Inspection Reports for
Clearview Nursing Center
430 SALCEDO ROAD, SIKESTON, MO, 63801-4802
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
19.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
260% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
60% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 9
Date: Dec 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations related to resident grievances, infection control, medication errors, and other care concerns at Clearview Nursing Center.
Complaint Details
This was a complaint investigation triggered by allegations of missing resident belongings, failure to respond to grievances, inaccurate documentation of code status, unsafe environment, inaccurate assessments, medication errors, and infection control issues. The complaint was substantiated as evidenced by multiple deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to respond to resident grievances, lack of inventory documentation for resident belongings, inaccurate documentation of residents' code status, unsafe and unclean environment, inaccurate assessments, medication errors, inadequate infection control, and failure to provide required in-service training for nurse aides.
Deficiencies (9)
F565 Resident/Family Group and Response: The facility failed to respond to grievances and maintain documentation of inventory for residents' belongings for sampled residents.
F578 Request/Refuse/Discontinue Treatment/Formulate Advance Directive: The facility failed to obtain physician orders for residents' code status and did not maintain accurate documentation of advance directives.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a safe, clean, and comfortable environment, including worn furniture, exposed sheetrock, and peeling paint in multiple resident rooms.
F641 Accuracy of Assessments: The facility failed to accurately code the Minimum Data Set (MDS) assessments for sampled residents.
F645 PASARR Screening for Mental Disorder and Intellectual Disability: The facility failed to provide required PASARR screening and documentation for sampled residents.
F692 Nutrition/Hydration Status Maintenance: The facility failed to implement and monitor acceptable nutritional parameters and weight management interventions for residents.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to maintain a medication error rate below 5 percent, with errors observed in medication administration for sampled residents.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including proper hand hygiene and use of personal protective equipment.
F947 Required In-Service Training for Nurse Aides: The facility failed to provide required annual in-service training for nurse aides, including dementia care and abuse prevention training.
Report Facts
Facility census: 59
Sampled residents: 15
Medication error opportunities: 37
Medication error rate: 8.11
Weight loss percentage: 7.5
In-service training hours: 12
Inspection Report
Life Safety
Census: 59
Deficiencies: 4
Date: Dec 6, 2024
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 exits free of obstructions and did not properly maintain smoke barrier walls, including a hole in the west smoke wall and an unsealed sprinkler pipe in the east smoke wall. These deficiencies potentially affected all residents and staff.
Deficiencies (4)
K211 Means of Egress - General: The facility failed to maintain exits free of obstructions, as evidenced by a blocked exit door leading from the dining hall. This potentially affected all residents and staff.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to properly maintain smoke walls, including a five-foot by one-foot hole in the west smoke wall and a three-inch sprinkler pipe with no sealing in the east smoke wall. This potentially affected all residents and staff.
A2037 Exit Requirements: The facility did not meet the requirement for at least two unobstructed exits remote from each other, with one exit leading directly outside or to an enclosed stair separated by one-hour fire-rated construction. This regulation was not met as evidenced by K211.
A2054 Smoke Section Walls/Doors: The facility did not meet the requirement for smoke sections to be separated by one-hour fire-rated walls with self-closing doors that may be held open only by automatic fire alarm activation. This regulation was not met as evidenced by K372.
Report Facts
Facility census: 59
Inspection Report
Routine
Census: 59
Deficiencies: 9
Date: Dec 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, treatment, environment, assessments, medication administration, infection control, and staff training at Clearview Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to respond to resident grievances, incomplete documentation of code status orders, unsafe and unclean environment, inaccurate resident assessments, failure to conduct required PASARR screenings, inadequate nutritional monitoring, medication administration errors, improper infection control practices, and insufficient nurse aide training.
Deficiencies (9)
Failed to respond or act upon grievances and failed to keep documentation of inventory for residents.
Failed to obtain physician's order for code status and inconsistently document code status for residents.
Failed to provide a safe, clean, comfortable and homelike environment.
