Inspection Reports for
Communities of Wildwood Ranch
3222 SOUTH JOHN DUFFY DR, JOPLIN, MO, 64804-1569
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
86% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the administration of blood pressure medication to a resident (Resident #22) outside the physician-ordered parameters.
Complaint Details
Complaint investigation found that Resident #22 received hydralazine HCl when systolic blood pressure was below the ordered parameter of 110 mm/Hg without documented physician approval or explanation. Staff interviews confirmed doses were administered outside parameters and documentation was missing.
Findings
The facility failed to ensure that blood pressure medication was administered according to physician orders, as staff administered hydralazine HCl to Resident #22 when the resident's systolic blood pressure was below the ordered threshold of 110 mm/Hg without documented physician approval. Interviews with staff confirmed the medication was given outside parameters without proper documentation or physician notification.
Deficiencies (1)
Failure to ensure each resident’s drug regimen was free from unnecessary drugs; blood pressure medication was administered outside physician-ordered parameters without documentation.
Report Facts
Resident ID: 22
Medication dosage: 50
Systolic Blood Pressure threshold: 110
Dates of medication administration outside parameters: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medicine Technician (CMT) 1 | Confirmed administration of medication outside parameters and lack of documentation | |
| Licensed Practical Nurse (LPN) 1 | Described procedure for holding medication and notifying physician if parameters not met | |
| Administrator, Director of Nursing (DON), and Regional Nurse Consultant | Confirmed policy that medication should not be given outside parameters unless physician contacted and documented |
Inspection Report
Renewal
Census: 103
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance due to failure to ensure all residents were free from unnecessary medications. Specifically, staff administered blood pressure medication to one resident outside the physician ordered parameters.
Deficiencies (1)
F757: The facility failed to ensure all residents were free from unnecessary medications when staff administered blood pressure medication to one resident outside the physician ordered parameters for administration.
Report Facts
Survey Census: 103
Sample Size: 25
Supplemental Residents: 8
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 11, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Survey were conducted on 02/11/2025 to assess compliance with federal regulations and fire safety requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 for Emergency Preparedness and with the Life Safety Code requirements for participation in Medicare/Medicaid at 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Jan 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident where the facility staff failed to ensure staff awareness and adherence to care planned fall interventions for a resident, resulting in injury.
Complaint Details
The investigation was complaint-driven, focusing on a resident who fell from bed due to staff not following fall prevention interventions. The resident sustained facial lacerations, hematomas, and skin tears, requiring hospital transfer. Staff interviews indicated lack of awareness of the resident's fall risk and care plan.
Findings
The facility failed to ensure an environment free from accident hazards and adequate supervision to prevent falls. Staff were unaware of or did not follow fall prevention care plans, leading to a resident falling from a raised bed and sustaining multiple injuries requiring hospital transfer. Interviews revealed staff lacked knowledge of the resident's fall risk and care plan details.
Deficiencies (1)
Facility staff failed to ensure staff were aware of and followed care planned fall interventions for a resident, resulting in a fall from a raised bed and injuries.
Report Facts
Facility census: 111
Resident admission date: Dec 24, 2022
Fall risk assessment date: Oct 13, 2023
Care plan revision dates: Care plan revised on 10/14/23, 10/18/23, 12/19/23, and 12/30/23
Incident dates: Resident fell on 12/19/23 and 12/30/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Documented resident fall and injuries, interviewed about incident |
| CNA D | Certified Nurse Aide | Raised resident bed and left resident unattended, interviewed about incident |
| LPN F | Licensed Practical Nurse | Interviewed about resident fall and staff knowledge |
| RN G | Registered Nurse | Updates care plans and interviewed about fall interventions |
| Director of Nursing | Director of Nursing (DON) | Interviewed about fall prevention policies and staff expectations |
| LPN B | Licensed Practical Nurse | Interviewed about resident fall history |
| CNA E | Certified Nurse Aide | Interviewed about staff leaving resident bed up and care plans |
| LPN C | Licensed Practical Nurse | Interviewed about fall reporting and care plan updates |
| Administrator | Administrator | Interviewed about staff communication and fall interventions |
| Medical Director | Medical Director | Interviewed about expectations for staff awareness of fall risks |
Inspection Report
Plan of Correction
Census: 111
Deficiencies: 2
Date: Jan 10, 2024
Visit Reason
The inspection was conducted to investigate and document deficiencies related to resident safety, specifically regarding fall prevention and supervision.
