Inspection Reports for
Community Manor
783 WEBER ROAD, FARMINGTON, MO, 63640-3318
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
15.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
180% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
98% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 97
Deficiencies: 11
Date: Jun 6, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices, inadequate documentation of resident transfers and bed-hold policies, inaccurate resident assessments, incomplete care plans, medication errors, improper dialysis care, unsafe infection control practices, food storage and sanitation issues, and unsafe environmental conditions such as items stored on overbed light fixtures.
Deficiencies (11)
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to residents discharged from Medicare Part A with benefit days remaining.
Failed to notify residents or representatives in writing of hospital transfers and bed-hold policies.
Failed to document accurate Minimum Data Set (MDS) assessments reflecting resident medication use.
Failed to update and revise care plans with specific interventions to meet individual resident needs.
Failed to obtain and follow physician orders timely after pharmacist recommendations and allowed CNA to perform duties outside scope of practice.
Failed to ensure proper tracheostomy care including suctioning and infection control practices.
Failed to obtain correct dialysis orders specific to resident's port access instead of fistula.
Failed to maintain medication error rate below 5%, with errors in medication administration and handling.
Failed to procure, store, and prepare food in sanitary conditions, including expired and undated food items and unclean kitchen environment.
Failed to implement infection prevention and control practices including enhanced barrier precautions, hand hygiene, wound care, urinary catheter care, medication administration, and blood glucose monitoring.
Failed to maintain a safe environment by allowing items to be stored on overbed light fixtures in resident rooms.
Report Facts
Medication errors: 4
Facility census: 97
Residents affected: 2
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN I | Licensed Practical Nurse | Named in findings related to improper tracheostomy care and infection control breaches. |
| CMT K | Certified Medication Technician | Named in medication administration errors including dropping medication and poor hand hygiene. |
| ADON G | Assistant Director of Nursing | Provided clarifications on dialysis orders and medication errors. |
| DON | Director of Nursing | Provided expectations on care plans, medication administration, and infection control. |
| Administrator | Provided expectations on regulatory compliance and care standards. | |
| CNA F | Certified Nurse Aide | Named in infection control breaches during peri and catheter care. |
| CNA O | Certified Nurse Aide | Named in infection control breaches during peri and catheter care. |
| LPN J | Licensed Practical Nurse | Named in medication administration and infection control breaches. |
| LPN N | Licensed Practical Nurse | Named in infection control breaches during insulin administration. |
| LPN L | Licensed Practical Nurse | Named in infection control breaches during gastrostomy tube dressing change. |
Inspection Report
Routine
Census: 96
Deficiencies: 8
Date: Jun 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication administration, restorative services, nutrition, dialysis care, food safety, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to follow physician's medication orders, incomplete restorative nursing services, inadequate nutrition monitoring and communication, lack of dialysis care documentation and monitoring, improper food storage and sanitation practices, failure to maintain required QAPI committee attendance, and lapses in infection control practices.
Deficiencies (8)
Failed to document an accurate Minimum Data Set (MDS) for one resident.
Failed to follow physician's orders for medication administration for one resident.
Failed to perform restorative nursing services as ordered for two residents.
Failed to ensure Registered Dietician's recommendations for weight loss were provided to the physician and implemented for one resident.
Failed to provide documentation of ongoing assessments, monitoring, and communication related to dialysis care for one resident.
Failed to store and distribute food under sanitary conditions, increasing risk of cross-contamination and food-borne illness.
Failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with required members.
Failed to maintain proper infection control practices during resident care and failed to provide appropriate documentation of tuberculosis testing for five residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 96
Residents affected: 96
Residents affected: 5
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 8
Date: Jun 21, 2024
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations and facility policies at Community Manor nursing facility.
Findings
The facility was found deficient in multiple areas including accuracy of resident assessments, professional standards in services provided, mobility and restorative nursing, nutrition and hydration maintenance, dialysis care, food safety, infection control, and quality assurance. Deficiencies were documented with specific resident cases and facility policy reviews.
