Inspection Reports for
Camdenton Windsor Estates
2042 N BUSINESS ROUTE 5, CAMDENTON, MO, 65020-2611
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
107% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
56% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 46
Deficiencies: 13
Date: Apr 10, 2025
Visit Reason
Routine inspection of Camdenton Windsor Estates nursing home to assess compliance with regulatory requirements including resident privacy, bed hold policy, PASRR notifications, medication management, activities program, safety, respiratory care, nursing coverage, psychotropic medication use, medication error rates, food service, infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy, failure to notify residents of bed hold policy, failure to notify appropriate authorities of PASRR changes, medication management errors including unavailable medications and incorrect dosages, lack of certified activity director, unsafe smoking material practices, improper oxygen therapy management, inadequate RN coverage, failure to implement psychotropic medication stop dates and gradual dose reductions, medication administration errors, failure to follow food preparation and storage standards, and inadequate infection prevention and control practices including hand hygiene and use of enhanced barrier precautions.
Deficiencies (13)
Failure to protect residents' personal information and privacy during medication administration and perineal care.
Failure to provide written bed hold policy information to residents or representatives at time of hospital transfer.
Failure to notify Central Office Medical Review Unit of significant change in mental health status for PASRR evaluation.
Failure to maintain professional standards in medication management including failure to notify physician of unavailable medications, incorrect medication dosages, and failure to document weights and food intake as ordered.
Failure to have certified activity director overseeing the activities program.
Failure to ensure residents did not retain smoking materials and failure to supervise smoking materials properly.
Failure to provide safe and appropriate respiratory care including oxygen delivery at prescribed flow rate and proper cleaning and maintenance of oxygen equipment.
Failure to provide RN coverage for at least eight consecutive hours per day, seven days a week.
Failure to implement psychotropic medication stop dates and gradual dose reductions as ordered.
Medication administration errors including incorrect dosages of medications given to residents.
Failure to serve food according to nutritional recipes and menus, failure to maintain proper food storage temperatures, failure to properly reheat pureed foods, and failure to perform proper hand hygiene in food service.
Failure to maintain infection prevention and control program including failure to implement enhanced barrier precautions, improper cleaning and disinfection of glucometers, failure to perform hand hygiene during blood sugar checks, insulin administration, toileting, and wound care.
Failure to designate a qualified infection preventionist with specialized training for the facility's infection prevention and control program.
Report Facts
Census: 46
Medication error rate: 5.26
Freezer temperature: 9
Freezer temperature: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in medication administration errors and infection control deficiencies |
| LPN D | Licensed Practical Nurse | Named in respiratory care and infection control deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding deficiencies and facility policies |
| Administrator | Facility Administrator | Named in multiple interviews regarding facility oversight and deficiencies |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies and facility policies |
| LPN E | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| Dietary Manager | Dietary Manager | Named in food service deficiencies |
| DA M | Dietary Aide | Named in food service hand hygiene deficiencies |
| CNA H | Certified Nurse Aide | Named in personal care and hand hygiene deficiencies |
| NA I | Nurse Aide | Named in personal care and hand hygiene deficiencies |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 3
Date: Jan 23, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for Camdenton Windsor Estates.
Findings
The facility was found deficient in comprehensive care plan timing and revision, and in meeting professional standards for services provided, specifically neurological checks after resident falls. Deficiencies were related to failure to update care plans after falls and incomplete neurological assessments.
Deficiencies (3)
F657 Care Plan Timing and Revision: Facility staff failed to review and revise comprehensive care plans for three sampled residents who sustained falls. The care plans did not include new fall interventions after each fall.
F658 Services Provided Meet Professional Standards: Facility staff failed to ensure neurological checks were completed and documented for two residents after unwitnessed falls, as required by facility policy.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies F657 and F658.