Findings
The facility failed to ensure an environment free of accident hazards and adequate supervision to prevent falls, resulting in a resident falling from bed and sustaining injuries. Staff were unaware of care plans and interventions related to fall risk, and the resident's bed was left in a high position unattended.
Deficiencies (2)
F689: The facility did not ensure the resident environment was free of accident hazards and failed to provide adequate supervision and assistance devices to prevent falls, resulting in a resident falling from bed and sustaining facial injuries and skin tears.
A4074: The facility failed to provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, as required by regulation.
Report Facts
Facility census: 111
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Dec 7, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident being transferred via slide transfer during a facility evacuation without ensuring the area was free from hazards, resulting in the resident's leg getting caught in a blanket and causing pain.
Complaint Details
The complaint investigation found that Resident #1 was transferred by slide transfer during an emergency evacuation without ensuring the area was free of hazards, resulting in the resident's leg getting caught in a blanket and causing pain. The resident reported pain rated ten out of ten when moved. Staff were unaware of emergency transfer protocols and used slide transfer due to unavailability of mechanical lift.
Findings
The facility failed to ensure all residents were free from accident hazards during transfers. Specifically, Resident #1 was slide transferred during an emergency evacuation, and staff did not ensure the transfer area was free of hazards, resulting in the resident's leg getting caught in a blanket causing pain. The resident had continued pain despite an unremarkable x-ray. Staff interviews revealed lack of knowledge of emergency transfer protocols and that the Hoyer lift was unavailable at the time.
Deficiencies (1)
Failed to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents during resident transfer.
Report Facts
Census: 109
Residents affected: 1
Staff involved: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Assistant (CNA) A | Certified Nurses Assistant | Stated resident is totally dependent on staff for transfers |
| Registered Nurse (RN) B | Registered Nurse | Assisted with transfer during evacuation and provided details on transfer |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Assisted with transfer during evacuation and described transfer circumstances |
| Certified Nurses Assistant (CNA) D | Certified Nurses Assistant | Present during transfer and commented on appropriateness of slide transfer |
| Director of Nursing (DON) | Director of Nursing | Unaware of slide transfer until after evacuation; discussed transfer safety and assessment |
| Administrator | Administrator | Commented on emergency transfer methods and staff responsibilities |
Inspection Report
Plan of Correction
Census: 109
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to investigate compliance with safety regulations related to accident hazards, supervision, and devices during resident transfers, specifically following an incident involving a resident's leg injury during a facility evacuation.
Findings
The facility failed to ensure all residents were free from accident hazards during transfers, resulting in a resident's leg getting caught in a blanket causing pain. Staff did not follow proper transfer protocols during an emergency evacuation, leading to injury risk.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision and assistance devices during a slide transfer, causing a resident's leg to get caught in a blanket and resulting in pain.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave Each resident must receive 24-hour protective oversight and supervision during voluntary leave. This regulation was not met as referenced by F689.
Report Facts
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Cones | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Named in plan of correction and interview regarding transfer techniques |
Inspection Report
Routine
Census: 103
Deficiencies: 3
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to staff background checks, resident bed-hold policies during hospital transfers, and safety measures to prevent resident elopement and accidents.
Findings
The facility failed to complete required criminal background checks and registry verifications prior to employment for several staff members. The facility also failed to provide written bed-hold policy notices to residents or their representatives upon hospital transfers. Additionally, the facility did not ensure proper functioning and monitoring of wander guard alarms, resulting in a resident exiting the building undetected for a short period.
Deficiencies (3)
Failure to implement policies and procedures to prevent abuse by ensuring required criminal background checks, employee disqualification list checks, and CNA registry checks were completed prior to employment for multiple staff members.
Failure to notify residents or their representatives in writing about the facility's bed-hold policy during hospital transfers for four residents.
Failure to provide adequate supervision and ensure wander guard alarms functioned properly, resulting in a resident exiting the building and the alarm not being heard on all halls or pagers.
