Inspection Reports for
Campbell Healthcare &Amp; Senior Living
17108 US HIGHWAY 62, CAMPBELL, MO, 63933-6383
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
10.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
70% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 63
Deficiencies: 7
Date: Aug 22, 2025
Visit Reason
The inspection was conducted to evaluate compliance with federal and state regulations regarding resident assessments, care planning, medication management, infection control, dietary services, and equipment safety at Campbell Healthcare & Senior Living.
Findings
The facility was found deficient in timely electronic transmission of Minimum Data Set assessments, development and implementation of individualized care plans, updating care plans after incidents, narcotic medication reconciliation, sanitary food handling and storage practices, infection prevention including enhanced barrier precautions, and regular inspection of bed frames and mobility rails. All deficiencies were associated with minimal harm or potential for harm affecting few to many residents.
Deficiencies (7)
Failed to electronically transmit Minimum Data Set (MDS) assessments timely for three residents.
Failed to develop and implement care plans with specific interventions tailored to individual needs for three residents.
Failed to update and revise care plans with specific interventions after multiple falls for two residents.
Failed to ensure staff reconciled narcotics at each shift change for medication carts and medication storage room.
Failed to store, prepare, distribute, and serve food under sanitary conditions including lack of air gap on ice machine, uncovered trash cans, and dietary staff not wearing beard covers.
Failed to implement enhanced barrier precautions (EBP) including use of gowns during incontinent and catheter care for residents on EBP.
Failed to conduct regular maintenance inspections of bed frames, mattresses, and mobility rails for safety for four residents.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 2
Medication reconciliation missed opportunities: 13
Medication reconciliation missed opportunities: 15
Medication reconciliation missed opportunities: 40
Facility census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician K | Certified Medication Technician | Described narcotic counting procedures and confirmed counting narcotics before and after each shift. |
| Licensed Practical Nurse L | Licensed Practical Nurse | Described narcotic reconciliation process during shift changes. |
| Dietary Aide F | Dietary Aide | Observed not wearing beard covering and improper food handling practices. |
| Dietary Manager | Dietary Manager | Discussed dietary PPE and ice machine air gap requirements. |
| Maintenance Supervisor | Maintenance Supervisor | Discussed ice machine air gap installation and mobility rail inspections. |
| Director of Nursing | Director of Nursing | Provided statements on care plan requirements, narcotic reconciliation, and infection control expectations. |
| Administrator | Administrator | Provided statements on care plan requirements, narcotic reconciliation, dietary practices, infection control, and equipment safety. |
| Certified Nurse Aide A | Certified Nurse Aide | Observed failing to wear gown during catheter care and acknowledged the error. |
| Certified Nurse Aide B | Certified Nurse Aide | Observed failing to wear gown during incontinent care and acknowledged the error. |
| Certified Nurse Aide C | Certified Nurse Aide | Observed failing to wear gown during incontinent care and acknowledged the error. |
| Licensed Practical Nurse D | Licensed Practical Nurse | Observed failing to wear gown during incontinent care and acknowledged the error. |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed mobility rail inspections and resident moves. |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 14
Date: Sep 12, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, environmental safety and cleanliness, timely notification of transfers, accurate resident assessments, PASARR screening, baseline care planning, adherence to physician orders, trauma-informed care, staffing adequacy, food safety, infection control practices, vaccination education, and nurse aide training.
Deficiencies (14)
Failed to ensure staff treated residents with dignity and respect by leaving residents exposed during care.
Failed to provide a safe, clean, and homelike environment with issues such as peeled paint, broken trim, and unclean shower facilities.
Failed to provide timely written notification of transfer or discharge to residents, responsible parties, and LTC Ombudsman.
Failed to complete significant change Minimum Data Set (MDS) assessment within 14 days for a resident admitted to hospice.
Failed to document accurate Minimum Data Set (MDS) assessments for residents.
Failed to provide documentation of Level I PASARR screening for residents with mental disorders or intellectual disabilities.
Failed to ensure baseline care plan included specific interventions and written summary was provided to resident or guardian within 48 hours of admission.
Failed to follow physician's order for fall mats on both sides of the bed for a resident.
Failed to identify, assess, and provide supportive interventions for a resident with PTSD, including lack of PTSD assessment and care planning.
Failed to provide sufficient nursing staff to answer call lights in a timely manner, resulting in delayed responses up to several hours.
Failed to store and distribute food under sanitary conditions, including lack of temperature monitoring, expired and undated food items, unclean kitchen equipment and floors.