Report Facts
Facility census: 49
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marci Richards | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for interventions after resident falls and neurological assessments |
| MDS Coordinator | Interviewed regarding care plan updates and neurological assessments | |
| Certified Nurse Aide B | Certified Nurse Aide (CNA) | Interviewed regarding purpose of care plan and staff guidance |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse (LPN) | Interviewed regarding neurological checks after falls |
Inspection Report
Routine
Census: 49
Deficiencies: 2
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care plan development and revision requirements following resident falls, and to assess whether neurological checks were completed and documented for residents who had unwitnessed falls.
Findings
The facility failed to review and revise comprehensive care plans for three residents who sustained falls, and failed to complete and document neurological checks for two residents after unwitnessed falls, as required by facility policy. The deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Facility staff failed to review and revise the comprehensive care plan for three residents who sustained falls.
Facility staff failed to complete and document neurological checks for two residents who had unwitnessed falls as directed by facility policy.
Report Facts
Residents affected: 3
Residents affected: 2
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding updating care plans and neurological assessments | |
| Administrator | Interviewed regarding expectations for care plan updates and neurological assessments | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations and responsibility for care plan updates and neurological assessments |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding neurological check procedures |
| Certified Nurse Aide B | Certified Nurse Aide (CNA) | Interviewed regarding purpose of care plans and responsibilities |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Nov 19, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse involving a resident at Camdenton Windsor Estates.
Complaint Details
The complaint investigation substantiated that the facility staff failed to report an allegation of physical abuse within the required timeframe. The alleged perpetrator was a Registered Nurse who slapped a resident and threw a sheet over the resident's head. The facility delayed reporting the incident to the Department of Health and Senior Services.
Findings
The facility failed to report an allegation of physical abuse within the required two-hour timeframe. Interviews and record reviews confirmed delayed reporting and lack of immediate notification to management and the State Survey Agency.
Deficiencies (2)
F609: The facility failed to report an allegation of physical abuse for one resident within the two-hour required timeframe. Staff delayed reporting the incident to management and the State Survey Agency.
A8025: The facility did not immediately report suspected abuse or neglect to the Department of Health and Senior Services and the Department of Mental Health as required by regulation.
Report Facts
Facility census: 50
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of physical abuse involving one resident.
Complaint Details
The complaint involved an allegation that a Registered Nurse hit a resident and threw a sheet over the resident's head. The Certified Nurse Aide who witnessed the incident did not report it immediately, resulting in delayed notification to the Department of Health and Senior Services. The complaint was substantiated with findings of delayed reporting.
Findings
The facility failed to report an allegation of physical abuse by a staff member against a resident within the required two-hour timeframe. Interviews revealed lack of staff knowledge about immediate reporting requirements, and the facility subsequently educated the involved staff.
Deficiencies (1)
Failure to timely report suspected abuse of a resident within the two-hour required timeframe.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in allegation of physical abuse against resident |
| CNA A | Certified Nurse Aide | Witnessed abuse and delayed reporting |
Inspection Report
Annual Inspection
Census: 44
Capacity: 82
Deficiencies: 10
Date: Mar 21, 2024
Visit Reason
Annual inspection survey to assess compliance with federal regulations and state requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies related to housekeeping, infection control, medication management, care planning, and resident safety. Corrective actions were required to address unsafe conditions and ensure compliance with regulatory standards.
Deficiencies (10)
F584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance issues such as dirty floors and debris in resident rooms and hallways.
F641: The facility failed to accurately assess and document residents' Minimum Data Set (MDS) and care plans, including failure to update care plans for residents using BiPAP and oxygen therapy.
F656: The facility failed to develop and implement comprehensive person-centered care plans for residents, including those with complex medical needs and hospice care.
F677: The facility failed to provide necessary care and services to maintain good nutrition, grooming, and personal hygiene for residents, including failure to document showers and shaving.
F689: The facility failed to ensure medication carts were locked and medications stored securely, and failed to maintain proper medication administration procedures.
F695: The facility failed to properly store and maintain oxygen and respiratory equipment, including failure to clean and store equipment according to policy.