Report Facts
Facility census: 103
Days delay in background checks: 11
Days delay in background checks: 5
Days delay in background checks: 6
Days delay in background checks: 2
Days delay in background checks: 1
Days delay in background checks: 142
Residents affected by bed-hold policy failure: 4
Wander guard checks missed: 3
Resident off floor time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in deficiency related to delayed background checks |
| LPN D | Licensed Practical Nurse | Named in deficiency related to delayed background checks |
| SS A | Social Services | Named in deficiency related to delayed background checks |
| Office Staff C | Named in deficiency related to delayed background checks | |
| COTA F | Certified Occupation Therapy Assistant | Named in deficiency related to delayed background checks |
| CNA E | Certified Nurse Aide | Named in deficiency related to delayed background checks |
| LPN H | Licensed Practical Nurse | Interviewed regarding bed-hold form procedures and nursing responsibilities |
| RN Q | Registered Nurse | Interviewed regarding bed-hold form procedures |
| LPN R | Licensed Practical Nurse | Interviewed regarding bed-hold form procedures |
| Social Services Director | Interviewed regarding transfer notices and bed-hold policy communication | |
| Assistant Director of Nursing | Interviewed regarding hospital transfer procedures and bed-hold policy | |
| CNA L | Certified Nurses Aide | Interviewed regarding elopement incident and alarm system |
| CNA M | Certified Nurses Aide | Interviewed regarding elopement incident and alarm system |
| Certified Medication Technician S | Interviewed regarding resident elopement risk and wander guard use | |
| Certified Nurses Aid K | Interviewed regarding resident elopement risk and wander guard use | |
| Licensed Practical Nurse O | Interviewed regarding residents wearing wander guard devices | |
| Administrator | Interviewed regarding staff responsibilities for wander guard alarms | |
| Director of Nurses | Interviewed regarding staff responsibilities for wander guard alarms |
Inspection Report
Plan of Correction
Census: 103
Deficiencies: 3
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to abuse/neglect policies, bed hold policies, and free of accident hazards/supervision/devices at Communities of Wildwood Ranch nursing facility.
Findings
The facility failed to implement required abuse and neglect policies including criminal background checks and registry checks for staff. The facility also failed to provide proper written notice of bed hold policies to residents and representatives and did not ensure adequate supervision and protective oversight to prevent accidents and elopements.
Deficiencies (3)
F607: The facility failed to implement abuse and neglect policies by not completing required criminal background checks and registry checks for multiple staff members prior to employment.
F625: The facility failed to provide written notice of bed hold policies to residents and representatives at the time of transfer or discharge for multiple residents.
F689: The facility failed to provide adequate supervision and protective oversight to prevent accidents and elopements, including failure to ensure wander guard devices were checked and alarms responded to appropriately.
Report Facts
Facility census: 103
Deficiency count: 3
Inspection Report
Life Safety
Census: 103
Capacity: 120
Deficiencies: 2
Date: Jul 28, 2023
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety and oxygen storage regulations.
Findings
The facility failed to properly separate full and empty oxygen canisters in the oxygen storage rooms, posing a potential safety risk. The Emergency Preparedness portion of the survey did not result in deficiencies.
Deficiencies (2)
42 CFR 483.90 (a) The facility does not meet the applicable provisions of the 2012 edition of the Life Safety Code regarding gas equipment cylinder and container storage. The facility failed to properly separate full and empty oxygen canisters, risking safety in an emergency.
19 CSR 30-85.022(6) Oxygen storage is not in accordance with NFPA 99, 1999 edition. Facilities must use permanent racks or fasteners to prevent accidental damage or dislocation of oxygen cylinders. This regulation is not met as evidenced by the failure to separate full and empty oxygen tanks.
Report Facts
Facility capacity: 120
Census: 103
Date of survey: Jul 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding oxygen tank storage practices | |
| Licensed Practical Nurse (LPN) U | Interviewed regarding oxygen tank storage practices | |
| Administrator | Interviewed regarding oxygen tank storage and signage |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Date: Dec 12, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of a controlled substance medication (Belsomra) from one resident at the facility.
Complaint Details
The complaint investigation was substantiated as the facility failed to protect a resident from medication misappropriation. The resident's Belsomra medication was found missing, and staff interviews and record reviews confirmed failures in medication administration and storage procedures.