Failed to maintain proper infection control practices during incontinent care and wound care, including failure to wear gowns, change gloves, perform hand hygiene, and implement enhanced barrier precautions.
Failed to provide and document education to residents or their representatives regarding influenza and pneumococcal vaccines.
Failed to provide at least twelve hours of nurse aide in-service education annually for two sampled CNAs.
Report Facts
Facility census: 72
Call light response times: 7
Call light response times: 1
Call light response times: 42
In-service training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Assistant | Named in dignity and infection control findings |
| CNA E | Certified Nurse Assistant | Named in dignity and infection control findings |
| LPN G | Licensed Practical Nurse | Named in wound care and infection control findings |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, assessments, infection control, and staffing |
| Administrator | Administrator | Interviewed regarding multiple deficiencies including transfer notifications, infection control, staffing, and vaccine education |
| Dietary Manager | Dietary Manager | Named in food safety and infection control findings |
| CNA T | Certified Nurse Assistant | Interviewed regarding call light system use |
| CNA N | Certified Nurse Assistant | Interviewed regarding call light system use |
| Dietary Staff K | Dietary Staff | Named in food safety and infection control findings |
| Dietary Staff L | Dietary Staff | Named in food safety and infection control findings |
| Dietary Staff M | Dietary Staff | Named in food safety and infection control findings |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 14
Date: Sep 12, 2024
Visit Reason
Annual survey conducted at Campbell Healthcare & Senior Living to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including resident rights, safe environment, notice requirements before transfer/discharge, comprehensive assessments, accuracy of assessments, PASARR screening, baseline care plans, infection control, and staff training. Deficiencies affected multiple residents and had potential to impact all residents.
Deficiencies (14)
F550 Resident Rights: Facility failed to ensure staff treated residents with dignity and respect, exposing residents during care and not maintaining privacy.
F584 Safe/Clean/Comfortable Environment: Facility failed to provide a safe, clean, and homelike environment with maintenance issues and unsanitary conditions observed.
F623 Notice Requirements Before Transfer/Discharge: Facility failed to provide written notice of transfer/discharge to residents and Ombudsman for three residents.
F637 Comprehensive Assessment After Significant Change: Facility failed to complete significant change MDS assessments within 14 days for one resident.
F641 Accuracy of Assessments: Facility failed to document accurate Minimum Data Set assessments for sampled residents and did not provide an MDS policy.
F645 PASARR Screening for MD & ID: Facility failed to provide PASARR screening and policy for residents with mental disorders or intellectual disabilities.
F655 Baseline Care Plan: Facility failed to develop and implement baseline care plans within 48 hours for sampled residents.
F658 Services Provided Meet Professional Standards: Facility failed to provide services according to comprehensive care plans and professional standards.
F699 Trauma Informed Care: Facility failed to identify and provide trauma-informed care for one resident with PTSD diagnosis.
F725 Sufficient Nursing Staff: Facility failed to maintain sufficient nursing staff to meet resident needs and respond timely to call lights.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to store and distribute food under sanitary conditions increasing risk of foodborne illness.
F880 Infection Prevention & Control: Facility failed to maintain an effective infection control program including hand hygiene and wound care.
F883 Influenza and Pneumococcal Immunizations: Facility failed to provide education and documentation for influenza and pneumococcal vaccines for residents.
F947 Required In-Service Training for Nurse Aides: Facility failed to provide at least 12 hours of annual in-service training for nurse aides.
Report Facts
Facility census: 72
Deficiencies cited: 13
In-service training hours: 12
Inspection Report
Life Safety
Census: 69
Deficiencies: 2
Date: Sep 12, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and sprinkler system maintenance regulations.
Findings
The facility failed to maintain the sprinkler system in accordance with NFPA 25 standards, with corrosion and paint buildup found on sprinkler heads. Additionally, the facility failed to restrict the use of portable space heaters, which are prohibited in health care occupancies except under specific conditions.
Deficiencies (2)
K353 Sprinkler System maintenance and testing was deficient due to corrosion and paint buildup on sprinkler heads, potentially affecting all building occupants.
K781 Portable space heaters were found in use in the therapy room, violating NFPA 101 requirements prohibiting such devices in health care occupancies.
Report Facts
Facility census: 69
Inspection Report
Routine
Census: 56
Deficiencies: 6
Date: Apr 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, discharge planning, infection control, and call light system functionality at Campbell Healthcare & Senior Living.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of residents' code status, failure to maintain a safe and homelike environment, inadequate discharge planning and summaries, failure to implement proper infection prevention and control measures including improper use of PPE and sanitization of glucometers, and failure to ensure a working wireless nurse call system with timely response to resident call lights.