Deficiencies (8)
F641 Accuracy of Assessments: The facility failed to document an accurate Minimum Data Set (MDS) for one resident out of 20 sampled. The resident's MDS was not coded accurately for hospice care.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician's orders for one resident outside the sample, including medication administration and documentation.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility staff failed to ensure residents with limited range of motion received appropriate treatment and restorative services for two residents.
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure the Registered Dietitian's recommendations for weight loss were provided to the physician for one resident.
F698 Dialysis: The facility failed to provide documentation of ongoing assessments, monitoring, and communication related to dialysis care for one resident receiving dialysis.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, including improper labeling and storage of food items.
F868 QAA Committee: The facility failed to maintain a quality assessment and assurance committee with required members and failed to ensure infection preventionist participation.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including proper tuberculosis testing documentation for residents.
Report Facts
Residents sampled: 20
Facility census: 96
Deficiencies cited: 8
Inspection Report
Life Safety
Census: 96
Capacity: 99
Deficiencies: 2
Date: Jun 21, 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 magnetically locked exit doors that would delay evacuation in an emergency and failed to ensure the kitchen stove hood was free of grease buildup. These deficiencies had the potential to affect all occupants of the building.
Deficiencies (2)
K222 Egress Doors: The facility failed to maintain magnetically locked exit doors which would delay evacuation of all occupants in the event of an emergency. The 200, 300, and 400 hall exit doors did not open within 15 seconds of initiating the opening push bar.
K324 Cooking Facilities: The facility failed to ensure the kitchen stove hood was free of an accumulation of grease and debris, posing a fire hazard to all occupants.
Report Facts
Facility capacity: 99
Census: 96
Inspection Report
Census: 98
Deficiencies: 1
Date: Apr 29, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, specifically regarding notification to residents' families or next of kin after a change in condition or new injuries.
Findings
The facility failed to notify the family or next of kin for two of three sampled residents after changes in condition or new injuries such as skin tears and bruising. Documentation of notifications was lacking, and interviews with staff confirmed inconsistent notification practices.
Deficiencies (1)
Failure to notify a resident's family or next of kin for two of three sampled residents after a change in condition or new injuries.
Report Facts
Facility census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding facility policy on notification of family or next of kin |
| RN B | Registered Nurse | Interviewed regarding notification practices and documentation |
| Hospice Clinical Director | Interviewed about family concerns regarding lack of notification | |
| Director of Nursing | Director of Nursing | Interviewed about expectations for nursing notification and documentation |
Inspection Report
Plan of Correction
Census: 98
Deficiencies: 2
Date: Apr 29, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care and nursing regulations, specifically regarding notification of family or next of kin after changes in resident condition.
Findings
The facility failed to notify family or next of kin for two of three sampled residents after changes in condition, including new skin tears and bruising. Documentation of notifications was missing, and interviews revealed inconsistent notification practices.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to notify a resident's family or next of kin after changes in condition for two of three sampled residents, including new skin tears and bruising. Documentation of notifications was missing.
A4074 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the failure to notify family or next of kin as cited in F658.
Report Facts
Facility census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Emanuel | Director of Nursing | Named in plan of correction and documentation of notification |
Inspection Report
Routine
Census: 95
Deficiencies: 8
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to assess compliance with Medicare and Medicaid regulations, including resident assessments, care planning, hygiene, trauma-informed care, immunizations, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to issue required Medicare notices, incomplete significant change assessments, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, failure to provide trauma-informed care, improper garbage disposal, and failure to document immunizations or refusals.
Deficiencies (8)
Failed to issue Medicare Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Non-Coverage forms as required.
Failed to complete significant change assessments within 14 days for residents admitted to hospice care.
Failed to accurately code Minimum Data Set assessments for several residents.
Failed to implement comprehensive care plans addressing all resident needs including catheter care, anticoagulants, psychotropic medications, oxygen therapy, and mental health diagnoses.
Failed to provide adequate assistance with personal hygiene including hair care and oral hygiene for residents unable to perform these tasks.
Failed to identify, assess, and provide trauma-informed care and supportive interventions for a resident with Post-Traumatic Stress Disorder.