Findings
The facility failed to protect residents from misappropriation when tablets of a controlled substance medication went missing while in possession of the facility. The investigation revealed discrepancies in medication administration and storage procedures.
Deficiencies (2)
F602 Free from Misappropriation/Exploitation CFR(s): 483.12 The facility failed to protect residents from misappropriation when tablets of one resident's Belsomra medication went missing while in possession of the facility.
A4055 19 CSR 30-85.042(46) Safe/Effective Medication System There shall be a safe and effective system of medication distribution, administration, control, and use. This regulation is not met as evidenced by Class II deficiency related to F602.
Report Facts
Facility census: 104
Medication tablets missing: 10
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in investigation staff interviews regarding medication misappropriation |
| LPN D | Licensed Practical Nurse | Named in investigation staff interviews and medication handling |
| LPN E | Licensed Practical Nurse | Named in investigation staff interviews regarding medication misappropriation |
| Registered Nurse F | Registered Nurse | Interviewed regarding medication counts and procedures |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding medication handling and resident interactions |
| Director of Nursing | Director of Nursing | Interviewed and responsible for investigation and corrective actions |
| Administrator | Administrator | Interviewed and responsible for oversight and reporting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 28, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related regulations and CDC recommended practices.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Plan of Correction
Census: 98
Deficiencies: 1
Date: May 12, 2022
Visit Reason
The inspection was conducted to assess compliance with COVID-19 vaccination requirements for facility staff as part of regulatory oversight.
Findings
The facility failed to ensure 100% of staff were fully vaccinated against COVID-19 or granted qualifying exemptions. Two staff members were identified with vaccination deficiencies: one with a medical exemption not recognized by CDC and another who did not receive the second vaccine dose timely.
Deficiencies (1)
F888 COVID-19 Vaccination of Facility Staff. The facility failed to ensure all staff were fully vaccinated or had qualifying exemptions. One staff member had an unrecognized medical exemption and another did not receive the second vaccine dose timely.
Report Facts
Facility census: 98
Total staff: 164
Staff with completed vaccination: 93
Staff with granted exemption: 65
Staff partially vaccinated: 6
Staff pending exemptions: 0
Temporary delay on new hires: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Had a medical exemption not recognized by CDC | |
| Employee B | Did not receive second dose of COVID-19 vaccine timely |
Inspection Report
Plan of Correction
Census: 91
Deficiencies: 5
Date: Aug 30, 2021
Visit Reason
The inspection was conducted to investigate deficiencies related to resident rights, quality of care, infection control, and other regulatory compliance issues at Communities of Wildwood Ranch.
Findings
The facility was found deficient in treating residents with dignity and respect, providing adequate wound care, maintaining infection prevention and control, and ensuring proper continence care. Multiple residents reported inappropriate staff behavior and inadequate care practices.
Deficiencies (5)
F550 Resident Rights/Exercise of Rights: The facility failed to ensure all residents were treated with dignity and respect, as evidenced by inappropriate staff interactions with residents #4, #5, #6, and #7 making them uncomfortable.
F684 Quality of Care: The facility failed to administer wound care as ordered and failed to monitor and fully assess resident #8's wound, which showed signs of infection.
F690 Bowel/Bladder Incontinence, Catheter UTI: The facility failed to provide incontinence care to prevent infection for residents #1, #2, and #3, with staff failing to perform hand hygiene before and during care.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including proper hand hygiene and wound care practices for residents #1, #2, and #3.
A8030 Dignity/Privacy: The facility failed to ensure residents' dignity and privacy in accordance with regulatory requirements.
Report Facts
Facility census: 91
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 22, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Complaint Details
This was a complaint investigation related to COVID-19 focused emergency preparedness and infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
This was a complaint investigation related to COVID-19 focused infection control and emergency preparedness. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation to assess compliance with relevant regulations and CDC recommended practices.
Complaint Details
This was a complaint investigation related to COVID-19 focused emergency preparedness and infection control. No deficiencies were cited, indicating the complaint was not substantiated.
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. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
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. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
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. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 2
Date: Nov 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 11/4/20 to assess compliance with COVID-19 related regulations and CDC recommendations.
