Inspection Reports for
Cottages of Lake St. Louis
2885 Technology Dr, Lake St Louis, MO 63367, United States, MO, 63367
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
82% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
The inspection was conducted due to complaints regarding the treatment of residents, specifically concerns about dignity and respect during care.
Complaint Details
The complaint investigation found substantiated issues regarding disrespectful treatment of residents. Resident #75 reported being abruptly awakened and treated discourteously by staff during night care. Resident #100 reported a caretaker throwing off his/her sheet without asking and touching a private area, though the resident did not feel scared or that the incident was sexual. Interviews with the Director of Nursing and Administrator confirmed expectations for respectful and dignified treatment of residents.
Findings
The facility failed to ensure that two residents were treated with dignity and respect. Residents reported feeling disrespected and discouraged by staff behavior during care, including abrupt awakenings, loud announcements, and inappropriate handling during bed checks.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Report Facts
Residents sampled: 18
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for staff behavior and resident care |
| Administrator | Administrator | Interviewed regarding expectations for staff behavior and resident care |
Inspection Report
Life Safety
Census: 49
Capacity: 60
Deficiencies: 4
Date: Oct 16, 2023
Visit Reason
A Life Safety Code survey was conducted by the Missouri Department of Health and Senior Services to assess compliance with Medicare/Medicaid participation requirements and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including means of egress obstructions, corridor door issues, and electrical system maintenance. These deficiencies had the potential to affect residents in multiple buildings within the facility.
Deficiencies (4)
K211 Means of Egress - General: The facility failed to ensure the means of egress was continuously maintained free of all obstructions, including improperly posted stop signs on exit doors, affecting multiple buildings with capacities ranging from 9 to 10 residents.
K363 Corridor - Doors: The facility failed to ensure corridor bedroom doors were without impediments to closing, with several doors stuck in frames after attempts to close, affecting residents in multiple cottages.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain the essential electrical system, including generator transfer switches lacking battery powered lighting, affecting all residents in several cottages.
K926 Gas Equipment - Qualifications and Training of Personnel: The facility failed to provide documented evidence of staff training on the safe handling of medical gases and cylinders, affecting all residents in multiple cottages.
Report Facts
Occupied beds: 49
Total capacity: 60
Building capacity: 10
Census per building: 9
Census per building: 10
Census per building: 7
Census per building: 7
Census per building: 10
Census per building: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Kessel | Administrator | Signed the report and mentioned in interview verifying findings |
| Vice President of Operations | Interviewed to verify presence of signs and door issues | |
| Maintenance Director | Interviewed to verify electrical system deficiencies and lighting issues | |
| Administrator | Interviewed regarding staff training on medical gases |
Inspection Report
Routine
Census: 48
Deficiencies: 4
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations related to pressure ulcer care and food safety in a nursing home facility.
Findings
The facility failed to provide timely identification, assessment, and treatment of pressure ulcers for two residents, resulting in actual harm. Additionally, the facility failed to ensure proper labeling and dating of thawed foods, adequate monitoring of dishwasher temperatures, and proper food temperature monitoring during meal preparation and service.
Deficiencies (4)
Failure to conduct timely identification, assessment, and treatment of pressure ulcers for residents resulting in progression to advanced stages.
Failure to ensure thawed foods were properly labeled and/or dated as required.
Failure to ensure the high-temperature dishwasher was monitored for effective sanitation.
Failure to ensure food temperatures were properly monitored during meal preparation and service.