Failed to maintain covered trash containers in the kitchen and maintain dumpster area to prevent pests and contamination.
Failed to provide and document influenza and pneumococcal vaccinations or refusals with education for residents.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 4
Facility census: 95
Inspection Report
Life Safety
Census: 95
Deficiencies: 3
Date: Feb 23, 2023
Visit Reason
The inspection was conducted as an Emergency Preparedness Survey and Life Safety Code survey to assess compliance with fire safety and hazardous area regulations.
Findings
The facility failed to meet applicable provisions of the 2012 Life Safety Code related to hazardous areas, fire alarm system testing and maintenance, and electrical equipment power cords. Several deficiencies were noted including unsealed holes in the mechanical room ceiling, lack of annual fire alarm inspection in 2022, and improper use of power strips.
Deficiencies (3)
K321 Hazardous Areas - The facility failed to maintain hazardous areas, including unsealed holes in the mechanical room ceiling. This potentially affected all residents and staff.
K345 Fire Alarm System - The facility failed to ensure an annual fire alarm inspection was conducted as required by NFPA 72. The last inspection was dated 10/12/2021.
K920 Electrical Equipment - Power cords and extension cords were improperly used, including ordinary power strips not meeting UL standards in patient care areas. This potentially affected all residents and staff.
Report Facts
Facility census: 95
Date of last fire alarm inspection: Oct 12, 2021
Inspection Report
Plan of Correction
Census: 91
Deficiencies: 1
Date: May 26, 2022
Visit Reason
The document is a Plan of Correction related to a COVID-19 vaccination deficiency identified during a survey of Community Manor on 05/26/2022.
Findings
The facility failed to ensure 100% of staff had received all doses of a COVID-19 vaccine series or had been granted exemptions or temporary delays. The facility had 95.7% of staff fully vaccinated or exempted, with zero resident infections in the past four weeks and a census of 91.
Deficiencies (1)
F888 COVID-19 vaccination of facility staff. The facility failed to ensure all staff were fully vaccinated or properly exempted according to CDC guidelines. The facility had 95.7% of staff vaccinated or exempted but did not meet the 100% requirement.
Report Facts
Staff vaccination percentage: 95.7
Facility census: 91
Staff total count: 71
Partially vaccinated staff: 3
Inspection Report
Routine
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was 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 infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 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
Routine
Deficiencies: 0
Date: Sep 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's 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 infection control practices for COVID-19.
Report Facts
Regulation reference: 42
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 2
Date: May 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess infection prevention and control practices related to COVID-19.
Findings
The facility failed to use proper infection control practices to prevent and minimize the spread of COVID-19, including improper use of PPE and lack of an Infection Prevention Control Program (IPCP). The facility's census was 91 at the time of the survey.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to use proper infection control practices to prevent and minimize the spread of COVID-19, including failure to wear PPE correctly and lack of an IPCP program.
A4085 Infection Control/Communicable Disease: The facility failed to report communicable diseases as required by state regulations.
Report Facts
Census: 91
Sampled residents: 11
Completion dates: Jul 8, 2020
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 25
Date: Feb 28, 2020
Visit Reason
Annual inspection survey conducted on February 28, 2020, to assess compliance with federal and state regulations for nursing facility Community Manor in Farmington, MO.
Findings
The facility failed to treat three residents with dignity and respect, ensure accuracy of residents' advance directives, provide timely and accurate notices for Medicare and transfers, maintain accurate care plans, and implement effective infection control and medication administration practices. Multiple deficiencies were cited related to resident rights, advance directives, notice requirements, care planning, infection control, and medication errors.
Deficiencies (25)
F550 Resident Rights: The facility failed to treat three residents with dignity and respect during meal assistance and care activities.
F578 Advance Directives: The facility failed to ensure accuracy of one resident's advance directive regarding resuscitation status.
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue required notices to beneficiaries of covered skilled services ending for two residents.
F623 Notice Requirements Before Transfer/Discharges: The facility failed to provide timely written notification of transfer or discharge to residents and representatives for five residents.