F761: The facility failed to accurately count and document controlled medications and maintain proper narcotic counts.
F804: The facility failed to maintain proper food temperatures and ensure food was palatable, safe, and served at appropriate temperatures.
F880: The facility failed to establish and maintain an infection prevention and control program, including water management to prevent Legionella and proper hand hygiene.
F883: The facility failed to develop and implement policies to ensure residents received pneumococcal immunizations and document refusals or contraindications.
Report Facts
Facility census: 44
Total capacity: 82
Deficiency count: 10
Inspection Report
Life Safety
Census: 44
Capacity: 82
Deficiencies: 5
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found deficient in maintaining complete and compliant fire alarm and sprinkler system policies, fire drills, electrical system maintenance, and exhaust ventilation. Several fire safety systems were out of service and policies for fire watch and emergency preparedness were incomplete or not followed.
Deficiencies (5)
K346 Fire Alarm System - Out of Service. The facility failed to ensure a complete policy for procedures when the fire alarm system is out of service for more than four hours in a 24-hour period. The census was 44 with a capacity of 82.
K354 Sprinkler System - Out of Service. The facility failed to ensure a complete policy for procedures when the sprinkler system is out of service for more than four hours in a 24-hour period. The census was 44 with a capacity of 82.
K521 HVAC. The facility staff failed to provide functioning exhaust ventilation units to vent vapors and odors from resident toilet rooms. The census was 44 with a capacity of 82.
K712 Fire Drills. Facility staff failed to conduct fire drills quarterly on each shift for March 2023 through February 2024 and failed to consult with the local fire department for review of the emergency plan and resident evacuation.
K911 Electrical Systems - Other. Facility staff failed to maintain electrical wiring in compliance with NFPA 70 and failed to replace faulty electrical receptacles with hospital grade receptacles. The census was 44 with a capacity of 82.
Report Facts
Facility census: 44
Total capacity: 82
Inspection date: Mar 21, 2024
Inspection Report
Routine
Census: 44
Capacity: 82
Deficiencies: 10
Date: Mar 21, 2024
Visit Reason
Routine inspection of Camdenton Windsor Estates nursing home to assess compliance with regulatory requirements including resident care, environment, medication management, infection control, and other standards.
Findings
The inspection identified multiple deficiencies including failure to maintain a clean environment, incomplete and inaccurate resident assessments and care plans, improper medication and chemical storage, inadequate respiratory care equipment handling, improper food temperature management, incomplete infection prevention policies, poor hand hygiene practices, and failure to document pneumococcal vaccinations for several residents.
Deficiencies (10)
Failure to maintain a clean, homelike, and comfortable environment with debris and dirty mop water used for cleaning.
Failure to document complete and accurate Minimum Data Set (MDS) assessments for residents using BiPAP, CPAP, and anticoagulants.
Failure to develop and implement comprehensive person-centered care plans for residents including oxygen use, BiPAP, hospice care, and risk factors.
Failure to provide necessary assistance with activities of daily living including hair care, facial hair care, and nail care for residents unable to perform these tasks.
Failure to ensure medication and treatment carts were locked and medications were not left unattended or unsecured; failure to lock housekeeping carts with chemicals.
Failure to store oxygen, nebulizer, CPAP, and BiPAP equipment properly to prevent contamination and infection; tubing and masks were often undated, uncovered, or on the floor.
Failure to accurately count controlled medications and failure to remove expired medications and supplies from storage.
Failure to ensure pureed food items were reheated to proper temperatures and held at safe temperatures during meal service; failure to follow puree recipes; failure to ensure hot food on room trays was maintained at 120°F at time of delivery.
Failure to develop and implement complete water management policies and procedures to inhibit growth of Legionella and other pathogens; failure to perform proper hand hygiene by staff.
Failure to document administration of pneumococcal vaccine for six of eight sampled residents despite signed consents.