Findings
The facility was found in compliance with 42 CFR §483.73 related to emergency preparedness but was not in compliance with CMS and CDC recommended infection control practices. Deficiencies were noted in infection prevention and control program implementation, staff screening, PPE use, and COVID-19 testing protocols.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to implement CDC and CMS recommendations to prevent COVID-19 spread, including inadequate staff screening, lack of follow-up on symptomatic staff, and improper PPE use on COVID-19 positive units.
F886 COVID-19 Testing-Residents & Staff: The facility failed to perform staff testing at the required frequency of twice weekly despite a county positivity rate of 12.2%, not meeting CMS guidelines.
Report Facts
Total residents: 78
Total sample: 3
County COVID-19 positivity rate: 12.2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess 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 for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess 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 for COVID-19.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: May 27, 2020
Visit Reason
The inspection was conducted to investigate infection prevention and control deficiencies related to COVID-19 and hand hygiene practices following a complaint or allegation.
Complaint Details
The investigation was triggered by concerns about infection control practices during the COVID-19 pandemic. The complaint was substantiated as the facility failed to follow CDC guidelines for hand hygiene and mask use.
Findings
The facility failed to fully implement infection control practices recommended by the CDC during the COVID-19 pandemic, including improper hand hygiene and face mask use by staff. Observations showed staff did not wash or sanitize hands appropriately during medication administration and wore masks improperly.
Deficiencies (2)
F880 Infection Control: The facility failed to implement an effective infection prevention and control program, including failure to ensure staff performed hand hygiene and wore face coverings properly during medication administration and resident care.
A4085 Infection Control/Communicable Disease: The facility did not meet requirements for infection control procedures to prevent the spread of communicable diseases as required by Missouri state regulations.
Report Facts
Facility census: 82
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding hand hygiene skills checks |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding hand hygiene expectations |
| Director of Nursing | Director of Nursing | Interviewed regarding competency checks on hand hygiene and mask use |
| Administrator | Administrator | Interviewed regarding staff competency checks and mask wearing policies |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 9
Date: Jan 24, 2020
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for nursing facilities, including comprehensive assessments, quarterly assessments, respiratory care, bedrails, and medication error rates.
Findings
The facility was found deficient in multiple areas including failure to complete comprehensive and quarterly resident assessments timely, inadequate respiratory care and CPAP management, incomplete bed rail assessments, and medication error rates exceeding 5%. The facility submitted plans of correction with completion dates.
Deficiencies (9)
F636 Comprehensive Assessments & Timing: Facility failed to complete annual Minimum Data Set assessments for three residents within required timeframes.
F638 Quarterly Assessments: Facility failed to complete quarterly Minimum Data Set assessments for four residents within required 14-day timeframe.
F640 Encoding/Transmitting Resident Assessments: Facility failed to transmit a Death in Facility Minimum Data Set within 14 days for one resident.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility failed to ensure staff cleaned and maintained CPAP equipment and followed physician orders for oxygen and CPAP use for residents.
F700 Bedrails: Facility failed to complete side rail assessments and obtain informed consent for four residents and failed to ensure proper installation and maintenance of bed rails.
F759 Free of Medication Error Rates 5 Percent or More: Facility had a medication error rate of 7.14%, exceeding the 5% threshold, including errors in dose and administration for one resident.
A4029 Communicable Disease-Employees: Facility failed to complete second step of two-step Tuberculosis screening for three staff members.
A4054 Safe/Effective Medication System: Refer to F759 for medication error deficiencies.
A4074 Nursing Care per Resident Condition: Refer to F695 and F700 for nursing care deficiencies related to respiratory and bed rail care.
Report Facts
Facility census: 91
Medication error rate: 7.14
Medication errors: 2
Residents sampled for assessments: 19
Staff members sampled for TB screening: 10
Inspection Report
Life Safety
Census: 91
Capacity: 120
Deficiencies: 4
Date: Jan 24, 2020
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness training and testing requirements and to evaluate adherence to the 2012 edition of the Life Safety Code.
Findings
The facility failed to define a process for staff training on the disaster plan and did not ensure completion of required emergency preparedness drills. Additionally, the facility did not meet Life Safety Code requirements related to corridor doors, including smoke tightness and door closing mechanisms.