F624 Preparation for Safe/Orderly Transfer/Discharge: The facility failed to document preparation and orientation for transfer to hospital for four residents.
F641 Hospice Care: The facility failed to ensure hospice care plans were updated and accurate for three residents.
F655 Baseline Care Plan: The facility failed to develop and implement baseline care plans for three residents within 48 hours of admission.
F656 Care Plan Timing and Revision: The facility failed to update and revise care plans with specific interventions for six residents.
F678 Cardiopulmonary Resuscitation (CPR): The facility failed to ensure CPR certification for staff on each shift for 33 residents who were full code.
F679 Activities Meet Interests/Needs Each Resident: The facility failed to provide an ongoing program of activities for one resident.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide appropriate treatment and services to maintain or improve mobility for three residents.
F689 Diagnoses of pneumonia and altered mental status: The facility failed to provide adequate care for a resident admitted to a locked unit due to confusion and wandering.
F690 Bowel/Bladder Incontinence, Catheter, JTI: The facility failed to provide appropriate catheter care and infection prevention for one resident.
F759 Free of Medication Error Rts 5 Pront or More: The facility failed to maintain an error rate of less than 5% for medication administration with 27 errors in 27 opportunities.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure one resident was free from significant medication errors.
F880 Infection Control: The facility failed to establish and maintain an infection prevention and control program including antibiotic stewardship and infection tracking.
F881 Antibiotic Stewardship Program: The facility failed to include all core elements of an antibiotic stewardship program and provide education to staff.
A4054 Nursing Care per Res Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice.
A4080 Restorative Nursing, Res Out of Bed: Facilities shall provide restorative nursing to encourage independence and activity for each resident.
A4085 Infection Control/Communicable Disease: Residents shall be cared for using acceptable infection control procedures to prevent spread of infection.
A4074 Nursing Care per Res Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice.
A4010 Activity Program: The facility shall designate an employee responsible for the activity program to meet residents' activity needs.
A4074 Nursing Care per Res Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice.
A4054 Nursing Care per Res Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice.
A4080 Restorative Nursing, Res Out of Bed: Facilities shall provide restorative nursing to encourage independence and activity for each resident.
Report Facts
Facility census: 65
Residents sampled: 18
Medication error opportunities: 27
Medication error rate: 11.11
Residents with medication errors: 1
Residents on antibiotics: 16
Residents with CPR full code: 33
Inspection Report
Life Safety
Census: 85
Deficiencies: 2
Date: Feb 28, 2020
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 fire alarm notification devices in resident use areas and failed to remain free of combustibles mixed with cigarettes. These deficiencies potentially affected all residents and staff.
Deficiencies (2)
K343 Fire Alarm System - Notification: The facility failed to maintain fire alarm notification devices in resident use areas. Observation showed no horn and strobe notification device for the fire alarm in the south courtyard.
K741 Smoking Regulations: The facility failed to remain free of combustibles mixed with cigarettes. Observation showed a trash can with a large amount of cigarette butts mixed with combustibles.
Report Facts
Facility census: 85
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 6
Date: Jul 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on complaint numbers #MO157817 and #MO158370, focusing on deficiencies related to baseline care plans, care plan timing and revision, bowel/bladder incontinence, catheter care, and drug regimen review.
Complaint Details
Complaint #MO157817 and Complaint #MO158370 triggered the investigation. The complaints involved issues with care planning, catheter care, and medication management. Substantiation status is not explicitly stated.
Findings
The facility failed to develop and implement baseline and comprehensive care plans for certain residents, ensure appropriate catheter care and treatment, and adequately respond to pharmacist recommendations regarding psychotropic medications. Multiple deficiencies were identified related to care planning, catheter management, and medication review.
Deficiencies (6)
F655 Baseline Care Plan: The facility failed to develop and implement a baseline care plan including specific interventions for one resident out of nine sampled. The facility census was 82.
F657 Care Plan Timing and Revision: The facility failed to develop a comprehensive care plan within seven days after the comprehensive assessment for one resident. The facility census was 82.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide appropriate treatment and obtain a physician's order for a resident with a clinically-justified indwelling catheter. The facility census was 82.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to ensure physician response to pharmacist recommendations for psychotropic medications for one resident out of nine sampled. The facility census was 82.
