Deficiencies (last 8 years)
Deficiencies (over 8 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
89% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 4
Date: Jul 14, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding residents' inability to make confidential phone calls to the state abuse and neglect hotline and incidents of physical abuse involving residents.
Complaint Details
The complaint investigation was substantiated. The facility failed to allow residents to make confidential calls to the state abuse and neglect hotline and failed to protect residents from physical abuse. Immediate Jeopardy was identified related to abuse incidents involving Resident #18 and Resident #7. The Immediate Jeopardy was removed on 07/14/2025 after corrective actions were verified onsite.
Findings
The facility failed to allow residents to make confidential calls to the state abuse and neglect hotline from facility phones, impacting all residents. Additionally, the facility failed to protect residents from physical abuse, including an incident where a resident was rolled out of bed multiple times by a staff member resulting in a fracture, and another incident of resident-to-resident physical abuse. The facility also failed to conduct a thorough investigation of the abuse allegations.
Deficiencies (4)
Facility phones would not allow outgoing calls to the Missouri abuse and neglect hotline, impacting residents' rights to confidential communication.
Failure to protect residents from physical abuse, including an incident where LPN A rolled Resident #18 out of bed multiple times causing a fractured tibial plateau.
Failure to protect Resident #7 from physical abuse when Resident #27 hit him/her on the back of the head.
Failure to thoroughly investigate an allegation of abuse when Resident #18 reported being abused by LPN A resulting in injury.
Report Facts
Facility census: 56
Date of incident: 2025
Immediate Jeopardy removal date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in physical abuse incident involving Resident #18 and failure to properly investigate the incident |
| Certified Medication Technician A | CMT | Reported abuse hotline phone not working and resident abuse allegation |
| Administrator | Attempted to call abuse hotline unsuccessfully and acknowledged failure to investigate abuse allegations thoroughly | |
| Assistant Director of Nursing | ADON | Attempted to call abuse hotline unsuccessfully and involved in abuse incident response |
| Director of Nursing | DON | Attempted to call abuse hotline unsuccessfully and acknowledged residents' rights to private calls |
| LPN B | Licensed Practical Nurse | Witnessed resident-to-resident abuse incident |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 2
Date: Jul 14, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to residents' rights to make confidential phone calls to the state abuse and neglect hotline and to assess allegations of physical abuse involving residents.
Findings
The facility failed to allow residents to make confidential calls to the state abuse and neglect hotline from facility phones, impacting multiple residents. Additionally, the facility failed to protect residents from physical abuse, including an incident where a resident was rolled out of bed multiple times by staff resulting in a fracture, and another incident involving resident-to-resident physical abuse.
Deficiencies (2)
Facility phones would not allow outgoing calls to the Missouri abuse and neglect hotline, impacting residents' rights to confidential communication.
Failure to protect two residents from physical abuse, including a resident being rolled out of bed multiple times by staff resulting in a fracture and another resident being hit on the back of the head by another resident.
Report Facts
Facility census: 56
Residents affected: 3
Residents affected: 2
Immediate Jeopardy duration: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in physical abuse incident with Resident #18 resulting in fracture |
| Certified Medication Technician A | Certified Medication Technician | Reported knowledge of phone issue from Resident #109 and did not immediately report |
| Administrator | Attempted to call hotline unsuccessfully from facility phones; acknowledged phone issue and abuse hotline access rights | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Attempted to call hotline unsuccessfully and commented on phone system issues |
| Director of Nursing | Director of Nursing (DON) | Attempted to call hotline unsuccessfully and commented on residents' rights |
| LPN B | Licensed Practical Nurse | Witnessed resident-to-resident abuse incident involving Resident #7 and Resident #27 |
| Certified Nurses Aide A | Certified Nurses Aide | Assisted resident after fall and provided observations related to abuse incident |
| Certified Medication Technician C | Certified Medication Technician | Assisted resident after fall and provided observations related to abuse incident |
Inspection Report
Life Safety
Census: 53
Capacity: 63
Deficiencies: 5
Date: May 30, 2024
Visit Reason
An emergency preparedness survey was conducted on May 30, 2024, focusing on compliance with the Life Safety Code of the National Fire Protection Association.
Findings
The facility was found to be in substantial compliance with emergency preparedness regulations but did not meet several provisions of the 2012 Life Safety Code. Deficiencies were noted in hazardous areas, sprinkler system maintenance, electrical equipment clearance, smoking regulations, and extension cord usage.