Deficiencies (4)
E036: The facility failed to define a process for training staff on the disaster plan, affecting all residents, staff, and visitors. The facility had a census of 91 with a capacity of 120.
E039: The facility did not ensure two emergency preparedness drills annually, including a community-based full-scale exercise. Documentation of drills and incorporation of tabletop exercise information into the emergency plan were inadequate.
K363: Doors protecting corridor openings were not smoke tight and did not close properly, affecting resident rooms, offices, and ancillary areas. The facility had a capacity of 120 with a census of 91.
A3001: The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2).
Report Facts
Facility census: 91
Facility capacity: 120
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 6
Date: Jan 24, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federally mandated comprehensive and quarterly Minimum Data Set (MDS) assessments, respiratory care standards, bed rail safety, and medication administration.
Findings
The facility failed to complete timely annual and quarterly MDS assessments for multiple residents, failed to transmit a Death in Facility MDS record timely, failed to ensure proper respiratory care including CPAP and oxygen equipment management, failed to complete required assessments and obtain consent for bed rail use, and had a medication error rate exceeding 5% due to incorrect medication dosing and improper inhaler administration.
Deficiencies (6)
Failed to complete annual Minimum Data Set (MDS) assessments within required timeframes for three residents.
Failed to complete quarterly Minimum Data Set (MDS) assessments within required timeframes for four residents.
Failed to transmit a Death in Facility Minimum Data Set (MDS) record within required timeframe for one resident.
Failed to ensure proper cleaning, physician orders, diagnosis documentation, and care planning for CPAP and oxygen equipment for two residents.
Failed to complete side rail assessments, risk/benefit reviews, obtain informed consent, and document bed rail measurements for four residents using bed rails.
Medication error rate exceeded 5% due to failure to administer correct dose of medication and improper inhaler administration for one resident.
Report Facts
Residents sampled: 19
Facility census: 91
Medication error rate: 7.14
Medication administration opportunities: 28
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Reviewed resident medical records and medication orders; interviewed regarding CPAP and medication administration |
| MDS Coordinator C | MDS Coordinator | Interviewed regarding delays in MDS assessments and submissions |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen and CPAP orders, bed rail procedures, and medication administration expectations |
| Director of Therapy Services | Director of Therapy Services | Interviewed regarding bed rail evaluation and installation process |
| Certified Medication Technician A | Certified Medication Technician | Observed administering medications including inhalers |
Inspection Report
Plan of Correction
Census: 105
Deficiencies: 2
Date: Feb 11, 2019
Visit Reason
The inspection was conducted to identify deficiencies related to quality assessment and assurance and communicable disease employee screening policies at the facility.
Findings
The facility failed to maintain a quarterly quality assessment committee with required members and did not properly complete two-step tuberculosis testing for staff members. The facility census was 105 at the time of inspection.
Deficiencies (2)
F868 Quality assessment and assurance committee did not meet quarterly with required members including the medical director. The medical director did not attend or sign meeting minutes for the last three quarters.
A4029 The facility failed to complete two-step tuberculosis testing for two staff members as required by Missouri Department of Health regulations.
Report Facts
Facility census: 105
Inspection Report
Annual Inspection
Census: 105
Capacity: 120
Deficiencies: 2
Date: Feb 11, 2019
Visit Reason
Annual recertification survey to assess compliance with the Life Safety Code and related fire safety regulations.
Findings
The facility failed to maintain the required supply of spare sprinkler heads as mandated by NFPA 25. This deficiency had the potential to affect all residents, staff, and visitors in the event of a sprinkler head becoming dislodged or broken.
Deficiencies (2)
K353 Sprinkler System maintenance and testing: The facility failed to supply the sprinkler tool box with the required amount of spare sprinkler heads as required by NFPA 25. The sprinkler heads were not replaced after being used by an outside company.
A2035 Complete Sprinkler System: The facility did not install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition, as evidenced by the deficiency in K353.
Report Facts
Facility capacity: 120
Census: 105
Sprinkler heads purchased: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding sprinkler head replacement | |
| Administrator | Responsible for monitoring compliance and quality assurance |
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