Report Facts
Resident sample size: 21
Resident census: 48
Pressure ulcer measurements: 11.5
Pressure ulcer measurements: 20.9
Pressure ulcer measurements: 3
Pressure ulcer measurements: 5
Missed meal temperature documentation: 41
Missed meal temperature documentation: 22
Missed meal temperature documentation: 31
Missed meal temperature documentation: 42
Missed meal temperature documentation: 25
Missed meal temperature documentation: 44
Dishwasher wash cycle temperature: 137
Dishwasher rinse cycle temperature: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 2 | LPN | Provided wound measurements and treatment details for Resident 47 |
| Director of Nursing | DON | Reviewed wound care documentation and facility policies, provided insights on care deficiencies |
| In-House Physician | Physician | Provided medical oversight and comments on Resident 47's pressure ulcers |
| Care Partner 11 | Care Partner | Provided information on Resident 47's mobility and wound observations |
| Nurse Practitioner | NP | Monitored Resident 43's wound care and antibiotic treatment |
| Licensed Practical Nurse 1 | LPN | Performed wound care and communicated with nurse practitioner for Resident 43 |
| Care Partner 1 | Care Partner | Provided care details and wound care observations for Resident 43 |
| Infection Preventionist | IP | Oversaw wound care performance improvement plan and staff education |
| Medical Director | Medical Director | Oversight of wound care prior to Nurse Practitioner assuming responsibility |
| Dietary Manager | DM | Provided information on food service, training, and dishwasher temperature monitoring |
| Care Partner 8 | Care Partner | Observed food temperature monitoring and dishwasher use |
| Care Partner 9 | Care Partner | Observed food temperature monitoring |
| Care Partner 10 | Care Partner | Observed food temperature monitoring and documentation |
| Administrator | Administrator | Provided facility oversight and comments on food service processes |
| MDS Coordinator 1 | MDS Coordinator | Provided information on wound care documentation and antibiotic treatment for Resident 43 |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 4
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding inadequate pressure ulcer care and food safety concerns at the facility.
Complaint Details
The complaint investigation focused on pressure ulcer care failures for residents R43 and R47, including delayed wound assessment and treatment leading to advanced stage ulcers. It also included food safety concerns such as improper thawing, labeling, temperature monitoring, and dishwasher sanitation affecting 48 residents.
Findings
The facility failed to provide timely identification, assessment, and treatment of pressure ulcers for two residents, resulting in progression to advanced stage IV wounds causing actual harm. Additionally, the facility failed to ensure proper thawing, labeling, and temperature monitoring of foods, as well as effective sanitation of dishwashers, posing potential food-borne illness risks.
Deficiencies (4)
Failed to conduct timely identification, assessment, and treatment of pressure ulcers for residents R43 and R47, resulting in progression to stage IV pressure ulcers.
Failed to ensure thawed foods were properly labeled and/or dated as required.
Failed to ensure the high-temperature dishwasher was monitored for effective sanitation.
Failed to ensure food temperatures were properly monitored during meal preparation and service.
Report Facts
Resident sample size: 21
Pressure ulcer measurements: 11.5
Pressure ulcer measurements: 20.9
Pressure ulcer measurements: 3
Pressure ulcer measurements: 5
Missed meal temperature logs: 41
Missed meal temperature logs: 22
Missed meal temperature logs: 31
Missed meal temperature logs: 42
Missed meal temperature logs: 25
Missed meal temperature logs: 44
Food temperature: 145
Food temperature: 196
Food temperature: 128
Food temperature: 150
Food temperature: 205
Food temperature: 133
Food temperature: 98
Food temperature: 115
Dishwasher wash cycle temperature: 137
Dishwasher rinse cycle temperature: 110
Dishwasher wash cycle temperature: 158
Dishwasher rinse cycle temperature: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 2 | LPN | Provided wound measurements and treatment details for resident R47 |
| Director of Nursing | DON | Reviewed wound care documentation and facility policies, provided expectations for skin assessments |
| In-House Physician | Physician | Discussed resident R47's pressure ulcers and treatment |
| Care Partner 11 | CP | Provided information on resident R47's mobility and wound observations |
| Care Partner 1 | CP | Discussed wound care and showering practices for resident R43 |
| Licensed Practical Nurse 1 | LPN | Performed wound care and communicated with nurse practitioner for resident R43 |
| Nurse Practitioner | NP | Monitored wound care and antibiotic treatment for resident R43 |
| Medical Director | MD | Oversaw wound care prior to NP involvement |
| Infection Preventionist | IP | Managed wound tracking and staff education |
| MDS Coordinator 1 | MDSC | Confirmed wound care treatments and antibiotic use for resident R43 |
| Dietary Manager | DM | Discussed food safety practices, dishwasher monitoring, and temperature logs |
| Care Partner 8 | CP | Observed food temperature monitoring and dishwasher use |
| Care Partner 9 | CP | Discussed food temperature monitoring and recipe knowledge |
| Care Partner 10 | CP | Discussed food temperature documentation practices |
| Administrator | Administrator | Confirmed wound tracking program and food service concerns |
Inspection Report
Recertification And Complaint Investigation
Census: 49
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Missouri Department of Health and Senior Services to assess compliance with 42 CFR 483 subpart B.
Complaint Details
The survey included a complaint investigation component as indicated by the recertification and complaint survey description. Specific substantiation status is not explicitly stated.