A4109 Progress Notes - care/treatment: Facilities failed to ensure resident clinical records contained progress notes including response to care and treatment. Refer to F690.
A8013 Right to Plan Care/Refuse Treatment: Residents were not afforded the opportunity to participate in planning or refuse treatment as required. Refer to F655 and F657.
Report Facts
Facility census: 82
Sampled residents: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Smith | VN, CNHA | Laboratory Director or Provider/Supplier Representative signing the report |
| Licensed Practical Nurse (LPN) B | Interviewed regarding baseline care plan and catheter orders | |
| Director of Nursing (DON) | Interviewed regarding care plans, catheter care, and medication management |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: May 30, 2019
Visit Reason
The inspection was conducted in response to a complaint (#156287) regarding the facility's failure to follow a physician's order for one resident.
Complaint Details
Complaint #156287 was substantiated as the facility failed to follow a physician's order for medication for one resident.
Findings
The facility failed to follow a physician's order for medication (Keflex) for one resident, resulting in delayed medication administration. The facility did not have proper documentation or processes to ensure timely receipt and transcription of hospital discharge orders.
Deficiencies (2)
F658: The facility failed to follow a physician's order for one resident, resulting in delayed administration of Keflex medication. Documentation and communication processes for hospital discharge orders were inadequate.
A4074: The facility did not provide personal attention and nursing care in accordance with the resident's condition and current acceptable nursing practice, as evidenced by the deficiency in F658.
Report Facts
Resident census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Smith | LPN, LNHA | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: May 16, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding abuse and neglect involving a cognitively impaired resident.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews showing that a Certified Medication Tech took and shared a nude photo of Resident #1 without consent. The resident was cognitively impaired and unable to protect themselves from this abuse.
Findings
The facility failed to protect a cognitively impaired resident from mental abuse and humiliation when staff took an unauthorized nude photo of the resident. The photo was taken by a Certified Medication Tech and shared without consent, violating resident dignity and privacy.
Deficiencies (2)
F600: The facility did not protect Resident #1 from abuse and neglect as staff took an unauthorized nude photo of the resident, exposing the resident's breasts and waist up. The photo was shared via multimedia message without resident consent.
A8030: The facility failed to ensure resident dignity and privacy as evidenced by the unauthorized photo incident violating resident rights during care and treatment.
Report Facts
Facility census: 82
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 7
Date: Jan 30, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Community Manor, detailing deficiencies found during a survey conducted on January 30, 2019.
Findings
The facility was found deficient in several areas including surety bond security for residents' personal funds, notification requirements before transfer or discharge, development and implementation of comprehensive care plans, discharge summaries, posting of nurse staffing information, storage of drugs and biologics, and infection prevention and control practices.
Deficiencies (7)
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain a surety bond equal to at least one and one half times the average monthly balance of residents' personal funds for 12 consecutive months.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify the Missouri State Long-Term Care Ombudsman of resident transfers or discharges as required.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement an individualized comprehensive care plan for one resident, including measurable objectives and timeframes.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for one resident, lacking recapitulation of stay and medication reconciliation.
F732 Posted Nurse Staffing Information: The facility failed to post nurse staffing data with correct date and census for public access.
F761 Label/Store Drugs and Biologicals: The facility failed to store medications under proper temperature controls in locked compartments and maintain accurate temperature logs.
F880 Infection Prevention & Control: The facility failed to maintain adequate infection control practices, including hand hygiene and use of gloves, for residents at risk of infection.
