Inspection Reports for
Claru Deville Nursing Center

Complaint MO249053 was substantiated. The violation was determined to be at the immediate and serious jeopardy level "J" based on observation, interview, and record review. Corrective actions were implemented and a final revisit will be conducted.

The facility failed to provide adequate protective oversight and supervision to prevent accidents, including ingestion of batteries by residents, and failed to secure hazardous areas. The facility also lacked a policy regarding accidents and incidents. Corrective actions were implemented to address these issues.

Complaint MO249053 triggered the investigation. The complaint involved failure to protect residents from self-harm and unsafe environment. Immediate Jeopardy was identified beginning 02/25/25 and removed on 02/27/25 after corrective actions.

The facility failed to prevent two residents from swallowing AA batteries resulting in emergency room transfers, did not document required 15-minute checks for one resident, and failed to secure hazardous items such as safety razors and hot coffee in unlocked rooms on the secured behavioral unit. Immediate Jeopardy was identified but later removed after corrective actions.

The facility failed to maintain portable fire extinguishers, allowed use of prohibited portable space heaters, and stored flammable decorations improperly, creating potential fire hazards. Multiple deficiencies related to fire safety equipment and hazardous conditions were identified.

The complaint investigation revealed multiple deficiencies related to resident rights violations, abuse, behavioral health care, infection control, medication administration, and quality assurance.

The facility failed to protect residents' rights on the secured behavioral unit, including inappropriate use of restrictive actions and consequences without proper evaluation or consent. There was physical abuse by staff, inadequate behavioral health care planning, failure to clean respiratory equipment per manufacturer guidelines, medication administration errors, infection control lapses, and lack of an effective QAPI program.

The complaint investigation was triggered by allegations of abuse and neglect on the secured behavioral unit, including physical abuse by a CNA and deprivation of residents' rights and necessary items as punishment. Immediate Jeopardy was identified on 01/14/25 and removed on 01/17/25.

The facility failed to protect residents from abuse and neglect, including physical abuse by a staff member and deprivation of necessary items as a form of punishment. The facility lacked appropriate behavioral health care plans, staff training, and policies for the secured behavioral unit. Residents experienced humiliation, physical harm, and inadequate care interventions.

Complaint # MO00243414 regarding abuse and neglect involving two residents who engaged in a physical altercation causing injuries. The complaint was investigated and substantiated as the facility failed to prevent the incident.

The facility failed to ensure residents were free from abuse as evidenced by a physical altercation between two residents resulting in injuries. Staff intervened and provided services, and the deficiency was corrected prior to the survey date.

Complaint # MO00243414 involved a physical altercation between Resident #1 and Resident #2 on 10/10/24, resulting in injuries including redness and cuts to Resident #1's eyes and a bald spot, bruising, and abrasions on Resident #2. Both residents were assessed and treated, with Resident #1 sent to the emergency room and placed on 1:1 supervision after return. The complaint was substantiated by the investigation.

The facility failed to ensure residents' rights to be free from abuse were protected when two residents engaged in a physical fight resulting in injuries. Staff intervened promptly, separated the residents, notified administration, and provided assessments and services. The facility provided staff in-service on abuse and neglect prevention and corrected the deficiency.

The facility failed to properly notify residents and their representatives in writing about transfers or discharges for three sampled residents. The facility also failed to inform residents or their representatives about the bed hold policy at the time of transfer for three residents. Additionally, the facility did not ensure a registered nurse was scheduled for at least eight consecutive hours per day, seven days a week.

Complaint MO00235060 was referenced related to failure to properly notify residents and/or representatives of transfers and bed hold policy.

The facility failed to provide timely and proper written notification to residents and/or their representatives about transfers to hospitals and the bed hold policy for three sampled residents. Additionally, the facility failed to ensure a Registered Nurse was scheduled for at least eight consecutive hours per day, seven days a week, with no RN coverage on six days within the review period.

The facility failed to notify residents and their representatives in writing of transfers or discharges, failed to inform residents and families of bed hold policies at transfer, did not implement comprehensive care plans with specific interventions, and did not maintain a safe environment by allowing miscellaneous items on overbed light fixtures.