Failed to accurately code the Minimum Data Set (MDS) assessments for residents.
Failed to provide required PASARR screening for residents with mental disorders or intellectual disabilities.
Failed to implement, monitor, and modify interventions to maintain acceptable nutritional status for a resident.
Failed to maintain medication error rate below 5%, including failure to prime insulin pens and improper medication administration.
Failed to implement Enhanced Barrier Precautions during wound care and failed to perform proper hand hygiene during blood sugar testing.
Failed to conduct at least twelve hours of nurse aide in-service training and failed to provide required annual competencies in Dementia Care.
Report Facts
Facility census: 59
Weight loss percentage: 10.38
Medication error rate: 8.11
Number of residents sampled: 15
Number of nurse aide in-service hours required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN J | Registered Nurse | Named in medication administration errors and infection control deficiencies |
| CNA A | Certified Nurse Assistant | Named in nurse aide training deficiency |
| CNA B | Certified Nurse Assistant | Named in nurse aide training deficiency |
| SSD | Social Service Director | Named in grievance and PASARR screening deficiencies |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies and expectations |
| Administrator | Facility Administrator | Named in interviews regarding grievance policy and nurse aide training |
| QA Nurse | Quality Assurance Nurse | Named in interviews regarding weight monitoring and insulin administration |
| Housekeeper C | Named in environmental concerns reporting | |
| Housekeeper D | Named in environmental concerns reporting | |
| Maintenance Supervisor | Named in environmental concerns reporting | |
| CMT K | Certified Medication Technician | Named in medication administration deficiency |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 8
Date: Oct 20, 2023
Visit Reason
Annual survey conducted at Clearview Nursing Center to assess compliance with federal and state regulations including PASARR screening, comprehensive care planning, dialysis care, trauma-informed care, drug regimen review, staffing, and infection prevention.
Findings
The facility was found deficient in multiple areas including failure to provide Level I PASARR screening documentation, incomplete comprehensive care plans for residents, inadequate dialysis care documentation, lack of trauma-informed care interventions, insufficient drug regimen reviews, inadequate staffing qualifications, and incomplete infection preventionist training documentation.
Deficiencies (8)
F645 PASARR Screening: The facility failed to provide documentation of Level I PASARR screening for residents with mental disorders or intellectual disabilities as required by federal regulations.
F656 Comprehensive Care Plan: The facility did not develop or implement comprehensive care plans with measurable objectives and specific interventions for residents' medical, nursing, mental, and psychosocial needs.
F698 Dialysis Care: The facility failed to provide documentation of ongoing assessments, monitoring, and communication related to dialysis care for residents receiving dialysis.
F699 Trauma-Informed Care: The facility failed to identify, assess, and provide supportive interventions for residents with trauma or PTSD diagnoses.
F756 Drug Regimen Review: The facility failed to ensure timely pharmacist review of drug regimens and appropriate documentation of irregularities and physician responses.
F801 Staffing: The facility failed to employ a qualified dietary professional with appropriate credentials and experience to oversee food and nutrition services.
F882 Infection Preventionist Qualifications: The facility failed to ensure the infection preventionist completed specialized training and documentation for infection prevention and control.
F947 Required In-Service Training for Nurse Aides: The facility failed to provide required annual in-service training including dementia care and abuse prevention for nurse aides.
Report Facts
Facility census: 52
Deficiencies cited: 8
Completion dates: Dec 3, 2023
Inspection Report
Life Safety
Census: 52
Deficiencies: 4
Date: Oct 20, 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 one magnetically locked exit door that would delay evacuation, had kitchen hood filters heavily laden with grease, lacked required sprinkler coverage in certain hallways, and failed to maintain portable fire extinguishers with required inspections. These deficiencies potentially affected all residents and staff.
Deficiencies (4)
K222 Egress Doors: The facility failed to maintain one magnetically locked exit door that did not release within 15 seconds, delaying evacuation in an emergency.