Deficiencies (5)
K321 Hazardous Areas - The facility stored combustible materials under the stairwell, including propane and lighter fluid, creating unnecessary hazards near resident and staff areas.
K353 Sprinkler System - The facility failed to ensure all sprinkler heads were properly sealed with escutcheon plates, leaving penetrations that could affect fire protection.
K511 Utilities - The facility did not maintain at least 36 inches of clearance in front of breaker boxes, with boxes and items blocking access, posing a hazard to life safety.
K741 Smoking Regulations - The facility combined trash and cigarette butts in self-closing containers, risking fire hazards for residents who smoke.
K920 Electrical Equipment - The facility allowed unsafe use of extension cords and USB hubs as permanent wiring, risking electrical hazards.
Report Facts
Facility capacity: 63
Resident census: 53
Deficiencies cited: 5
Inspection Report
Routine
Census: 53
Deficiencies: 4
Date: May 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights to a safe, clean, comfortable, and homelike environment, focusing on noise levels, staff intervention, and environmental safety concerns.
Findings
The facility failed to provide a comfortable and homelike environment for four sampled residents due to loud and disruptive noise levels in the dining room, lack of staff intervention during resident yelling, and a door to the smoking area that slammed shut causing distress. Several residents and staff reported concerns about noise, overstimulation, and inadequate staff training to manage mental health residents.
Deficiencies (4)
Failed to ensure sound levels were not loud and uncomfortable in the dining room.
Staff failed to intervene when a resident was yelling.
Facility failed to ensure the door to the smoking area did not slam shut causing distress to a resident.
Facility did not provide the requested policy regarding a comfortable and homelike environment.
Report Facts
Residents sampled: 20
Facility census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide (CNA) A | Reported no education about dealing with mental health residents and fear of intervening with a yelling resident | |
| Certified Nurses Aide (CNA) B | Reported no training and inability to manage noise and resident distress | |
| Administrator | Stated expectations for peaceful quiet areas and staff efforts to manage noise |
Inspection Report
Routine
Census: 53
Deficiencies: 10
Date: May 30, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, care planning, infection control, staff training, food safety, and facility environment standards.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and appropriate room change notices, incomplete and untimely Minimum Data Set (MDS) assessments and care plans, inadequate staff training especially for psychiatric care, unsanitary kitchen conditions, failure to maintain infection control with nebulizer and CPAP equipment, and an outdated facility-wide assessment. Several residents expressed distress due to noise, inappropriate behavior of other residents, and environmental issues.
Deficiencies (10)
Failed to provide a dignified existence for residents by allowing inappropriate exposure and disruptive behavior in common areas without staff intervention.
Failed to provide written notice to residents regarding room changes, causing emotional distress.
Failed to clarify and update Resident #11's Do Not Resuscitate (DNR) status accurately in medical orders.
Failed to provide a safe, clean, comfortable, and homelike environment including managing noise levels and preventing door slamming.
Failed to complete timely and accurate Minimum Data Set (MDS) assessments and care plans for several residents.
Failed to train staff adequately to care for residents with behavioral health needs, resulting in unsafe conditions for some residents.
Failed to maintain kitchen sanitation including dirty floors, vents, dust-covered equipment, outdated food, improper chemical storage, and incomplete dishwasher sanitizer logs.
Failed to update and maintain an accurate facility-wide assessment reflecting current resident needs and staffing.
Failed to maintain infection control by allowing nebulizer machines, tubing, and CPAP masks to rest on the floor without barriers.
Failed to provide required nurse aide education and competency evaluations annually, and lacked a tracking system for training hours.
Report Facts
Residents affected: 3
Facility census: 53
Residents with behavior health needs: 32
Residents sampled: 14
Nurse aide education hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Responsible for staff education and training |
| Administrator | Facility Administrator | Provided statements on facility expectations and deficiencies |
| Director of Nursing | Director of Nursing (DON) | Provided statements on MDS, care plans, and staff training |
| Certified Nurse Aide A | Certified Nurse Aide | Mentioned in relation to lack of training and response to behavioral incidents |
| Certified Nurse Aide B | Certified Nurse Aide | Mentioned in relation to lack of training and response to behavioral incidents |
| Dietary Manager | Dietary Manager | Provided statements on kitchen sanitation and maintenance |
| Registered Dietitian | Registered Dietitian | Provided statements on kitchen sanitation expectations |
| Maintenance Department Staff | Maintenance Staff | Provided statements on cleaning vents and maintenance requests |
| Infection Preventionist | Infection Preventionist | Provided statements on infection control for nebulizer and CPAP equipment |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 15
Date: May 30, 2024
Visit Reason
The inspection was the annual survey of Carroll House nursing facility to assess compliance with federal regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident rights, room change notifications, infection control, nursing services, and food safety. Several residents were affected by these deficiencies, and the facility submitted a plan of correction to address the issues.