Deficiencies (6)
Failed to ensure a code status was consistently documented throughout the medical record for two residents.
Failed to provide a safe, clean, comfortable and homelike environment with multiple maintenance issues observed.
Failed to ensure a discharge planning process was in place addressing goals and needs for one discharged resident.
Failed to complete a comprehensive discharge summary for one discharged resident.
Failed to implement infection prevention and control program including failure to wear facemasks during high community transmission, improper glove use, and inadequate sanitization of glucometers.
Failed to ensure a working wireless nurse call system with timely response to resident call lights; staff did not carry or use mobile call devices consistently.
Report Facts
Facility census: 56
Residents affected: 2
Residents affected: 56
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician F | Certified Medication Technician | Named in infection control deficiencies related to glove use, sanitization, and facemask use |
| Director of Nursing | Director of Nursing | Provided expectations on documentation, infection control, and call light system |
| Administrator | Administrator | Provided expectations on documentation, infection control, and call light system |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided expectations on discharge planning and summaries |
| Maintenance Supervisor | Maintenance Supervisor | Provided information on maintenance request process |
| Infection Preventionist | Infection Preventionist | Provided expectations on infection control practices |
| CNA D | Certified Nursing Assistant | Named in call light system deficiencies and observations |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 6
Date: Apr 21, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Campbell Healthcare & Senior Living.
Findings
The facility was found deficient in multiple areas including advance directives documentation, safe and homelike environment maintenance, discharge planning and summary, infection prevention and control, and resident call system functionality. Deficiencies had the potential to affect all residents.
Deficiencies (6)
F578 Advance Directives: The facility failed to ensure consistent documentation of residents' code status throughout medical records for sampled residents.
F584 Safe Environment: The facility failed to provide a safe, clean, and homelike environment as evidenced by damaged walls, broken furniture, peeling paint, and other maintenance issues affecting resident areas.
F660 Discharge Planning Process: The facility failed to develop and implement an effective discharge planning process for a sampled discharged resident.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for a sampled discharged resident.
F880 Infection Prevention & Control: The facility failed to implement infection prevention and control interventions, including failure to disinfect equipment and improper use of personal protective equipment, affecting multiple residents.
F919 Resident Call System: The facility failed to ensure the resident call system was fully functional and staff responded timely to call lights.
Report Facts
Facility census: 56
Deficiencies cited: 6
Inspection Report
Life Safety
Census: 56
Deficiencies: 6
Date: Apr 21, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain exit corridor doors and smoke barrier doors in proper functioning condition, and failed to restrict the use of temporary wiring such as extension cords and power strips. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K222 Egress Doors: The facility failed to maintain exit corridor doors that did not latch properly, allowing doors to remain slightly cracked or free swinging. This affected all residents and staff.
K374 Smoke Barrier Doors: The facility failed to maintain smoke barrier doors that did not completely close during fire alarm activation, potentially affecting all residents and staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict the use of temporary wiring, including extension cords and power strips, in patient care areas. This affected all residents and staff.
A2054 Smoke Section Walls/Doors: The facility did not meet the requirement for one-hour fire-rated walls and doors that close automatically upon fire alarm activation, as evidenced by K374.
A2055 Door Devices: The facility did not have required self-closing devices on doors to provide separation between floors, as evidenced by K222.
A3037 Extension Cords/Duplex Receptacles: The facility failed to comply with electrical appliance approval and use of extension cords, as evidenced by K920.
Report Facts
Facility census: 56
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
Annual inspection survey of Campbell Healthcare & Senior Living facility conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was 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
Plan of Correction
Census: 65
Deficiencies: 2
Date: Sep 29, 2022
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding care provided to dependent residents, specifically focusing on activities of daily living such as grooming, bathing, and personal hygiene.
Findings
The facility failed to ensure residents unable to carry out activities of daily living received necessary services, including adequate grooming and bathing. Multiple residents did not receive scheduled showers or baths due to staffing shortages, and the facility lacked a policy to address these issues.
Deficiencies (2)
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary grooming, bathing, and nail care services to five sampled residents. Staffing shortages resulted in residents missing scheduled showers and baths multiple times over several months.
A4077 19 CSR 30-85.042(68) Residents Groomed/Dressed Appropriately: The regulation was not met as residents were not consistently well-groomed or dressed appropriately, referencing the F677 deficiency.