K324 Cooking Facilities: The kitchen hood filters were heavily laden with grease and not properly maintained, posing a fire hazard.
K351 Sprinkler System - Installation: The facility failed to maintain required sprinkler coverage in the 100, 200, and 400 halls outside the exit doors.
K355 Portable Fire Extinguishers: The facility failed to maintain required inspections for portable fire extinguishers, including missing inspections for July 2023.
Report Facts
Facility census: 52
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 8
Date: Oct 20, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to document PASARR screenings, incomplete care plans for residents with specific needs, inadequate dialysis care and monitoring, lack of trauma-informed care for residents with PTSD, failure to address pharmacist recommendations timely, lack of certified dietary manager, incomplete infection preventionist training, and missing required annual CNA training in dementia care and abuse prevention.
Deficiencies (8)
Failure to provide documentation of Level I PASARR screening for two residents.
Failure to implement complete care plans with specific interventions for six residents.
Failure to provide safe, appropriate dialysis care and monitoring for two residents.
Failure to provide trauma-informed care and supportive interventions for two residents with PTSD.
Failure to ensure physician response to pharmacist's gradual dose recommendations for two residents.
Failure to employ a clinically qualified nutritional professional as Food and Nutritional Service Manager.
Failure to designate a qualified infection preventionist with completed specialized training.
Failure to provide required annual dementia care and abuse prevention training for two CNAs.
Report Facts
Residents affected: 2
Residents affected: 6
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 52
Residents affected: 2
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director (SSD) | Interviewed regarding PASARR screening for Residents #38 and #41 |
| Administrator | Facility Administrator | Interviewed regarding expectations for PASARR, care plans, pharmacist recommendations, and dietary manager certification |
| Certified Medication Technician A | Certified Medication Technician (CMT) | Interviewed regarding oxygen use for Resident #13 |
| Licensed Practical Nurse B | Licensed Practical Nurse (LP) | Interviewed regarding oxygen use and care planning for Resident #13 |
| Resident #18 | Resident | Interviewed regarding dialysis treatments and care |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding PTSD assessments and dialysis communication |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plans, dialysis care, pharmacist recommendations, infection preventionist training, and CNA training |
| Licensed Practical Nurse E | Licensed Practical Nurse (LPN) | Interviewed regarding dialysis access site assessment |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding certification status |
| Quality Assurance Nurse | Quality Assurance Nurse | Interviewed regarding CNA training tracking |
| Certified Nurse Aide C | Certified Nurse Aide (CNA) | Training record reviewed for dementia care and annual training |
| Certified Nurse Aide D | Certified Nurse Aide (CNA) | Training record reviewed for dementia care and annual training |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Aug 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation related to failure to notify a resident's family after a fall with injury.
Complaint Details
Complaint #MO222749 regarding failure to notify family after resident fall with injury.
Findings
The facility failed to notify a resident's family in a timely manner after a fall resulting in injury. Documentation and notification policies were not followed as required.
Deficiencies (2)
F580 Notification of Changes: The facility failed to promptly notify the resident's family after a fall with injury, violating notification requirements. Documentation of notification was missing despite policies requiring timely communication.
A4088 Notify Responsible Party-Change in Condition: Facility staff did not immediately notify the responsible party or designee of the resident's significant change in condition as required.
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding notification of incident | |
| Registered Nurse (RN) | Interviewed about incident documentation and notification | |
| Director of Nursing (DON) | Interviewed about notification expectations | |
| MDS Coordinator | Interviewed about documentation requirements | |
| Administrator | Interviewed about communication with family |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Aug 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's family in a timely manner after a fall with injury.
Complaint Details
Complaint #MO222749 regarding failure to notify family of a resident's fall with injury was investigated and substantiated.
Findings
The facility failed to notify the family or resident representative of a fall with injury for one resident out of three sampled residents at risk for falls. Documentation of notification was missing despite policies requiring timely communication.