Report Facts
Facility census: 44
Facility capacity: 82
Expired medication: 3
Controlled medication count discrepancy: 2
Food temperature: 118
Food temperature: 114
Food temperature: 111
Food temperature: 113
Food temperature: 117
Pureed food temperature: 124
Pureed food temperature: 130
Pureed food temperature: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN I | Licensed Practical Nurse | Named in medication count discrepancy and hand hygiene deficiencies |
| Housekeeping Supervisor | Named in deficiencies related to cleaning practices and chemical cart locking | |
| CMT G | Certified Medication Technician | Named in medication cart security deficiency |
| NA N | Nurse Assistant | Named in hand hygiene deficiency |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies and expectations |
| Administrator | Named in multiple interviews regarding deficiencies and expectations | |
| MDS Coordinator | Named in interviews regarding MDS assessments and care plans | |
| Dietary Manager | Named in interview regarding food preparation and temperature | |
| Medical Director | Named in interview regarding respiratory care and vaccination expectations | |
| CNA A | Certified Nurse Assistant | Named in interviews and observations regarding cleaning and hand hygiene |
| CNA O | Certified Nurse Assistant | Named in hand hygiene deficiency |
| NA K | Nurse Aide | Named in respiratory equipment handling deficiency |
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 3
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to evaluate compliance with transfer and discharge requirements, specifically regarding the facility's failure to provide appropriate 30-day discharge notice and to allow a resident to return after hospital discharge.
Findings
The facility failed to provide an appropriate 30-day discharge notice for one resident and did not allow the resident to return to the facility after hospital discharge. Documentation and communication regarding the resident's transfer and discharge were incomplete and inadequate.
Deficiencies (3)
F622 Transfer and Discharge Requirements: The facility failed to provide an appropriate 30-day discharge notice for one resident and did not allow the resident to return after hospital discharge. Documentation in the resident's medical record and communication to the receiving provider were incomplete.
A8015 30 Day Notice-Transfer/Discharge: No resident was given the required 30-day advance notice of transfer or discharge except in emergency cases. The facility failed to notify the resident or legally authorized representative as required.
A8017 Discharge Appeal Rights: The facility did not provide full and adequate notice of discharge rights or hearing opportunities to residents as required by regulation.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Konwinski | RN/DON | Signed the plan of correction and is identified as Director of Nursing |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jan 18, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide an appropriate 30-day discharge notice for one resident and failure to allow the resident to return to the facility after hospital discharge.
Complaint Details
The complaint investigation found that the facility did not provide the required discharge notice and did not accept the resident back after hospital transfer. The resident had a history of drug use, wound care needs, and behaviors unknown to the facility at admission. The hospital social worker confirmed placement had not been found for the resident after emergency room stay.
Findings
The facility failed to provide a 30-day discharge notice for Resident #1 and did not allow the resident to return after hospital discharge. The resident was admitted with IV antibiotics but was transferred to the emergency room due to adverse reactions, and the facility decided not to readmit the resident due to inability to meet care needs.
Deficiencies (1)
Failure to provide an appropriate 30 day discharge notice and failure to allow resident to return after hospital discharge.
Report Facts
Residents Affected: 1
Facility Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Designee (SSD) | Interviewed regarding resident admission and discharge | |
| Administrator | Interviewed regarding resident admission and hospital information | |
| Licensed Practical Nurse (LPN) | Interviewed regarding resident admission and care needs | |
| Hospital Social Worker | Interviewed regarding resident placement after emergency room stay |
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to assess compliance with residents' rights to communication and internet access at Camdenton Windsor Estates.
Findings
The facility failed to provide internet access to residents, violating their right to reasonable communication access. Interviews with staff and residents confirmed the lack of internet availability despite requests to management.