Deficiencies (15)
F550 Resident Rights: The facility failed to provide a dignified existence for three residents, allowing multiple residents to remain in common areas with bare skin exposed and no staff intervention. The facility census was 53.
F559 Room/Roommate Change: The facility failed to provide four residents with written notice regarding room changes before moving them, causing emotional distress. The facility census was 53.
F578 Right to Refuse Treatment: The facility failed to comply with advance directive requirements, including failure to clarify Do Not Resuscitate (DNR) status for a resident. The facility census was 53.
F584 Safe/Clean/Homelike Environment: The facility failed to provide a comfortable and home-like environment for four residents by not ensuring sound levels were appropriate and allowing distressing behaviors. The facility census was 53.
F636 Resident Assessment: The facility failed to complete accurate and timely Minimum Data Set (MDS) assessments for three of 14 sampled residents. The facility census was 53.
F656 Comprehensive Care Plans: The facility failed to develop and maintain comprehensive care plans for three of 14 sampled residents. The facility census was 53.
F726 Nursing Services: The facility failed to provide sufficient nursing staff with appropriate competencies and skills to assure resident safety and well-being. The facility census was 53.
F812 Food Procurement, Storage, and Safety: The facility failed to ensure staff stored food in a sanitary manner and maintain kitchen cleanliness, including outdated food items and unsanitary conditions. The facility census was 53.
F838 Facility Assessment: The facility failed to conduct and document a facility-wide assessment to determine necessary resources for resident care, including inaccurate administrator information and incomplete assessments. The facility census was 53.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices, including improper storage of nebulizer machines and CPAP masks, and inadequate staff education. The facility census was 53.
F947 Required In-Service Training for Nurse Aides: The facility failed to provide required annual in-service training for nurse aides, affecting two of two sampled aides. The facility census was 53.
K321 Maintenance: The facility failed to ensure the area under the stairwell remained free of hazards and properly stored propane tanks and lighter fluid. The facility census was 53.
K353 Maintenance: The facility failed to maintain missing escutcheon plates in mechanical rooms to prevent attic penetrations. The facility census was 53.
K511 Maintenance: The facility failed to maintain at least 36 inches of clearance in front of breaker boxes and ensure items were removed and maintained. The facility census was 53.
K741 Maintenance: The facility failed to ensure cigarette butts were not combined with trash in self-closing containers and monitor cigarette containers regularly. The facility census was 53.
Report Facts
Facility census: 53
Sampled residents: 20
Residents affected: 3
Residents affected: 4
Nurse aides affected: 2
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident-to-resident altercation where Resident 1 slapped Resident 2 on 12/18/2023, and the facility failed to report the incident to the Department of Health and Senior Services within the required two-hour timeframe.
Complaint Details
The complaint investigation found that the facility did not report a resident-to-resident abuse incident within two hours as required. The allegation was substantiated by interviews with staff, residents, and review of medical records. The Assistant Director of Nursing, Administrator, and Director of Nursing acknowledged the failure to report timely.
Findings
The facility failed to timely report a suspected abuse incident involving Resident 1 slapping Resident 2. Interviews and record reviews confirmed the incident and that staff did not report it within the mandated two-hour period as required by facility policy and state regulations.
Deficiencies (1)
Failure to timely report suspected abuse of a resident to the Department of Health and Senior Services within the required two-hour timeframe.
Report Facts
Census: 21
Date of incident: Dec 18, 2023
Date of interviews: Dec 25, 2023
Date of survey completion: Dec 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Documented the incident of Resident 1 slapping Resident 2 | |
| Certified Nurse Aid (CNA) A | Witnessed and reported the incident to LPN A | |
| Assistant Director of Nursing (ADON) | Interviewed and acknowledged failure to report incident timely | |
| Administrator | Interviewed and acknowledged failure to report incident timely | |
| Director of Nursing (DON) | Interviewed and acknowledged failure to report incident timely |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 26, 2023
Visit Reason
The inspection was conducted due to allegations of abuse involving resident altercations at Carroll House.
