Inspection Reports for
Delmar Gardens of O’fallon
7068 SOUTH OUTER 364, O'FALLON, MO, 63368-7757
Back to Facility Profile18 Reports
Inspection Report — Mar 19, 2025
Routine
Date: Mar 19, 2025
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health citation for failure to ensure safe transfers and supervision related to use of a sit-to-stand mechanical lift that resulted in a resident injury, and one Missouri state citation (Class II) for failure to provide nursing care per resident referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F689.
Inspection Report — Aug 23, 2024
Routine
Date: Aug 23, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form for licensure; the survey type is not stated.
Findings
Two deficiencies were cited: a federal health citation for inadequate pest control/rodent infestation in multiple resident rooms, and a Missouri state licensure violation for insufficient rodent control referencing the federal finding.
Deficiencies (1)
19 CSR 30-87.020(39) Inspect/Rodent Control: See the deficiency cited at F925.
Inspection Report — May 14, 2024
Life Safety
Date: May 14, 2024
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CMS-2567 Life Safety Code survey (federal K-tag life safety findings) accompanied by Missouri Department of Health and Senior Services State Form pages (state licensure citations); life safety survey.
Findings
There are 13 federal life safety deficiencies (K-tags) addressing means of egress obstructions, egress doors/delayed egress issues, exit illumination failures, sprinkler installation and maintenance problems, unsealed vertical openings, kitchen hood/filter issues, electrical/power-strip hazards and unsecured gas cylinders. There are 12 Missouri State Form deficiencies (19 CSR citations) reflecting corresponding violations including noncombustible material/vertical openings, range hood certification and maintenance, fire alarm testing, emergency lighting, sprinkler system requirements, smoke barrier construction, smoking area provisions, dryer lint/venting, building maintenance and electrical wiring standards.
Deficiencies (12)
19 CSR 30-85.022(3) Noncombustible Material Between Floors: Refer to K311.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(10)(E) Fire Alarm System, Monthly Activation: The facility failed to activate the complete fire alarm system at least once a month as required.
19 CSR 30-85.022(11)(B) No Complete Sprinkler System Prior to 8/28/07: Refer to K351.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(12) Exit Requirements: Refer to K211 and K222.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K281.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Refer to K741.
19 CSR 30-85.022(36) Clothes Dryers Vented, Lint Traps: Refer to K100.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K920.
Report Facts
smoke compartments: 21
gas clothes dryers observed: 2
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) are included in the file; a complaint number MO232779 is cited in the record.
Complaint Details
MO232779; substantiation not stated in the document.
Findings
2 deficiencies were cited: one federal health deficiency for failure to consistently complete skin assessments and implement timely interventions/treatment for a sampled resident related to pressure ulcers, and one Missouri State citation for pressure sore prevention/treatment (Class II) that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: Refer to F686.
Report Facts
residents sampled: 6
Inspection Report — Apr 25, 2023
Routine
Date: Apr 25, 2023
Visit Reason
This file contains a federal health survey (CMS-2567) statement of deficiencies and a Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency related to free of accident hazards/supervision/devices concerning transfer and bed mobility methods, and one Missouri state deficiency for nursing care per resident condition; both reference failure to follow required transfer methods/policy.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F689.
Report Facts
residents sampled: 4
residents affected: 1
Inspection Report — Oct 27, 2022
Routine
Date: Oct 27, 2022
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Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two state deficiencies were cited: one for ceilings with mold-like substance and one for vents/fixtures with thick dust buildup throughout resident and utility areas.
Deficiencies (2)
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Based on observation and interview, the facility failed to maintain ceilings in a clean condition; multiple 3 foot by 3 foot areas in resident closets were covered with a black mold-like substance.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Decor Cleanable: Based on observation and interview, the facility failed to maintain light fixtures and vents free from buildup; multiple exhaust and ceiling vents throughout resident rooms, utility rooms, kitchen and staff areas were covered with a thick layer of dust.
Inspection Report — Jun 24, 2022
Complaint Investigation
Date: Jun 24, 2022
Visit Reason
CMS-2567 federal health survey and Missouri state licensure survey (State Form); a complaint investigation is cited (MO 202962).
Complaint Details
Complaint number MO 202962 cited; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal health citation involving resident rights related to staff conduct and one Missouri state licensure citation for dignity/privacy that refers to the federal finding.
Deficiencies (1)
19 CSR 30-88.010(29) Dignity/Privacy: Refer to F550.
Report Facts
residents sampled: 5
residents to be interviewed: 3
Inspection Report — Mar 10, 2022
Complaint Investigation
Date: Mar 10, 2022
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CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form licensure survey; the file contains a complaint investigation (MO#197568).