Report Facts
Facility census: 76
Surety bond amount: 20000
Average monthly balance: 13563.17
Increased surety bond amount: 25000
Temperature range: 26
Temperature range: 36
Hand hygiene indication count: 68400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne W. Moore | Administrator | Signed the Statement of Deficiencies and Plan of Correction. |
| Director of Nursing | Director of Nursing | Interviewed regarding catheter care, discharge summary, nurse staffing, medication storage, and infection control practices. |
| LPN B | Licensed Practical Nurse | Interviewed and observed regarding hand hygiene and resident care. |
| Registered Nurse F | Registered Nurse | Interviewed regarding medication storage. |
| Certified Nurse Aide C | Certified Nurse Aide | Observed providing ostomy care and hand hygiene. |
| Certified Nurse Aide D | Certified Nurse Aide | Observed providing peri-care and hand hygiene. |
Inspection Report
Life Safety
Census: 76
Deficiencies: 4
Date: Jan 29, 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 fire safety regulations.
Findings
The facility failed to maintain smoke barrier walls and did not properly store oxygen tanks in accordance with NFPA standards. These deficiencies potentially affected all residents and staff.
Deficiencies (4)
K372: The facility failed to maintain smoke barrier walls, including an unsealed 4-inch electrical conduit penetrating the 100 hall wall. This deficiency potentially affected all residents and staff.
K923: The facility did not store oxygen tanks according to NFPA 99 standards, mixing empty and full tanks without proper separation or labeling. This deficiency potentially affected all residents and staff.
A1036: The facility lacked an oxygen storage room surrounded by one-hour rated construction with proper ventilation to the outside, violating 19 CSR 30-85.012(36).
A2054: Smoke section walls and doors were not properly separated by one-hour fire-rated walls and doors as required by 19 CSR 30-85.022(29).
Report Facts
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Harold W. Moore | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Annual Inspection
Census: 78
Capacity: 99
Deficiencies: 8
Date: Mar 8, 2018
Visit Reason
Annual survey conducted to assess compliance with Medicare and Medicaid regulations at Community Manor nursing facility.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare notices, inadequate reporting of alleged abuse, incomplete comprehensive care plans, insufficient discharge summaries, improper catheter care, inadequate RN staffing, incomplete facility-wide assessments, and infection control deficiencies.
Deficiencies (8)
F582 The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) and provide at least 48 hours notice of benefit end date for Medicare-covered services to residents.
F609 The facility failed to immediately report an allegation of resident-to-resident abuse to the administrator and other officials as required by state law.
F656 The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents.
F661 The facility failed to complete a comprehensive discharge summary for discharged residents as required.
F690 The facility failed to ensure proper care and maintenance of urinary catheters and to prevent urinary tract infections for residents.
F727 The facility failed to provide a registered nurse for at least 8 consecutive hours a day, 7 days a week, as required by regulation.
F838 The facility failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources for resident care during day-to-day operations and emergencies.
F880 The facility failed to establish and maintain an effective infection prevention and control program, including proper use of gloves and cleaning of glucometers.
Report Facts
Facility census: 78
Total capacity: 99
Sampled residents: 22
Days RN not scheduled: 38
Inspection Report
Life Safety
Census: 78
Deficiencies: 6
Date: Mar 8, 2018
Visit Reason
The inspection was a life safety code survey to assess compliance with fire sprinkler systems, corridor door requirements, heating devices, oxygen storage, and other fire safety regulations at Community Manor.
Findings
The facility failed to maintain complete fire sprinkler coverage, had corridor doors held open with blocks, used portable space heaters improperly, and failed to maintain proper oxygen cylinder storage. The facility census was 78 residents at the time of inspection.
Deficiencies (6)
K351 The facility does not meet the 2012 Life Safety Code requirements for complete fire sprinkler coverage throughout the building, including roof overhangs without sprinkler coverage.
K353 The facility failed to maintain the fire sprinkler system according to NFPA code, including accumulation of dust and debris on sprinkler heads.
K363 The facility failed to maintain corridor doors free from impediments preventing closure, including a door held open with a block.
K522 The facility failed to maintain gas-fired heating equipment with proper intake air from outside, including two gas-fired water heaters without proper venting.
K781 The facility failed to prohibit the use of portable space heaters in the facility, with a portable heater observed in a conference room.
K923 The facility failed to maintain proper oxygen cylinder storage, including mixing empty and full tanks and inadequate storage conditions.
Report Facts
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Travis W. Moore | Administrator | Signed the inspection report and plan of correction |
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