Findings
The facility failed to report a resident-to-resident altercation involving abuse within the required two-hour timeframe. The investigation revealed that staff did not report the incident to the Department of Health and Senior Services (DHSS) as mandated.
Deficiencies (2)
F609: The facility failed to report a resident-to-resident altercation involving abuse to the Department of Health and Senior Services within two hours as required by regulation.
A8025: The facility did not immediately report suspected abuse or neglect to the Department of Health and Senior Services or Department of Mental Health as required by regulation.
Report Facts
Date of incident: Dec 18, 2023
Date of survey: Dec 26, 2023
Plan of Correction completion date: Feb 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karla Lock | Administrator | Signed the plan of correction and statement of deficiencies |
Inspection Report
Routine
Census: 16
Deficiencies: 11
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, notification procedures, care planning, fall prevention, staffing, nutrition, and safety.
Findings
The facility was found deficient in multiple areas including failure to ensure physician signatures on advance directives, failure to provide required Medicare beneficiary notices, inadequate grievance procedures, failure to provide timely transfer/discharge notices and bed hold policies, incomplete and untimely care plan updates, inadequate fall prevention interventions, insufficient RN coverage, failure to follow menu recipes, and unsafe parking lot conditions.
Deficiencies (11)
Failure to ensure physician signatures on Outside of Hospital Do Not Resuscitate (OHDNR) forms and incapacity forms for sampled residents.
Failure to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 form to residents.
Failure to assure residents have the right to file grievances in writing, anonymously, and to have grievance contact information and timelines posted and accessible.
Failure to provide written notice of transfer or discharge and reasons for transfer in a language residents or responsible parties understand.
Failure to provide bed hold policy notification to residents or responsible parties when residents transferred to hospital.
Failure to develop and implement complete, individualized care plans addressing resident needs including vision changes and use of Warfarin.
Failure to update care plans with new interventions after resident falls and fluid restrictions.
Failure to provide an environment free from accident hazards and provide adequate supervision to prevent falls for residents at risk.
Failure to provide RN coverage for eight consecutive hours per day, seven days a week.
Failure to follow pre-prepared menus and recipes to meet nutritional needs of residents.
Failure to maintain walking surfaces free from obstructions and hazards, specifically holes and uneven asphalt in handicapped parking spot.
Report Facts
Facility census: 16
Fall risk score: 17
Fall risk score: 18
Fluid restriction: 1000
Biscuits: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Interviewed regarding advance directive and care plan deficiencies |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including grievance process, care plans, RN coverage |
| Social Services Designee | Social Services Designee | Interviewed regarding advance directive and grievance process |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding beneficiary notices, care plans, and grievance process |
| Administrator | Administrator | Interviewed regarding beneficiary notices and RN coverage |
| CNA A | Certified Nurse Aide | Interviewed regarding grievance process and resident care |
| CNA B | Certified Nurse Aide | Interviewed regarding grievance process and resident care |
| CNA C | Certified Nurse Aide | Interviewed regarding grievance process and resident care |
| Kitchen Manager | Kitchen Manager | Interviewed regarding menu substitution and recipe adherence |
| Registered Dietician | Registered Dietician | Interviewed regarding menu planning and recipe adherence |
| Maintenance Director | Maintenance Director | Interviewed regarding parking lot repairs |
Inspection Report
Life Safety
Census: 27
Capacity: 54
Deficiencies: 4
Date: Nov 4, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with fire safety and emergency preparedness regulations, including staff training and fire drill procedures.
Findings
The facility failed to properly train staff on responding to a kitchen grease fire, as evidenced by interviews, record reviews, and observations. The facility also lacked adequate documentation and training materials related to fire safety and emergency preparedness.
Deficiencies (4)
E037 Emergency Preparedness Training Program. The facility failed to properly train staff on responding to a kitchen grease fire, including use of fire extinguishers and suppression systems. The facility had a capacity of 54 with a census of 27 at the time of investigation.
A2058 Fire Drill/Emergency Preparedness Plans. The facility did not have an up-to-date written plan for fire drills and emergency preparedness as required by regulation.
A2064 Fire Safety Training Requirements-employee. The facility failed to ensure fire safety training was provided to all employees during orientation and at least every six months.
A2065 Fire Safety Training Requirements-elements. The facility did not provide training on fire prevention, alarm response, evacuation, and other fire safety elements as required.