The facility failed to meet the applicable provisions of the 2012 Existing Edition of the Life Safety Code related to the use of temporary wiring and power strips in patient care areas. Observations showed power strips in use in the activity room and a resident room, which is not permitted under NFPA 70 standards.

The facility failed to provide timely written notification to residents and their representatives regarding hospital transfers and bed hold policies for two residents. Additionally, care plans did not address smoking for residents who smoked, and the facility allowed residents to place items on overbed light fixtures, creating an unsafe environment. All deficiencies were assessed as minimal harm affecting few residents.

The complaint investigation substantiated neglect when Licensed Practical Nurse (LPN) A failed to assess or report a resident's fall and injury. The resident sustained fractures and pain, but staff delayed assessment and reporting. The facility census was 68.

The facility failed to ensure a resident was free from neglect when staff did not promptly assess or provide medical treatment after a fall resulting in fractures. The facility also failed to report the injury and fall to the state survey agency within required timeframes.

The complaint investigation found that Licensed Practical Nurse (LPN) A did not assess or report a fall and injury during a behavioral crisis physical intervention on 04/28/2023. The resident complained of pain and inability to bear weight, but LPN A ignored the complaints and did not perform an assessment or notify the Director of Nursing or administration until after the injury was discovered on 04/30/2023. The facility did not report the incident to the state survey agency as required.

The facility failed to ensure Resident #1 was free from neglect when staff did not promptly assess or treat injuries after a fall on 04/28/2023, resulting in fractures to the resident's left tibia, fibula, and humerus. Licensed Practical Nurse (LPN) A failed to assess or report the injury timely, and the facility failed to report the incident to the state survey agency. The investigation led to termination of LPN A and inservicing on abuse and neglect policies.

The facility was found deficient in multiple areas including failure to perform periodic checks of the Employee Disqualification List, inadequate documentation of transfer/discharge notices, lack of preparation and orientation for transfers, failure to notify residents of bed hold policies, unsafe transfer techniques, and failure to ensure proper monthly drug regimen reviews.

The facility failed to meet several fire safety requirements including ensuring designated exit doors function properly, maintaining adequate exit signage, sprinkler system coverage, smoke barrier doors, and electrical system clearance. These deficiencies potentially affected all residents and staff.

The visit was complaint-related, triggered by allegations of failure to perform required employee background checks, failure to notify residents or representatives of hospital transfers, failure to prepare residents for transfers, unsafe transfer techniques, and failure to review and act on pharmacy drug regimen recommendations. The complaint was substantiated with findings of minimal harm or potential for harm affecting a few residents.

The facility failed to perform quarterly EDL checks for employees, did not document notification or preparation for hospital transfers for several residents, improperly applied gait belts during resident transfers, and failed to ensure pharmacist recommendations were reviewed and addressed by physicians for multiple residents. The facility census was 63 residents.

The facility failed to accurately code the Minimum Data Set (MDS) assessments and did not update care plans timely for a resident who experienced falls related to mechanical lift transfers. The facility also failed to ensure safe transfers using a mechanical lift and did not maintain adequate policies or inspection procedures for equipment safety.

The facility failed to maintain high-hazard areas free of penetrations and failed to restrict the use of power strips, potentially affecting all residents and staff. Specific deficiencies included holes in mechanical room ceilings and improper use of power strips in patient care areas.

Complaint #MO157716 was investigated and substantiated based on observations, interviews, and record reviews showing insufficient staffing and lack of protective oversight for residents on voluntary leave.

The facility failed to provide sufficient direct care staff to meet the behavioral health needs of one resident on the secured behavioral unit. Additionally, the facility did not meet the requirement for 24-hour protective oversight and supervision for residents on voluntary leave.

The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) and obtain signatures prior to discharging residents from Medicare services. The facility also failed to provide required annual in-service education for nurse aides, ensure proper drug regimen review by a pharmacist, maintain infection control practices, and ensure proper use of anti-psychotic medications.

The facility failed to maintain exit illumination to the public way, maintain sprinkler heads free of dust and debris, and perform monthly checks on the kitchen fire suppression system. Portable fire extinguishers were also not properly inspected and maintained.