Findings
The facility was found not to be in substantial compliance with federal regulations, with deficiencies related to pressure ulcer prevention and treatment, and food safety practices including thawed food labeling and dishwasher temperature monitoring.
Deficiencies (2)
F686: The facility failed to conduct timely identification, assessment, and treatment of pressure ulcers for residents, resulting in harm and worsening of stage IV pressure ulcers.
F812: The facility failed to ensure proper thawing, labeling, and temperature monitoring of food, risking food-borne illness among residents.
Report Facts
Survey Census: 49
Sample Size: 21
Supplemental Residents: 0
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Kiesel | Administrator | Signed the initial comments page of the report |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 20, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
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
Census: 52
Deficiencies: 4
Date: Mar 29, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, and misappropriation of resident property involving medication administration by a Licensed Practical Nurse (LPN).
Complaint Details
The investigation was triggered by allegations of abuse, neglect, and misappropriation of medication by Licensed Practical Nurse LPN L. The complaint was substantiated based on interviews, record reviews, and pharmacy audits showing medication discrepancies and failure to report incidents.
Findings
The facility failed to report an allegation of misappropriation of medication involving one resident and failed to follow professional standards in administering narcotic pain medications for multiple residents. The facility also failed to initiate cardiopulmonary resuscitation (CPR) for a resident with a full code status. Additionally, the facility failed to ensure a safe environment free from accident hazards, resulting in a resident fall with injury.
Deficiencies (4)
F609: The facility failed to report an allegation of misappropriation of medication involving one resident and did not follow proper reporting procedures for suspected abuse or neglect.
F658: The facility failed to ensure staff followed professional standards in administering narcotic pain medications, including administering without physician orders and failing to document administration properly for multiple residents.
F678: The facility failed to initiate cardiopulmonary resuscitation (CPR) for a resident with a full code status and failed to maintain proper documentation and staff training related to CPR.
F689: The facility failed to maintain a safe environment free from accident hazards, resulting in a resident fall with injury and inadequate follow-up and documentation of falls.
Report Facts
Facility census: 52
Resident count reviewed: 20
Resident count with failed standards: 4
Resident count with falls: 1
Resident count with CPR failure: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Smith | Administrator | Signed the statement of deficiencies and plan of correction |
| LPN L | Named in findings related to medication misappropriation and failure to follow medication administration protocols | |
| LPN E | Named in findings related to failure to provide CPR and documentation | |
| Director of Nursing (DON) | Interviewed regarding medication administration and CPR failures |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and Infection Control Survey were 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 CFR483.73 and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 16, 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 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 3, 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 practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 2
Date: Feb 11, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards related to medication administration, specifically regarding the use of Coumadin for one resident.
Findings
The facility failed to follow physician orders for administering Coumadin to one resident, resulting in an incorrect medication start date and a missed dose. The facility did not identify the error prior to the investigation.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to follow physician orders for administration of Coumadin for one resident, resulting in an incorrect start date and missed dose.
A4074 19 CSR 30-85.042(67) Nursing Care per Res Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation is not met as evidenced by failure to follow physician orders for Coumadin administration.
Report Facts
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Blandi Smith | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 3
Date: Dec 13, 2019
Visit Reason
The inspection was conducted to evaluate food procurement, storage, preparation, and serving sanitary conditions at Cottages of Lake St Louis.
Findings
The facility failed to ensure food items were discarded when expired and failed to store scoops properly. Multiple observations found expired food items and food debris in refrigerators and freezers across several cottages.
Deficiencies (3)
F812 Food safety requirements were not met. The facility failed to discard expired food and maintain clean refrigerators and freezers free of dirt and food debris.
A7015 Food must be protected from contamination and held at proper temperatures. This regulation was not met as evidenced by expired food items and improper storage.
A7065 Food-contact surfaces must be washed, rinsed, and sanitized at intervals based on food temperature and type. This regulation was not met as evidenced by food-contact surfaces not properly sanitized.
Report Facts
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Smith | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Life Safety
Census: 10
Capacity: 10
Deficiencies: 2
Date: Dec 13, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain corridor doors in multiple cottages to resist the passage of smoke. Doors did not latch properly and had gaps large enough to see through, violating NFPA 101 standards.
Deficiencies (2)
42 CFR 483.90(a) and NFPA 101 Corridor Doors: The facility failed to maintain corridor doors in multiple cottages to resist the passage of smoke. Doors did not latch properly and had gaps large enough to see through.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: The building is not substantially constructed and maintained in good repair as required. Refer to K363 for details.