Report Facts
Facility capacity: 54
Census: 27
Inspection Report
Plan of Correction
Census: 25
Deficiencies: 2
Date: Dec 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from December 15 to December 18, 2020, to assess infection prevention and control practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness but failed to maintain proper infection control practices related to COVID-19, including improper use of PPE and allowing a symptomatic staff member to work. The facility census was 25 at the time of the survey.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain proper infection control practices based on facility policy and acceptable standards related to COVID-19, including improper PPE use and allowing a symptomatic staff member to work.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection and did not report communicable diseases within seven days as required by Missouri regulations.
Report Facts
Facility census: 25
COVID positive residents: 23
COVID positive residents: 20
COVID positive staff: 14
Resident deaths: 10
Residents remaining COVID negative: 2
Inspection Report
Routine
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from December 1 to December 3, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on July 6 and July 7, 2020, to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices to prepare for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC guidelines and 42 CFR 483.73 regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness requirements.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 2
Date: Sep 19, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident safety and nursing care.
Findings
The facility failed to ensure residents received adequate supervision and assistance to prevent accidents, specifically with mechanical lift use and smoking safety. Deficiencies were found related to improper use of mechanical lifts and incomplete smoking assessments for residents.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff transferred one resident safely using a mechanical lift and did not periodically assess residents for smoking safety. The facility census was 37.
A4074 Nursing Care per Resident Condition: The facility did not provide personal nursing care consistent with acceptable nursing practice, as evidenced by the issues noted in F689.
Report Facts
Facility census: 37
Number of sampled residents: 12
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 19, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and Emergency Preparedness regulations.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code with no deficiencies cited. The Emergency Preparedness portion of the survey also did not result in any deficiencies. No state licensure deficiencies were cited during this inspection.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 3
Date: Jul 20, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for Carroll House, a healthcare facility.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment, specifically regarding the cleaning of oxygen concentrator filters. Additionally, the facility did not ensure timely completion of quarterly assessments for residents as required.
Deficiencies (3)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to ensure oxygen concentrator filters were cleaned weekly as per manufacturer's guidelines, affecting three residents using oxygen. The facility census was 39 at the time.
F638 Quarterly Assessment at Least Every 3 Months: The facility failed to complete quarterly assessments for two sampled residents as required, with missed assessments documented and the facility census at 39.
A3038 Furniture/Equip, Provide Comfort & Safety: The facility failed to maintain furniture and equipment in good condition, referencing deficiency F584.
Report Facts
Facility census: 39
Sampled residents using oxygen: 3
Sampled residents for quarterly assessment: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clara Merrill | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Life Safety
Census: 48
Capacity: 63
Deficiencies: 7
Date: Jul 20, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) and related fire safety regulations for Carroll House nursing facility.
Findings
The facility failed to meet several Life Safety Code requirements including maintenance of smoke barriers, fire resistance ratings, emergency exit signage, emergency lighting, and sprinkler system coverage. Multiple deficiencies were cited that could potentially affect all residents in the event of a fire emergency.
Deficiencies (7)
K100: The facility failed to maintain one wall in Room #407 to prevent smoke or fire from entering the room, affecting seven residents. The sheetwork in the utility closet was removed and not repaired at the time of survey.
K161: The facility failed to maintain the required one-hour fire resistance rating of ceiling access panels in the protected wood-frame building. Panels were constructed of a single layer of plywood without the required fire rating.
K222: The facility failed to post required signage on emergency exit doors equipped with delayed-egress locks, restricting residents' ability to unlock doors in emergencies. Mesh screens blocked visibility of exit signage on some doors.
K281: The facility failed to provide emergency discharge lighting for all building portions, including main entrance and basement stairwell. Some emergency lighting units were missing or not connected to the emergency generator.
K351: The facility failed to extend automatic fire sprinkler protection to all spaces, including electrical closets and emergency generator transfer room. Some sprinkler heads were missing in critical areas.
K353: The facility failed to maintain automatic sprinkler heads in the walk-in refrigerator and freezer due to obstruction by frozen food boxes. Maintenance and testing records were incomplete.
K363: The facility failed to provide a substantial door capable of resisting fire for at least 20 minutes in one of five smoke compartments. A wooden hollow-core door was installed in the food-service window corridor.
Report Facts
Facility capacity: 63
Resident census: 48
Deficiency count: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clara Merrill | Administrator | Signed the plan of correction and administrative documents |
| Maintenance Supervisor | Interviewed and observed during inspection; provided information on fire safety issues | |
| Dietary Manager | Interviewed regarding sprinkler head obstructions in refrigerator and freezer |
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