Deficiencies (1)
F 576 Right to Forms of Communication with Privacy: The facility did not offer internet access to residents to the extent available, violating residents' rights to reasonable communication access including internet use.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN | Reported residents do not have internet access and management has been asked multiple times |
| Director of Nursing | DON | Confirmed residents do not have internet access despite requests |
| Administrator | Stated internet access was requested but denied due to expense |
Inspection Report
Census: 49
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding residents' access to communication methods, specifically the availability of internet access to residents.
Findings
The facility failed to provide internet access to residents despite the presence of younger residents who would benefit from it. Interviews with residents and staff confirmed the lack of internet availability, and management acknowledged requests for internet access were denied due to cost concerns.
Deficiencies (1)
Facility failed to offer internet access to residents, and no policy existed regarding resident internet usage.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Mentioned in interview regarding lack of internet access for residents |
| Director of Nursing | Director of Nursing | Interviewed about lack of internet access for residents |
| Administrator | Administrator | Interviewed about lack of internet access for residents and cost concerns |
Inspection Report
Routine
Census: 43
Deficiencies: 15
Date: Dec 2, 2022
Visit Reason
Routine inspection of Camdenton Windsor Estates nursing home to assess compliance with regulatory requirements including resident care, safety, infection control, staffing, and facility environment.
Findings
The facility was found deficient in multiple areas including resident dignity and care, timely provision of meals and call light accessibility, cleanliness and odor control, employee background checks, comprehensive care planning, medication administration, resident hygiene and grooming, activity provision, accident prevention, food safety and sanitation, staffing postings, and infection control practices.
Deficiencies (15)
F 0550: Facility staff failed to maintain resident dignity during feeding and failed to serve residents at the same time at the dining table. A cognitively dependent resident lacked a usable call system.
F 0577: Facility failed to post survey and complaint investigation results in a prominent and accessible area for residents and the public.
F 0584: Facility staff failed to maintain a safe, clean, comfortable, and homelike environment, with persistent foul odors, soiled privacy curtains, dirty rooms, and unclean mattresses.
F 0607: Facility failed to check Employee Disqualification List, Family Care Safety Registry, Criminal Background Check, and CNA Registry for multiple employees as required by policy.
F 0656: Facility failed to develop and implement complete, person-centered care plans for multiple residents, including missing directions for oral care, feeding assistance, fall prevention, and resident participation.
F 0658: Facility failed to meet professional standards in medication administration, including missed doses, failure to obtain orders, improper gastrostomy medication administration, and lack of neurological checks after a fall.
F 0677: Facility failed to provide adequate personal care and hygiene, including failure to maintain facial hair, timely incontinence care, repositioning, and clean clothing for dependent residents.
F 0679: Facility failed to provide activities to meet all residents' needs, including failure to engage dependent residents and lack of weekend activities.
F 0689: Facility failed to ensure safe environment and accident prevention by improperly propelling residents in wheelchairs, unsecured hazardous chemicals and razors, and unlocked medication carts.
F 0692: Facility failed to provide sufficient fluids to maintain hydration for dependent residents, with residents lacking fluids within reach and staff failing to offer fluids regularly.
F 0726: Facility failed to ensure licensed nursing staff had required competencies for tracheostomy care and suctioning, and failed to ensure nurse aides completed training within four months of hire.
F 0732: Facility failed to post required nurse staffing information daily, including total number of licensed and unlicensed staff and resident census.
F 0759: Facility medication error rate exceeded 5%, with errors including missed doses, wrong administration times, and failure to administer medications with food as ordered.
F 0812: Facility failed to properly store open food to prevent contamination, maintain kitchen equipment cleanliness, perform hand hygiene to prevent cross-contamination, ensure ice machine drained through an air gap, and maintain proper dishwasher sanitizing solution testing.
F 0880: Facility failed to maintain an infection prevention and control program, including failure to perform hand hygiene and glove changes appropriately during care, and failure to screen employees for tuberculosis upon hire.