Complaint Details
Complaint number MO#197568; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal health deficiency for inadequate supervision and accident hazards, and one Missouri state licensure deficiency for protective oversight/voluntary leave that refers to the federal finding.
Deficiencies (1)
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Refer to F689.
Inspection Report — Sep 15, 2021
Complaint Investigation
Date: Sep 15, 2021
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Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; complaint investigation. Complaint numbers cited: MO190569, MO190112, MO190055, MO190044.
Complaint Details
MO190569, MO190112, MO190055, MO190044; substantiation not stated in the report.
Findings
Ten deficiencies were cited: five federal health deficiencies concerning resident abuse/neglect, failure to report and investigate alleged abuse, deficiencies in urinary catheter care documentation, and fall/accident prevention; and five Missouri State Form deficiencies that reference and cross‑reference those federal findings.
Deficiencies (5)
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Refer to F689.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F658.
19 CSR 30-88.010(22) Free From Abuse: Refer to F600.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F610.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Refer to F609.
Report Facts
residents sampled: 15
Inspection Report — Feb 11, 2020
Complaint Investigation
Date: Feb 11, 2020
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Federal health survey (CMS-2567) and Missouri state licensure form are included in this file; the survey references a complaint number MO166043 indicating a complaint investigation.
Complaint Details
MO166043; substantiation not stated in the document.
Findings
Two deficiencies were cited: a federal health citation for failure to follow professional standards related to wound care and medication/treatment administration resulting in treatments not completed, and a Missouri state licensure citation for nursing care per resident condition (Class I) referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F658.
Report Facts
residents sampled: 5
Inspection Report — Jan 23, 2020
Complaint Investigation
Date: Jan 23, 2020
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Federal health survey (CMS-2567) and Missouri State Form were included; a complaint investigation is cited (Complaint #MO165136).
Complaint Details
Complaint MO165136 is cited in the file. The facility's Plan of Correction states there was no evidence to suggest abuse occurred to Resident #1 and that the allegations have been unsubstantiated.
Findings
Four deficiencies were cited: two federal F-tags involving failure to promptly report and to investigate an allegation of sexual abuse, and two Missouri state citations addressing policy development/implementation and reporting to DHSS/DMH.
Deficiencies (2)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F610.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Refer to F609.
Report Facts
residents sampled: 5
Inspection Report — Oct 16, 2019
Routine
Date: Oct 16, 2019
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 12 federal health survey deficiencies covering resident dignity/rights, resident choice/self-determination, assistance with activities of daily living and personal care, pressure ulcer prevention/treatment, accident hazards and supervision, catheter/urinary care, sufficient staffing, psychotropic medication practices, nutrition/meal service and food safety, and infection prevention and control. It also contains 11 Missouri State Form deficiencies addressing nursing staffing/qualifications, protective oversight/leave, nursing care/resident condition, repositioning/body alignment, infection control/communicable disease, nutrition, food protection/temperature/food storage, dignity/privacy and resident personal rights.
Deficiencies (11)
19 CSR 30-85.042(37) Nursing Staff Sufficient/Qualified: The facility failed to ensure an adequate number of nursing staff with appropriate competencies and skills to provide nursing and related services necessary to attain or maintain highest practicable physical, mental and psychosocial well-being.
19 CSR 30-85.042(67) Protective Oversight/Voluntary Leave: The facility failed to provide required protective oversight and supervision related to voluntary leave and residents' whereabouts as evidenced by the survey findings.
19 CSR 30-85.042(67) Nursing Care per Resident Condition: The facility failed to ensure each resident received nursing care in accordance with their condition and current acceptable nursing practice.
19 CSR 30-85.042(70) Reposition Every 2 hr/Maintain Body Alignment: The facility failed to reposition residents and maintain body alignment as required to prevent pressure injuries and maintain comfort.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Residents were not cared for using acceptable infection control procedures to prevent spread of communicable disease, as evidenced by the survey findings.
19 CSR 30-85.05(21) Nutritional Needs Met/Assess Res, Inform Dr: The facility failed to ensure residents received nutritious food and that changes in nutritional status were appropriately assessed and communicated.
19 CSR 30-87.030(13) Food - Protected, Temperature, Need to Contact DHSS: The facility failed to protect food and maintain required temperatures and to notify DHSS as required when necessary.
19 CSR 30-87.030(20) Frozen Food at Zero Degrees F or Below/Freezer Management: The facility failed to maintain frozen food at required temperatures and ensure proper frozen food storage.