Report Facts
Building capacity: 10
Census: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Smith | Administrator | Signed deficiency statements and plan of correction |
Inspection Report
Routine
Census: 57
Deficiencies: 1
Date: Dec 11, 2019
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically focusing on the procurement, storage, preparation, distribution, and serving of food in accordance with professional standards.
Findings
The facility failed to ensure expired food items were discarded and scoops were stored properly outside of food containers. Additionally, the bottoms of freezers and refrigerators were found to be dirty and covered with food debris across multiple kitchen areas.
Deficiencies (1)
Failed to discard expired food items and store scoops outside food containers; freezers and refrigerators were dirty and covered with food debris.
Report Facts
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding cleaning responsibilities and food safety practices | |
| Administrator | Interviewed regarding expectations for food discard and cleaning procedures |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 2
Date: Jul 16, 2019
Visit Reason
The inspection was conducted to assess compliance with quality of care regulations, specifically related to the care of residents with catheters and related treatment plans.
Findings
The facility failed to provide timely and appropriate care to a resident with a urinary catheter, resulting in discomfort and anxiety. Staff did not intervene promptly to address catheter obstruction and related symptoms, and communication with hospice and family was inadequate.
Deficiencies (2)
F684 Quality of care: The facility failed to identify and provide needed care and services to a resident with a urinary catheter, resulting in discomfort and anxiety due to catheter obstruction. Staff did not intervene timely to symptoms related to the catheter.
A4074 Nursing care per resident condition: Each resident shall receive personal attention and nursing care consistent with their condition and current acceptable nursing practice. This regulation was not met as evidenced by the deficiency at F684.
Report Facts
Facility census: 52
Medication dosage: 0.5
Medication dosage: 20
Medication dosage: 800
Plan of correction completion date: Aug 12, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Smith | Administrator | Signed the statement of deficiencies and plan of correction |
| RN A | Registered Nurse | Involved in resident care and catheter management |
| LPN D | Licensed Practical Nurse | Provided care and medication administration to resident |
| RN B | Hospice Registered Nurse | Provided hospice care and catheter changes |
| Director of Nursing | Interviewed regarding catheter care and staff response |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 17
Date: Oct 30, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for the Cottages of Lake St Louis facility.
Findings
The facility was found deficient in multiple areas including resident council responsiveness, staff screening and registry checks, discharge summary completion, activity programming, accident hazards, food safety, staffing adequacy, and elopement risk management. Several deficiencies were classified with severity levels ranging from Class I to Class III.
Deficiencies (17)
F565 Resident/Family Group and Response: The facility failed to provide a resolution regarding residents' grievances filed in the resident council and did not respond to concerns about missing items, activities, dietary issues, and staffing.
F606 Not Employ/Engage Staff with Adverse Actions: The facility failed to screen three new employees for nurse aide registry status and did not complete required background checks prior to employment.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary and recapitulation of stay for one resident, including clinical and functional status.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide an ongoing program of meaningful activities based on resident preferences and assessments for multiple residents.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision and protective oversight for residents at risk of elopement, resulting in a resident leaving the building unsupervised.
F725 Sufficient Nursing Staff: The facility failed to provide sufficient nursing staff to meet resident needs and answer call lights in a timely manner for several residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary food storage and preparation areas, including labeling, dating, and cleaning of equipment and food items.
A4018 Criminal History Facility Policy/Procedure: The facility failed to implement policies ensuring persons hired have disclosed prior criminal history as required by state law.
A4038 SNF RN-Day Shift, LPN/RN eve/nights: The facility failed to provide consistent licensed nurse coverage on day shifts and weekends, with no RN coverage for eight consecutive hours on multiple days.
A4044 Nursing Staff Sufficient/Qualified: The facility failed to employ sufficient nursing personnel with appropriate qualifications to meet resident needs on a daily and continuous basis.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave, including procedures to track resident whereabouts.
A4100 Activity Program: The facility failed to designate an employee responsible for the activity program and to provide a planned program meeting resident needs and interests.
A6009 Air Ducts-Maintain: The facility failed to maintain intake and exhaust air ducts free of dust, dirt, and other contaminants.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain required temperatures during storage and preparation.
A7042 Ice Store/Dispense, No Contamination, Air Gap: The facility failed to properly store and dispense ice to prevent contamination.
A7057 Ventilation Hoods, Clean, Filters Removable: The facility failed to maintain clean ventilation hoods and filters in food preparation areas.
