 Protective Oversight, Voluntary Leave: The facility did not meet requirements for protective oversight and supervision for residents on voluntary leave, as referenced in F600.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, as referenced in F609.
Report Facts
Resident census: 69
Number of residents involved in abuse: 4
Number of residents selected for review: 5
Deficiency counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Documented resident behaviors and medication changes related to Resident #1 |
| RN D | Registered Nurse | Reported observations of Resident #1's inappropriate behaviors |
| CNA C | Certified Nursing Assistant | Reported witnessing inappropriate behaviors and incidents involving Resident #1 |
| CNA E | Certified Nursing Assistant | Witnessed Resident #1 touching other residents inappropriately |
| Administrator | Administrator | Named in investigation and plan of correction approval |
| Director of Nursing | Director of Nursing | Involved in monitoring and reporting of abuse incidents |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Apr 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility operating a second business, a coffee shop, open to the public without approval from the Department of Health and Senior Services (DHSS).
Complaint Details
This complaint investigation was triggered by observations of a new coffee shop opening within the facility without DHSS approval. The complaint was not substantiated with federal deficiencies.
Findings
The facility failed to obtain DHSS approval for a second business operating within the facility. No federal deficiencies were cited during this complaint investigation.
Deficiencies (1)
19 CSR 30-85.042(3) Operator/Administrator Responsibilities: The facility failed to obtain approval from the Department of Health and Senior Services for a second business open to the public within the facility. The facility census was 43.
Report Facts
Facility census: 43
Document
Deficiencies: 0
Date: Jun 2, 2021
Visit Reason
The document does not contain any readable information to determine the visit reason.
Findings
No findings or content are available due to lack of readable text.
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