Deficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
40% occupied
Based on a March 2024 inspection.
Occupancy rate over time
Inspection Report
Life Safety
Census: 23
Deficiencies: 6
Date: Mar 5, 2024
Visit Reason
The inspection was a fire safety inspection conducted on March 5, 2024, to assess compliance with fire hazard and safety regulations at Churchill Terrace-Assisted Living.
Findings
The facility failed to maintain fire safety standards including lack of carbon monoxide detectors, inadequate fire separation for furnace rooms, emergency lighting failures, use of non-approved wastebaskets, building maintenance issues such as holes in ceilings and open electrical wiring. These deficiencies affected all 23 residents present during the inspection.
Deficiencies (6)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements. The facility failed to keep the building free of fire hazards by not having carbon monoxide detectors in the building. This deficiency affects all 23 residents.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to provide required one-hour fire separation for the furnace room and self-closing doors on hazardous areas. This deficiency affects all 23 residents.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The facility failed to maintain emergency lighting in good repair; an emergency light failed to activate during testing. This deficiency affects all 23 residents.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility used unapproved plastic and wicker wastebaskets instead of only metal or fire-resistant rated wastebaskets. This deficiency affects all 23 residents.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to maintain the building in good repair, including a one-inch hole in the ceiling near a sprinkler head. This deficiency affects all 23 residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to properly maintain electrical wiring, including an open electrical wiring connection in a storage closet. This deficiency affects all 23 residents.
Report Facts
Facility census: 23
Inspection Report
Plan of Correction
Census: 22
Deficiencies: 3
Date: Dec 8, 2021
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening, resident condition and medication review, and food safety regulations at Churchill Terrace Assisted Living by Americare.
Findings
The facility failed to screen or administer tuberculosis tests to several residents, maintain monthly summaries of residents' conditions and medication reviews, and protect food from potential contamination. Deficiencies were documented with specific examples and interviews with staff and consultants.
Deficiencies (3)
19 CSR 30-86.047(19) TB Screen Residents & Staff: Facility staff failed to screen or administer tuberculosis tests to three of four sampled residents as required. The facility census was 22.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Facility staff failed to maintain monthly summaries of residents' general condition, medication consumption, and referrals for services for four sampled residents. The facility census was 22.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility staff failed to protect food from potential contamination, including unsealed and undated food items in the kitchen and freezer. The facility census was 22.
Report Facts
Facility census: 22
Sampled residents for TB screening: 4
Residents failed TB screening: 3
Sampled residents for medication review: 4
Unsealed food items observed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Machelle Landin | Administrator | Signed the report and mentioned in interviews regarding TB testing and monthly summaries |
| Director of Nursing (DON) | Mentioned in interviews as responsible for TB testing and monthly summaries | |
| Regional Nurse Consultant | Interviewed regarding monitoring employee files and resident charts | |
| Dietary Manager | Interviewed regarding food handling and storage deficiencies |
Inspection Report
Plan of Correction
Census: 19
Deficiencies: 1
Date: Jan 7, 2020
Visit Reason
The document is a statement of deficiencies related to a licensure inspection conducted on January 7, 2020, focusing on fire drills and emergency preparedness.
Findings
The facility failed to conduct one fire drill every three months on each shift as required. The deficiency affected 19 residents and was evidenced by missing fire drills in June 2019 and incomplete records for other months.
Deficiencies (1)
19 CSR 30-86.022(5)(E) Fire Drill Records. The facility failed to conduct one fire drill every three months on each shift, missing a fire drill in June 2019 and not meeting the required documentation standards.
Report Facts
Facility census: 19
Fire drills performed: 12
Inspection Report
Plan of Correction
Census: 21
Deficiencies: 1
Date: Oct 31, 2019
Visit Reason
The document is a plan of correction filed in response to deficiencies cited during a facility inspection completed on 10/31/2019.
Findings
The facility failed to keep food-contact surfaces of cooking equipment clean, resulting in encrusted grease and food debris on grills, griddles, microwaves, ovens, and other kitchen equipment. The dietary manager and administrator acknowledged the need for improved cleaning policies and procedures.
Deficiencies (1)
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: The facility failed to keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and food debris, risking contamination of food products.
Report Facts
Facility census: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding cleaning practices in the kitchen | |
| Administrator | Interviewed about kitchen cleaning policies |
Inspection Report
Plan of Correction
Census: 22
Deficiencies: 1
Date: Jan 30, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding insulin administration by certified medication aides at Churchill Terrace Assisted Living by Americ.
Findings
The facility failed to ensure that two staff members were properly certified to administer insulin. Documentation and personnel files showed one aide's certification was missing and another's certification was inactive.
Deficiencies (1)
19 CSR 30-86.047(45) Insulin Administration: The facility failed to ensure two staff members were certified to administer insulin as required by state regulations.
Report Facts
Resident census: 22
Units of insulin administered: 10
Units of insulin administered: 8
Completion date: Jan 31, 2019
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