Deficiencies (1)
Failed to notify a resident's family after a fall with injury in a timely manner.
Report Facts
Facility census: 54
Date of fall incident: Aug 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) | Found the resident on the floor after the fall | |
| Licensed Practical Nurse (LPN) A | Interviewed; stated family or POA should be notified | |
| Licensed Practical Nurse (LPN) B | Interviewed; stated responsible party or POA should be notified | |
| Registered Nurse (RN) E | Interviewed; assessed resident and documented incident | |
| Director of Nursing (DON) | Interviewed; expected staff to notify responsible party | |
| MDS Coordinator | Interviewed; stated nurses should document actions | |
| Administrator | Interviewed; spoke with nurse who tried to call family |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 6
Date: Dec 14, 2021
Visit Reason
The inspection was the annual survey of Clearview Nursing Center to assess compliance with federal regulations and identify deficiencies.
Findings
The facility was found deficient in accurately coding the Minimum Data Set (MDS), developing and implementing comprehensive care plans, ensuring appropriate placement and care of indwelling catheters, maintaining infection prevention and control measures, and implementing an antibiotic stewardship program.
Deficiencies (6)
F641 Accuracy of Assessments: The facility failed to accurately code the Minimum Data Set (MDS) for multiple residents, as evidenced by discrepancies in smoking status and wound care documentation.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement individualized comprehensive care plans meeting residents' highest practicable physical, mental, and psychosocial well-being for sampled residents.
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with specific interventions tailored to meet individualized needs for sampled residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure appropriate placement and care of indwelling catheters and prevent urinary tract infections for a sampled resident.
F880 Infection Prevention & Control: The facility failed to maintain infection control measures, including hand hygiene, glove use, and catheter care, for sampled residents.
F881 Antibiotic Stewardship Program: The facility failed to implement an antibiotic stewardship program including infection surveillance and antibiotic use protocols.
Report Facts
Facility census: 52
Sampled residents: 15
Inspection Report
Life Safety
Census: 52
Deficiencies: 6
Date: Dec 14, 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 reference documents.
Findings
The facility failed to maintain self-closing mechanisms on exit doors, maintain full separation of hazardous areas, maintain fire extinguisher inspections, maintain ash trays in smoking areas, keep the facility free of combustible decorations, and restrict the use of temporary wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K223 Doors with Self-Closing Devices: The facility failed to maintain self-closing mechanisms on all doors in exit corridors, with an activity room door closure removed.
K321 Hazardous Areas - Enclosure: The facility failed to maintain full separation of hazardous areas, including unsealed passages and holes in mechanical rooms.
K355 Portable Fire Extinguishers: The facility failed to maintain fire extinguisher inspections, with the kitchen extinguisher last inspected in June 2021.
K741 Smoking Regulations: The facility failed to maintain ash trays in smoking areas, with a metal food can used as an ashtray behind the kitchen door.
K753 Combustible Decorations: The facility failed to maintain the facility free of combustible decorations, with candles with wicks observed on walls and piano.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict the use of temporary wiring, with multiple power strips in use in various areas.
Report Facts
Facility census: 52
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 6
Date: Dec 14, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident assessments, care planning, catheter care, infection control, and antibiotic stewardship.
Findings
The facility failed to accurately code Minimum Data Set assessments for several residents, did not implement individualized comprehensive care plans addressing residents' needs, failed to ensure proper catheter care and placement, did not maintain proper infection control practices during care, and lacked an effective antibiotic stewardship program.
Deficiencies (6)
Failed to accurately code the Minimum Data Set (MDS) assessments for multiple residents.
Failed to implement individualized comprehensive care plans with measurable goals and timely revisions for residents.
Failed to develop complete care plans within 7 days of assessment and revise them by a team of health professionals.
Failed to provide appropriate catheter care, including proper placement of indwelling catheter tubing.
Failed to maintain proper infection prevention and control measures, including hand hygiene, glove use, and catheter care.
