Inspection Reports for The Bishop Spencer Place, Inc
4301 MADISON AVE, MO, 64111-3491
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
48 residents
Based on a July 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Jul 29, 2024
Visit Reason
The inspection was conducted due to complaints regarding medication errors involving residents at the facility.
Findings
The facility failed to ensure residents were free from medication errors, including wrong medication administration, double dosing, and a significant overdose of morphine concentrate. The facility implemented corrective actions during the survey.
Complaint Details
The complaint involved medication errors with three residents: Resident #2 received the wrong medication; Resident #3 was given medication twice due to a family member administering medication without documentation; Resident #1 was given a 10-fold overdose of morphine concentrate, resulting in immediate jeopardy which was later abated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure two sampled residents were free from medication errors, including wrong medication and double dosing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure one sampled resident was free from a significant medication error involving a 10-fold overdose of morphine concentrate. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents affected: 2
Residents affected: 1
Medication overdose amount: 5
Medication ordered dose: 0.5
Facility census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in medication error administering wrong medication to Resident #2 |
| CMT B | Certified Medication Technician | Involved in medication error administering wrong medication to Resident #2 |
| ADON | Assistant Director of Nursing | Administered 5 mL morphine concentrate overdose to Resident #1 and administered Narcan |
| CMT A | Certified Medication Technician | Assisted ADON with medication preparation for Resident #1 overdose incident |
| DON | Director of Nursing | Notified and involved in response to Resident #1 medication overdose |
Inspection Report
Routine
Census: 53
Deficiencies: 9
Feb 6, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey of Bishop Spencer Place, Inc. to assess compliance with healthcare facility regulations, including resident fund management, PASARR screening, medication administration, pressure ulcer care, respiratory care, medication storage, food safety, infection control, and immunization procedures.
Findings
The facility was found deficient in multiple areas including failure to disperse resident trust funds timely after death, incomplete PASARR Level I screening, improper medication administration and storage, inadequate pressure ulcer care including missing pressure reducing mattress, improper respiratory care including oxygen tubing storage and CPAP maintenance, unlocked medication carts, food safety violations in the kitchen, lapses in infection control practices during wound care and Foley catheter management, and incomplete pneumococcal immunization consent and re-offering.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to disperse remaining resident trust account funds and provide final accounting within 30 days of death for three sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain a complete PASARR Level I Screening for one sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pain patch was not left unattended on resident's breakfast tray and medications were not left for self-administration without nursing supervision. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a physician ordered Low Air Loss mattress was in place for a resident with a Stage III pressure ulcer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure oxygen tubing was stored in a dated bag when not in use and CPAP masks were cleaned daily and stored properly for sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication carts were locked when unattended by nursing staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen sanitation including clean floors, operable thermometers, timely oil changes, and intact cutting boards. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly screen for tuberculosis and implement infection control practices during wound care and Foley catheter management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete pneumococcal immunization consent form correctly and failed to re-offer immunization yearly. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents census: 53
Resident trust fund remaining balances: 400.57
Resident trust fund remaining balances: 164.17
Resident trust fund remaining balances: 100
Medication carts observed unlocked: 3
Deep fryer oil change frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Accounting Specialist | Responsible for completing forms and returning resident funds after death | |
| Administrator | Responsible for oversight of personal finance account paperwork | |
| Director of Nursing (DON) | Provided multiple interviews regarding PASARR screening, medication administration, wound care, infection control, oxygen therapy, and immunizations | |
| Licensed Practical Nurse (LPN) B | Observed medication pass and provided interview on medication cart locking and medication administration | |
| Registered Nurse (RN)/Wound Care Nurse (WCN) A | Performed wound care and provided interview on wound care practices | |
| Certified Nursing Assistant (CNA) H | Provided interview on oxygen tubing and Foley catheter care | |
| Certified Medication Technician (CMT) C | Provided interview on medication cart locking and hand hygiene | |
| Dietary Manager (DM) | Provided interview on kitchen sanitation and food preparation | |
| Licensed Practical Nurse (LPN) A | Provided interview on CPAP care | |
| Certified Nursing Assistant (CNA) D | Provided interview on CPAP mask care | |
| Assistant Director of Nursing (ADON) | Provided interview on oxygen tubing, CPAP care, medication cart locking, and infection control |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Aug 29, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to arrange a safe and orderly discharge for a resident (Resident #2) who was discharged to a lodging facility without appropriate outside services in place, despite resident and family concerns.
Findings
The facility failed to ensure a safe discharge for Resident #2, who was discharged to a lodging facility without necessary services or caregiver support. The resident experienced distress and complications due to the rushed and poorly coordinated discharge process, which was driven by insurance limitations and lack of available long-term care placements.
Complaint Details
The complaint investigation found that the resident was discharged due to insurance no longer paying for the stay, with no options provided for transfer or paying out of pocket. The resident and family expressed concerns about the discharge process and placement at the lodging facility. The resident experienced mental distress and health decline after discharge. The facility did not confirm if services were in place prior to discharge and referrals for long-term care were denied due to the resident's condition and pending state aid insurance.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to arrange for a safe and orderly discharge for one sampled resident when discharged to a lodging facility without outside services in place. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 46
Sampled residents: 7
Discharge date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SW A | Social Worker | Interviewed regarding discharge process and coordination with resident's family |
| SW B | Social Worker | Interviewed regarding discharge to lodging facility and referral process |
| Administrator | Facility Administrator | Interviewed regarding discharge policies and resident placement |
| Cancer Support SW | Cancer Support Social Worker | Interviewed about resident's distress after discharge and placement concerns |
| Lodging Facility Worker | Interviewed about lodging facility admission requirements and concerns |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Jun 6, 2023
Visit Reason
The inspection was conducted due to allegations of exploitation and failure to administer prescribed medication properly, involving multiple residents.