A8020 Exercise Rights/Voice Grievances: The facility failed to ensure residents were encouraged and assisted to exercise their rights and voice grievances.
Report Facts
Facility census: 39
Deficiencies cited: 16
Inspection Report
Life Safety
Deficiencies: 13
Date: Oct 30, 2018
Visit Reason
The inspection was conducted as an emergency preparedness survey and life safety code tour to assess compliance with emergency power systems, fire safety, and related regulations.
Findings
The facility failed to develop and maintain an emergency preparedness plan including an emergency generator fuel supply. Multiple fire safety deficiencies were cited including unsealed ceiling penetrations, inadequate fire barriers, delayed egress locking issues, and incomplete fire drills.
Deficiencies (13)
E041 Emergency and standby power systems: The facility failed to develop and maintain an emergency preparedness plan including an emergency generator fuel supply. The facility census was 39.
K161 Building Construction Type and Height: The facility failed to maintain fire barriers with a one-hour fire resistance rating by not repairing ceiling penetrations, affecting multiple residents and staff. The building capacity was 10 and census ranged from 3 to 8 in affected areas.
K222 Egress Doors: Delayed egress locking systems did not release within 15 seconds on multiple exit doors, potentially affecting residents, visitors, and staff in emergency exits. The building capacity was 10 and census was 3 to 8.
K343 Fire Alarm System - Notification: The facility failed to ensure complete annunciator communication from the main fire alarm panel to the smoke compartments, affecting all residents in two smoke compartments. The building capacity was 10 and census was 5.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of paint and debris in multiple cottages, potentially affecting all residents in two smoke compartments. The building capacity was 10 and census was 5 to 8.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers with unsealed holes and penetrations in multiple locations, affecting all residents in two smoke compartments. The building capacity was 10 and census was 5 to 8.
K712 Fire Drills: The facility failed to conduct fire drills quarterly on all shifts in two smoke compartments, potentially affecting all occupants. The building capacity was 10 and census was 3 to 8.
A2007 Noncombustible Material Between Floors: The facility failed to meet fire-stopping requirements for openings between floors, as referenced to K161.
A2019 Fire Alarm System-Test/Maintain: The facility failed to maintain complete fire alarm systems as evidenced by issues referenced to K343.
A2035 Complete Sprinkler System: The facility failed to maintain sprinkler systems as referenced to K353.
A2041 Door Locks: The facility failed to meet door lock requirements as referenced to K222.
A2054 Smoke Section Walls/Doors: The facility failed to maintain smoke section walls and doors as referenced to K372.
A2061 Fire Drill Requirements, Evacuation: The facility failed to conduct required fire drills and resident evacuations as referenced to K712.
Report Facts
Facility census: 39
Building capacity: 10
Census counts: 3
Census counts: 8
Deficiency counts: 13
Inspection Report
Routine
Census: 39
Deficiencies: 7
Date: Oct 30, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements including resident rights, staffing, discharge planning, activities, safety, and food service.
Findings
The facility failed to provide timely resolution of resident council grievances, failed to screen new employees for abuse or neglect history, failed to complete discharge summaries, failed to provide adequate activities, failed to prevent resident elopement and wandering, failed to ensure sufficient nursing staff to meet resident needs, and failed to maintain food safety and sanitation standards.
Deficiencies (7)
Failed to provide resolution regarding residents' grievances filed in resident council related to missing items, activities, dietary, and staffing.
Failed to screen three new employees for Federal Nurse Aide Registry indicators prohibiting employment.
Failed to complete a comprehensive discharge summary and recapitulation of stay for one resident.
Failed to provide an ongoing program of meaningful activities on a daily basis to meet residents' interests and well-being for four residents.
Failed to provide protective oversight to prevent elopement of one resident and wandering and intrusion into other residents' rooms and kitchen area by another resident.
Failed to ensure sufficient nursing staff to meet resident needs and answer call lights in a timely manner for three residents.
Failed to ensure food items were labeled, dated, covered or discarded when expired; failed to maintain ice machines, range hoods, fan shrouds, and ceiling vents; failed to ensure sanitary food preparation practices.
Report Facts
Facility census: 39
Call light wait times: 77
Call light wait times: 65
Call light wait times: 38
Call light wait times: 53
Call light wait times: 44
Call light wait times: 87
Call light wait times: 372
Call light wait times: 14
Call light wait times: 42
Call light wait times: 56
Call light wait times: 15
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