Failed to implement an antibiotic stewardship program including infection surveillance, antibiotic use protocols, and monitoring.
Report Facts
Residents sampled: 15
Residents affected: 52
Antibiotic use records: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) C | Interviewed regarding wound care and catheter care practices | |
| Social Service Director (SSD) | Interviewed about MDS coordinator and care plan completion | |
| Director of Nursing (DON) | Interviewed about expectations for MDS coding, care plans, catheter care, and antibiotic stewardship | |
| Certified Nursing Assistant (CNA) F | Observed and interviewed regarding catheter care practices | |
| Certified Nursing Assistant (CNA) D | Observed and interviewed regarding catheter care and resident hygiene | |
| Certified Nursing Assistant (CNA) E | Observed and interviewed regarding resident care and glove use | |
| Administrator | Interviewed about staffing and antibiotic stewardship program challenges |
Inspection Report
Routine
Deficiencies: 0
Date: Oct 20, 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
Complaint Investigation
Deficiencies: 0
Date: Sep 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted with a complaint investigation on 09/30/2020 to assess compliance with CMS and CDC recommended practices.
Complaint Details
The complaint investigation found no deficiencies and confirmed compliance with CMS and CDC COVID-19 infection control recommendations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and no deficiencies were cited as a result of the visit.
Inspection Report
Routine
Deficiencies: 0
Date: May 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/29/20 to assess compliance with CMS and CDC guidelines and related regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 13
Date: Nov 22, 2019
Visit Reason
Annual inspection of Clearview Nursing Center to assess compliance with federal and state regulations related to nursing/restorative care, medication management, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including accuracy of advance directives, Medicaid/Medicare notices, comprehensive assessments, care planning, medication administration, infection control, and environmental safety. Deficiencies were documented with specific resident cases and facility policy failures.
Deficiencies (13)
F578 Advance Directives: The facility failed to ensure accuracy of a resident's advance directive status, showing conflicting documentation and signage for Do-Not-Resuscitate (DNR) orders.
F582 Medicaid/Medicare Notices: The facility failed to issue required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms with proper signatures for residents whose Medicare covered services ended.
F637 Comprehensive Assessment: The facility failed to complete significant change assessments within required timeframes for sampled residents.
F641 Accuracy of Assessments: The facility failed to accurately code Minimum Data Set (MDS) assessments for sampled residents.
F656 Comprehensive Care Plan: The facility failed to develop and implement comprehensive, individualized care plans addressing resident needs and risks, including falls and infections.
F695 Respiratory/Tracheostomy Care: The facility failed to follow physician orders for supplemental oxygen therapy for a resident.
F730 Nurse Aide In-Service Training: The facility failed to provide required annual nurse aide in-service education and competency evaluations.
F758 Psychotropic Drug Regimen: The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic drugs and failed to provide proper monitoring and documentation.
F761 Medication Storage: The facility failed to label and store medications properly and maintain appropriate temperature logs for medication storage.
F809 Frequency of Meals: The facility failed to provide snacks at bedtime for residents as required by their care plans and resident interviews.
F812 Food Safety: The facility failed to store and distribute food under sanitary conditions, including unsealed and undated food items.
F880 Infection Prevention and Control: The facility failed to maintain proper infection control practices, including glove use, hand hygiene, and safe chemical storage, affecting resident safety.
F921 Safe Environment: The facility failed to maintain a safe environment by leaving chemicals unlocked and accessible to residents.
Report Facts
Facility census: 42
Sampled residents: 15
Plan of Correction completion dates: Jan 5, 2020
Inspection Report
Life Safety
Census: 42
Deficiencies: 6
Date: Nov 22, 2019
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 regulations.
Findings
The facility failed to maintain adequate exit egress lighting, maintain smoking bins free of combustibles, and keep the facility free of temporary wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K281 Illumination of Means of Egress: The facility failed to maintain adequate exit egress illumination, with inadequate lighting observed at all exits leading to the public way.