Findings
The facility failed to protect two residents from financial exploitation by an employee who misused a resident's debit card and accepted personal checks from another resident. Additionally, the facility failed to administer prescribed medication (Xarelto) properly to one resident, missing doses without proper documentation or notification to the physician.
Complaint Details
The complaint investigation revealed exploitation by Server A who obtained and used Resident #1's debit card and accepted personal checks from Resident #2. Server A was terminated following the investigation. The medication administration failure involved Resident #3 missing doses of Xarelto without proper documentation or notification to the physician.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect residents from wrongful use of belongings or money, involving misuse of debit card and acceptance of personal checks by an employee. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer two doses of Xarelto 20 mg by mouth daily for one resident, with missed doses not documented or reported. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Missed medication doses: 3
Checks given: 3
Facility census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Server A | Employee who exploited residents by misusing debit card and accepting personal checks; terminated on 4/17/23 | |
| LPN A | Licensed Practical Nurse | Documented missed medication doses and interviewed regarding medication administration failure |
| LPN B | Licensed Practical Nurse | Documented missed medication doses and interviewed regarding medication administration failure |
| Director of Nursing | Director of Nursing | Interviewed regarding staff education and expectations about resident exploitation and medication administration |
| Administrator | Facility Administrator | Interviewed regarding exploitation investigation and staff education |
| Nurse Practitioner A | Nurse Practitioner | Interviewed regarding lack of notification about missed medication doses |
Inspection Report
Routine
Census: 44
Deficiencies: 4
Jul 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, dialysis care, food safety, and dietary services at the nursing home.
Findings
The facility was found deficient in multiple areas including improper storage of oxygen nasal cannula tubing, lack of physician orders and individualized care plans for residents receiving dialysis, unsanitary food storage and preparation practices in the kitchen, and improper cooking temperatures compromising food quality and safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure oxygen nasal cannula tubing was stored per facility policy when not in use for one sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents receiving dialysis had physician's orders indicating dialysis location and schedule and to maintain ongoing communication with dialysis centers for two sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store food in the refrigerated walk-in unit and to practice sanitary and hygienic practices before, during and after food preparation tasks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure foods were prepared in accordance with FDA standards to preserve nutrients; pork sausage links were overcooked to temperatures exceeding 200°F. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 44
Sampled residents: 12
Temperature of pork sausage links: 200
Inspection completion date: Jul 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding oxygen tubing storage practices |
| Registered Nurse A | Registered Nurse | Interviewed regarding oxygen tubing storage practices |
| Certified Nurse's Aide A | Certified Nurse's Aide | Interviewed regarding oxygen tubing storage practices |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen tubing storage and dialysis communication |
| Registered Nurse B | Registered Nurse | Interviewed regarding dialysis resident assessments and communication |
| Licensed Practical Nurse A | Agency Licensed Practical Nurse | Interviewed regarding dialysis communication practices |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding dialysis resident assessments |
| MDS Coordinator A | MDS Coordinator | Interviewed regarding dialysis care plans and assessments |
| Social Worker B | Social Worker | Interviewed regarding care plan meetings and dialysis care plans |
| Sousse Chef | Sousse Chef | Interviewed regarding food storage and sanitation practices |
| Executive Chef | Executive Chef | Interviewed regarding food storage, sanitation, and cooking practices |
Inspection Report
Routine
Census: 46
Deficiencies: 5
Sep 19, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, medication management, dental services, infection control, and other aspects of facility operations.
Findings
The facility failed to provide baseline care plans to residents and/or their representatives within 48 hours of admission, did not ensure pharmacy gradual dose reduction recommendations were acted upon with physician rationale, failed to limit PRN psychotropic medication orders to 14 days with proper re-evaluation, did not ensure dental services were obtained for a resident with poor dental condition, and failed to ensure proper hand hygiene and oxygen tubing storage practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide baseline care plans to residents and/or their representatives within 48 hours of admission for four sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pharmacy gradual dose reduction recommendations were acted upon including physician rationale for not reducing medications for two sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure PRN psychotropic medication orders were limited to 14 days with physician re-evaluation and documentation for one sampled resident receiving hospice services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dental services were obtained for one sampled resident with teeth in poor repair. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure hand hygiene during personal care for one sampled resident and failed to ensure infection control best practices for oxygen tubing storage for two sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Facility census: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in hand hygiene deficiency for Resident #8 |
| LPN A | Licensed Practical Nurse, Unit Manager | Named in PRN psychotropic medication and oxygen tubing storage deficiencies |
| RN A | Registered Nurse | Named in pharmacy recommendation and dental services deficiencies |
| RN B | Registered Nurse, Assistant Director of Nursing | Named in pharmacy recommendation and PRN psychotropic medication deficiencies |
| Social Worker A | Social Worker | Named in dental services deficiency |
| DON | Director of Nursing | Named in multiple deficiencies including hand hygiene and oxygen storage |
| MDS Coordinator | Minimum Data Set Coordinator, previous Director of Nursing | Named in multiple deficiencies including pharmacy recommendations and oxygen storage |
| Administrator | Named in pharmacy recommendation and oxygen storage deficiencies |
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