Report Facts
Medication error rate: 20
Facility census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nurse Aide | Named in findings related to resident dignity, feeding, incontinence care, and hydration |
| LPN L | Licensed Practical Nurse | Named in findings related to feeding practices, medication administration, and infection control |
| RN O | Registered Nurse | Named in findings related to tracheostomy care and medication administration |
| CMT Q | Certified Medication Technician | Named in medication administration errors |
| DON | Director of Nursing | Named in multiple interviews regarding care practices, policies, and deficiencies |
| NA S | Nurse Aide | Named in infection control and incontinence care findings |
| CNA K | Certified Nurse Aide | Named in infection control and incontinence care findings |
| NA M | Nurse Aide | Named in infection control and incontinence care findings |
| DM | Dietary Manager | Named in food safety and kitchen sanitation findings |
| Administrator | Named in interviews regarding survey postings, food safety, and infection control |
Inspection Report
Follow-Up
Census: 44
Deficiencies: 2
Date: Feb 22, 2022
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies related to safe, clean, comfortable, and homelike environment conditions, including leaking pipes and roof leaks.
Findings
The facility was found to have ongoing issues with leaking pipes and roof leaks causing water accumulation in resident areas. The facility submitted a plan of correction and was monitoring repairs and resident safety.
Deficiencies (2)
F 584 Safe Environment. Facility staff failed to ensure the resident environment was safe by leaving residents in room #10 with a leaking pipe and using a bucket to catch leaking water in the walkway. The facility census was 44.
A3001 Substantially Constructed/Maintained. The building was not maintained in good repair as evidenced by roof leaks and water damage. This regulation was not met as evidenced by Class III deficiency.
Report Facts
Facility census: 44
Facility census: 39
Number of ceiling tiles removed: 13
Number of ceiling tiles stained: 11
Completion date for corrective action: 4/4/2022 and 5/11/2022 for various corrective actions
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deloris McQueen | Administrator | Signed plan of correction and involved in interviews |
| Director of Nursing | Interviewed regarding maintenance and resident safety | |
| Maintenance Director | Repaired leaking drain and involved in monitoring repairs |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 26, 2021
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No state licensure deficiencies were cited as a result of this complaint only investigation.
Findings
The facility was found to be in compliance with the relevant COVID-19 emergency preparedness and infection control regulations. No deficiencies were cited as a result of this complaint-only investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jan 4, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 4
Date: Apr 5, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations regarding resident rights, infection control, and overall facility operations at Camdenton Windsor Estates.
Findings
The facility was found deficient in ensuring residents' rights were respected, including dignity and privacy issues. Infection prevention and control practices were also inadequate, with failures in hand hygiene, glove use, and catheter care observed.
Deficiencies (4)
F550 Resident Rights: The facility failed to treat residents with dignity, did not provide dignity bags for catheter bags, and did not assist a resident to cover exposed body parts. Staff spoke harshly to residents and failed to knock before entering rooms.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection control program. Staff did not use appropriate hand hygiene or gloves during care, and catheter tubing was left on the floor. The facility census was 57.
A4085 Infection Control/Communicable Disease: The facility did not make timely reports to the state for communicable diseases as required by Missouri regulations.
A8030 Dignity/Privacy: Residents were not treated with full recognition of dignity and privacy in treatment and care, violating Missouri state regulations.
Report Facts
Facility census: 57
Deficiencies cited: 4
Inspection Report
Life Safety
Census: 57
Capacity: 82
Deficiencies: 4
Date: Apr 5, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code, including emergency lighting, sprinkler system installation, corridor doors, and fire-rated doors.
Findings
The facility failed to meet several Life Safety Code requirements including emergency lighting testing, sprinkler system clearance, corridor door latching, and fire-rated door inspection and maintenance. Deficiencies were identified that could affect all facility occupants.
Deficiencies (4)
K291 Emergency Lighting: Facility staff failed to conduct the required annual 1.5-hour functional test of all emergency lighting equipment. Testing documentation was incomplete and the facility lacked a policy for inspection and maintenance.