K741 Smoking Regulations: The facility failed to maintain smoking bins free of combustibles, with combustible trash and cigarette butts found in the smoking bin in the courtyard.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the facility free of temporary wiring, with power strips in use in multiple areas.
A2050 Emergency Lighting: Facilities shall have emergency lighting of sufficient intensity for safety. This regulation was not met as evidenced by deficiencies noted under K281.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Designated smoking areas shall have ashtrays of noncombustible material and safe design. This regulation was not met as evidenced by deficiencies noted under K741.
A3037 Extension Cords/Duplex Receptacles: Extension cords must be UL-approved and not placed under rugs or in locations subject to damage. This regulation was not met as evidenced by deficiencies noted under K920.
Report Facts
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Signed the statement of deficiencies and plan of correction | |
| Maintenance Supervisor | Interviewed regarding exit egress lighting and power strips | |
| Maintenance Director | Interviewed regarding smoking bins |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Apr 3, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to pressure ulcer prevention and treatment at Clearview Nursing Center.
Complaint Details
Complaint #MO154242 was investigated and substantiated based on findings related to pressure sore prevention and treatment.
Findings
The facility failed to identify, assess, and treat an open wound for one resident, resulting in a pressure ulcer. Documentation and timely reporting of skin conditions were inadequate.
Deficiencies (2)
F686 Skin Integrity: The facility failed to prevent pressure ulcers and did not properly assess or treat an open wound on a resident's right buttock. Documentation and reporting of skin conditions were incomplete or missing.
A4082 Pressure Sore Prevention/Treatment: The facility did not keep residents free from avoidable pressure sores and failed to provide adequate treatment as required by regulation.
Report Facts
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dandy McMullin | Administrator | Signed the plan of correction and facility representative |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 10
Date: Jan 11, 2019
Visit Reason
Annual inspection of Clearview Nursing Center to assess compliance with federal regulations including abuse prevention, comprehensive assessments, care planning, medication administration, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to check the CNA registry for new hires, incomplete significant change assessments, inadequate care plan revisions, medication errors exceeding 5%, and improper storage of drugs and biologicals. Several residents were affected by these deficiencies.
Deficiencies (10)
F607 Develop and implement abuse/neglect policies. The facility failed to check the Certified Nurse Aide Registry prior to employment for two of nine new employees. This deficient practice had the potential to affect all residents.
F637 Comprehensive assessment after significant change. The facility failed to complete a significant change assessment for one resident out of 12 sampled residents.
F657 Care plan timing and revision. The facility failed to revise and update comprehensive care plans with specific interventions to meet the needs of two residents related to falls and injuries.
F658 Services provided meet professional standards. The facility failed to follow the physician's orders for one resident outside of the sampled residents.
F759 Free of medication error rates 5 percent or more. The facility failed to maintain a medication error rate of five percent or less, with an error rate of 6.06 percent affecting one resident outside the sampled residents.
F761 Label/store drugs and biologicals. The facility failed to store drugs in accordance with accepted professional standards, affecting two residents outside the sample.
A4018 Criminal history - facility policy/procedure. The facility failed to develop and implement policies requiring disclosure of prior criminal history for persons hired for any position with resident contact.
A4054 Safe/effective medication system. The facility failed to maintain a safe and effective medication system as evidenced by medication errors.
A4063 Medication storage. The facility failed to store medications at appropriate temperatures and secure medications properly.
A4074 Nursing care per resident condition. The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
Report Facts
Deficiencies cited: 10
Medication error rate: 6.06
Resident census: 44
Sampled residents: 12
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 5
Date: Jan 11, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations at Clearview Nursing Center.
Findings
The facility failed to meet several fire safety requirements including smoke barrier construction, maintenance of ashtrays, and combustible decorations. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
K 372: The facility failed to maintain smoke barriers with a 1/2-hour fire resistance rating as required by NFPA 101. The smoke wall at the electrical generator room was not sealed at the roof deck.