Report Facts
Facility census: 65
Scheduled showers missed: 3
Scheduled showers missed: 5
Scheduled showers missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Stated expectations for shower frequency and discussed staffing shortages impacting resident care |
Inspection Report
Routine
Deficiencies: 0
Date: Jan 7, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was 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
Plan of Correction
Census: 62
Deficiencies: 3
Date: Sep 3, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding the safety, cleanliness, and accuracy of resident assessments at General Baptist Nursing Home.
Findings
The facility failed to maintain a safe, clean, and homelike environment as evidenced by mold, peeling surfaces, and damaged furniture. Additionally, the facility did not accurately code Minimum Data Set assessments for residents, leading to medication order classification errors.
Deficiencies (3)
F584 Safe Environment. The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment. Observations included mold in bathrooms, holes in walls, peeling laminate and baseboards, and damaged furniture.
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set assessments for two residents, resulting in incorrect classification of antipsychotic medication orders.
A3038 Furniture/Equip, Provide Comfort & Safety. The facility failed to maintain furniture and equipment in good condition, with broken, torn, or heavily soiled items compromising resident comfort and safety.
Report Facts
Facility census: 62
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication classification and correction plans |
| Maintenance supervisor | Interviewed about maintenance and repair efforts |
Inspection Report
Life Safety
Census: 62
Deficiencies: 2
Date: Sep 3, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related smoking regulations.
Findings
The facility failed to ensure a safe smoking environment by allowing trash to be mixed with cigarette butts in a metal bin in the central courtyard smoking area. This posed a potential risk to residents, staff, and visitors.
Deficiencies (2)
K741 Smoking Regulations: The facility failed to ensure a safe smoking environment by allowing trash to be mixed with cigarette butts in a metal bin in the central courtyard smoking area. This had the potential to affect all residents, staff, and visitors.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Designated smoking areas did not have ashtrays of noncombustible material and safe design. The contents of ashtrays were not disposed of properly in receptacles made of noncombustible material.
Report Facts
Census: 62
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Jan 14, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to pressure ulcer prevention and treatment at General Baptist Nursing Home.
Complaint Details
Complaint #MO179548 triggered the investigation regarding pressure sore prevention and treatment.
Findings
The facility failed to accurately assess, document, and treat unstageable pressure ulcers for multiple residents, resulting in inadequate wound care and a resident being hospitalized for wound-related complications.
Deficiencies (2)
F686 Skin Integrity: The facility failed to accurately assess and document rationale for continuing wound care treatments for an unstageable pressure ulcer for Resident #1 and failed to document, measure, and stage pressure ulcers for Residents #2 and #3.
A4082 Pressure Sore Prevention/Treatment: The facility did not keep residents free from avoidable pressure sores and failed to provide adequate treatment as evidenced by the findings in F686.
Report Facts
Facility census: 58
Deficiencies cited: 2
Inspection Report
Routine
Deficiencies: 0
Date: Nov 17, 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 federal 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: Nov 2, 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: Oct 6, 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: Aug 18, 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: Jun 3, 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
Annual Inspection
Census: 66
Deficiencies: 3
Date: Aug 16, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident transfer/discharge procedures and infection prevention and control at General Baptist Nursing Home.
Findings
The facility failed to document sufficient preparation and orientation for resident transfers to hospitals for multiple residents. Additionally, the facility did not maintain adequate infection control practices, including hand hygiene and cleaning protocols, leading to infection prevention deficiencies.
Deficiencies (3)
F624 Transfer/Discharge: The facility failed to document preparation and orientation for transfer or discharge for six residents out of 17 sampled. This included incomplete documentation of transfer preparation and orientation in resident records and nurse progress notes.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices to prevent transmission of infection for multiple residents. Observations included improper glove use, failure to wash hands, and inadequate cleaning of insulin vials.
A4085 Infection Control/Communicable Disease: The facility failed to report communicable diseases within seven days as required by Missouri Department of Health regulations.
Report Facts
Residents sampled: 17
Residents with transfer documentation deficiencies: 6
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for staff documentation of resident transfer orientation and infection control practices | |
| Certified Nurse Assistant (CNA) | Observed during infection control practices related to glove use and resident care | |
| Certified Medication Technician (CMT) | Observed and interviewed regarding insulin administration and infection control |
Inspection Report
Life Safety
Census: 66
Deficiencies: 5
Date: Aug 16, 2019
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain documentation of collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Additionally, hazardous areas were not maintained free of penetrations, and power strips were improperly used in resident areas, potentially affecting all residents and staff.