K351 Sprinkler System - Installation: Facility staff failed to maintain the sprinkler system clearance of 18 inches or greater between the deflector and storage. Multiple storage areas were found with insufficient clearance.
K363 Corridor Doors: Facility staff failed to ensure one corridor door to a room containing flammable materials had positive latching hardware and was fully closed, risking containment of fire and smoke.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to inspect, test, and maintain fire-rated doors in accordance with NFPA standards. Documentation of inspections was incomplete and staff were unaware of inspection requirements.
Report Facts
Facility census: 57
Total capacity: 82
Fire-rated doors inspected: 6
Fire drills required: 12
Fire drills unannounced: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Miller | Inspected 6 fire-rated doors on April 23, 2019 |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 6
Date: May 3, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for skilled nursing facilities, including review of employee background checks, resident care, nutrition, hydration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to conduct required background checks for employees, inadequate assistance with activities of daily living for dependent residents, failure to meet nutritional and hydration needs of residents, and deficiencies in infection prevention and control practices.
Deficiencies (6)
F606: The facility failed to employ or engage staff with proper background checks including Family Care Safety Registry, Criminal Background Check, and Nurse Aide Registry for six of eight newly hired staff. This was evidenced by missing documentation in employee files.
F677: The facility failed to provide necessary assistance with bathing or showers for four dependent residents, as documented by resident assessments and interviews.
F803: The facility failed to serve food in accordance with physician-ordered diets for residents requiring pureed and mechanical soft diets, as observed and documented in meal tray reviews.
F807: The facility failed to ensure residents received adequate fluids and hydration, with observations showing water pitchers not refilled and residents reporting insufficient access to fluids.
F812: The facility failed to maintain kitchen refrigeration units in good repair, including torn seals on the reach-in refrigerator and freezer, and failed to maintain frozen foods at required temperatures.
F880: The facility failed to establish and maintain an infection prevention and control program, including inadequate sanitization of glucometers and failure to follow hand hygiene protocols.
Report Facts
Facility census: 44
Number of newly hired staff missing background checks: 6
Number of dependent residents not assisted with bathing: 4
Number of residents affected by hydration deficiency: 7
Inspection Report
Plan of Correction
Census: 44
Capacity: 82
Deficiencies: 8
Date: May 3, 2018
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness, fire safety, and other regulatory requirements at Camdenton Windsor Estates.
Findings
The facility failed to develop and maintain adequate emergency preparedness plans, policies, and training. Deficiencies were also found in fire safety inspections, fire drills, and staff training, with multiple failures to meet regulatory standards.
Deficiencies (8)
E009 Emergency Plan: The facility failed to develop an emergency preparedness plan that includes cooperation with local, tribal, regional, State, and Federal emergency preparedness officials. Documentation of efforts to contact such officials was also lacking.
E020 Policies for Evacuation and Primary/Alternate Communication: The facility failed to develop policies and procedures for transportation to safely relocate occupants during emergencies, affecting all facility occupants.
E035 LTC and ICF/IID Sharing Plan: The facility failed to develop and implement a method for sharing emergency preparedness information with residents and their families or representatives.
E037 Emergency Preparedness Training Program: The facility failed to provide initial and annual emergency preparedness training to all staff, volunteers, and contractors consistent with their expected roles.
E039 Emergency Preparedness Testing Requirements: The facility failed to conduct required full-scale community-based emergency exercises and other emergency preparedness drills and exercises.
K324 Cooking Facilities: The facility failed to inspect and test the kitchen range hood and suppression system in accordance with NFPA 96, increasing fire risk.
K712 Fire Drills: The facility failed to conduct and document required quarterly fire drills under various conditions for all shifts, potentially delaying emergency response.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to inspect, test, and maintain rated and non-rated egress doors, including smoke barrier doors, as required by NFPA standards.
Report Facts
Facility census: 44
Total capacity: 82
Date of survey: May 3, 2018
Alleged compliance date: Jun 14, 2018
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