K 741: The facility failed to maintain ashtrays of noncombustible material and safe design in all areas where smoking is permitted. Multiple used cigarettes were found in a trash can.
K 753: The facility failed to maintain a facility free of combustible decorations, including candles, which were observed in multiple locations such as the dietary manager's office and resident sitting room.
A2054: Each smoke section shall be separated by one-hour fire-rated walls and doors. This regulation was not met as referenced to K 372.
A2057: Designated smoking areas shall have ashtrays of noncombustible material and safe design. This regulation was not met as referenced to K 741.
Report Facts
Facility census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dandy McMullin | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 15
Date: Feb 23, 2018
Visit Reason
Annual inspection survey of Clearview Nursing Center to assess compliance with federal and state regulations related to resident care, privacy, care planning, discharge summaries, activities, respiratory care, medication use, and food safety.
Findings
The facility was found deficient in multiple areas including resident privacy during toileting, comprehensive care planning, discharge summaries, provision of activities, respiratory care orders, psychotropic medication diagnoses, and food safety practices. The facility submitted a plan of correction addressing these deficiencies with completion dates in April 2018.
Deficiencies (15)
F583 Personal privacy was not maintained for Resident #10 during toileting as the resident's door and privacy curtain were open and staff did not always close the door for privacy.
F656 The facility failed to implement comprehensive care plans with specific interventions tailored to meet individual needs for Residents #3 and #42.
F657 The facility failed to update the care plan for Resident #13 as required by regulation.
F661 The facility failed to complete a comprehensive discharge summary for Resident #41 upon discharge.
F679 The facility failed to provide an ongoing program of activities meeting the interests and psychosocial well-being of residents, affecting seven residents outside the sampled group.
F695 The facility failed to obtain a physician's order for supplemental oxygen therapy for Resident #3.
F758 The facility failed to ensure proper diagnoses for antipsychotic medications for Resident #22 and others.
F812 The facility failed to store and distribute food under sanitary conditions, including lack of air gap for ice machine, food debris in kitchen, and improper food labeling.
A4074 The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4108 The facility failed to ensure clinical records contained sufficient information to identify discharge or transfer destination.
A6012 Floors and surfaces in food preparation and storage areas were not maintained in good repair and cleanliness, increasing risk of contamination.
A7015 Food was not protected from potential contamination during storage and preparation, with improper temperatures and handling observed.
A7025 Hot food storage facilities were inadequate to assure proper temperature control.
A8013 Residents were not afforded the opportunity to participate in planning of care and treatment or refuse treatment as required.
A8030 Residents' dignity and privacy were not fully respected during treatment and care.
Report Facts
Facility census: 40
Sampled residents: 12
Completion dates: Apr 8, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dandy McMullin | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Life Safety
Census: 40
Deficiencies: 5
Date: Feb 23, 2018
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, including emergency preparedness, means of egress, cooking facilities, sprinkler system maintenance, smoke barriers, and HVAC systems.
Findings
The facility failed to maintain unobstructed exits, clean filters in the kitchen range hood, maintain the fire sprinkler system to NFPA code, maintain smoke barriers free from penetrations, and provide required ventilation for HVAC equipment. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (5)
K271 Discharge from Exits: The facility failed to maintain unobstructed exits at all times, with locks observed on exit doors. This affected all occupants. The facility census was 40.
K324 Cooking Facilities: The facility failed to maintain clean filters in the range hood in the kitchen, with grease-coated and damaged filters observed. The facility census was 40.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the fire sprinkler system to NFPA code, including missing monthly checks on the Ansul fire suppression system and food stacked too close to ceilings.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier walls free from penetrations, with multiple holes observed in the smoke barrier wall. The facility census was 40.
K521 HVAC: The facility failed to provide required ventilation within 18 inches of the floor for gas-fueled HVAC equipment, and a smoke damper did not function during fire alarm testing.
Report Facts
Facility census: 40
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