Deficiencies (5)
E009 Emergency Plan: The facility failed to maintain documentation of efforts to collaborate with local, tribal, regional, State, and Federal emergency preparedness officials as part of the emergency preparedness program.
K321 Hazardous Areas - Enclosure: The facility failed to maintain hazardous areas free of penetrations, including two one-foot holes in the sheetrock in the hot water heater room, potentially affecting all residents and staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict the use of power strips in resident use areas, with observation of a resident using an oxygen concentrator plugged into a power strip, potentially affecting all residents and staff.
A1125 Electrical System Complies With Code: The facility did not ensure the entire electrical system and its maintenance complied with the National Electrical Code and Life Safety Code requirements.
A2008 Hazardous Areas: Hazardous areas were not separated by construction of at least one-hour fire-resistant construction or protected by an automatic sprinkler system with self-closing or automatic closing doors.
Report Facts
Facility census: 66
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator provided emergency preparedness policies and procedures and was interviewed regarding emergency plan documentation | |
| Maintenance Supervisor | Maintenance supervisor interviewed regarding hazardous area repairs and power strip usage |
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 10
Date: Jul 27, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident transfer/discharge notices, care plan timing and revision, drug regimen review, food procurement and sanitary conditions, and communicable disease employee screening at General Baptist Nursing Home.
Findings
The facility was found deficient in providing timely and proper transfer/discharge notices to residents and their representatives, updating and revising care plans, conducting monthly drug regimen reviews, ensuring food safety and sanitary conditions, and screening employees for communicable diseases. Several deficiencies were noted related to documentation, monitoring, and policy implementation.
Deficiencies (10)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and their representatives in writing of transfers or discharges for nine sampled residents. The facility census was 76.
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with the interdisciplinary team or involve the resident or representative for two of 20 sampled residents. The facility census was 76.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to ensure proper documentation and review of antipsychotic medication use for two residents. The facility census was 76.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to properly document diagnoses and behaviors to support antipsychotic medication use for residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, increasing risk of cross-contamination and food-borne illness. The facility census was 76.
A4029 Communicable Disease-Employees: The facility failed to correctly screen employees for tuberculosis (TB) and document results for three employees. The facility census was 76.
A4054 Safe/Effective Medication System: The facility failed to ensure a safe and effective medication system as evidenced by deficiencies in drug regimen review and documentation.
A4060 Drug Regimen Review-Monthly: The facility failed to ensure monthly pharmacist or nurse review of drug regimens with proper documentation.
A7019 Food Stored in Identifying Containers: The facility failed to store bulk food in containers identifying the food by common name.
A8016 Reasons to Transfer/Discharge: The facility failed to transfer or discharge residents only for medical reasons, welfare, or nonpayment as required.
Report Facts
Facility census: 76
Number of sampled residents with transfer notice deficiencies: 9
Number of sampled residents with care plan deficiencies: 2
Number of residents with antipsychotic medication review deficiencies: 2
Number of employees with TB screening deficiencies: 3
Inspection Report
Life Safety
Census: 76
Deficiencies: 5
Date: Jul 27, 2018
Visit Reason
The inspection was a life safety code survey conducted to evaluate compliance with fire safety and emergency preparedness regulations at General Baptist Nursing Home.
Findings
The facility failed to provide clear exit discharge paths, adequate illumination of means of egress, smoke barrier integrity, proper smoking regulation compliance, and correct storage of gas equipment cylinders. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
K271 NFPA 101 Discharge from Exits: The facility failed to provide a clear path of egress out of the facility in case of emergency, with a gate dragging on concrete preventing full opening.
K281 NFPA 101 Illumination of Means of Egress: The facility failed to provide exit illumination all the way to the public way, with no emergency lighting observed at the west courtyard exit door.
K372 NFPA 101 Subdivision of Building Spaces - Smoke Barrier: The facility failed to provide smoke barrier walls free of penetrations, including a two-inch hole in the smoke barrier wall and an unsealed roof deck.
K741 NFPA 101 Smoking Regulations: The facility failed to provide adequate cigarette butt containers in the designated smoking area, with burnt cigarette butts found in the trash container.
K923 NFPA 101 Gas Equipment - Cylinder and Container Storage: The facility did not store oxygen tanks in accordance with NFPA 99, mixing full and empty tanks in the same room without proper labeling and separation.
Report Facts
Facility census: 76
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