19 CSR 30-87.030(40) Ice Storage/Dispense, No Contamination, Air Gap: The facility failed to ensure ice handling and storage practices prevented contamination and maintained required separation/air gap.
19 CSR 30-88.01(029) Dignity/Privacy: The facility failed to treat residents with consideration and respect and to ensure recognition of each resident's privacy in treatment and care.
19 CSR 30-88.010(41) Resident Lives Not Regulated/Controlled: The facility failed to ensure residents have reasonable personal lives and schedules as appropriate to the facility and residents' safety, privacy and personal rights.
Report Facts
residents sampled: 25
Inspection Report — Oct 16, 2019
Life Safety
Date: Oct 16, 2019
Visit Reason
Federal CMS-2567 life safety pages (K-tags) and Missouri Department of Health and Senior Services State Form pages; Life Safety Code survey (K-tags present).
Findings
Six deficiencies were cited in this survey: three federal life safety deficiencies involving means of egress, exit signage/emergency illumination testing, and cooking facility suppression/hood inspection; and three Missouri state licensure deficiencies referencing range hood certification, exit requirements, and exit sign maintenance/illumination.
Deficiencies (3)
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(12) Exit Requirements: Refer to K211.
19 CSR 30-85.022(24) Exit Sign-Maintain/Illuminate: Refer to K293.
Report Facts
smoke compartments: 21
required emergency illumination test duration (minutes): 90
Inspection Report — Oct 30, 2018
Abbreviated Survey
Date: Oct 30, 2018
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Federal health survey (CMS-2567) and Missouri State Form licensure survey; the survey is an abbreviated survey.
Findings
Two deficiencies were cited: one federal health deficiency for failure to report an injury/allegation of abuse and one state licensure deficiency for failure to develop and implement abuse/neglect policies.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F609.
Report Facts
residents sampled: 9
Inspection Report — Sep 13, 2018
Routine
Date: Sep 13, 2018
Visit Reason
The file contains a federal health survey (CMS-2567) and a Missouri state licensure survey (State Form); the survey type is not stated in the forms.
Findings
22 deficiencies were cited. Federal findings addressed resident funds management, baseline care plans and care plan revisions, perineal/personal hygiene, pressure ulcer prevention and treatment, supervision/transfers and safe handling, incontinence and catheter care, food service/temperature and sanitation issues, infection prevention and control practices, and pneumococcal/immunization documentation. State licensure findings reference related violations of nursing care, pressure sore prevention, infection control, food service, resident funds procedures, and environmental/housekeeping standards.
Deficiencies (12)
19 CSR 30-85.042(67) Nursing Care per Resident Condition: See the deficiency cited at F689 and F690.
19 CSR 30-85.042(68) Clean, Dry, Odor Free: See the deficiency cited at F677.
19 CSR 30-85.042(75) Pressure Sore Prevention/Treatment: See the deficiency cited at F677.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F880 and F883.
19 CSR 30-87.020(12) Floor Surfaces: See the deficiency cited at F812.
19 CSR 30-87.003(3) Clean Clothing, Hair Restraints: See the deficiency cited at F812.
19 CSR 30-87.003(13) Food-Protected Temperature, Need to Contact DHSS: See the deficiency cited at F812.
19 CSR 30-87.003(20) Frozen Food at Zero Degrees F or Below: See the deficiency cited at F812.
19 CSR 30-87.003(65) Nonfood Contact Surfaces, Cleaned as Needed: See the deficiency cited at F812.
19 CSR 30-88.010(42) Resident Funds - Written Statement: See the deficiency cited at F567.
19 CSR 30-88.010(43) Resident Funds - Itemized Bill: See the deficiency cited at F567.
19 CSR 30-88.020(2) Resident Fund Use: See the deficiency cited at F567.
Report Facts
residents sampled: 27
total resident funds found in operating account: 47542.53
Inspection Report — Sep 13, 2018
Life Safety
Date: Sep 13, 2018
Visit Reason
CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form are present in the file; the survey type is not stated.
Findings
Seven deficiencies were cited: four federal Life Safety deficiencies concerning egress doors, kitchen/cooking equipment and grease accumulation, corridor door latching, and smoking area hazards; and three Missouri state deficiencies addressing door locks, ashtray/disposal in designated smoking areas, and building construction/maintenance (state items refer to the related K-tag findings).
Deficiencies (3)
19 CSR 30-85.022(16) Door Locks: Refer to K222.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Refer to K741.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
Report Facts
smoke compartments: 21
residents in certified beds: 136
Inspection Report — Jun 4, 2018
Routine
Date: Jun 4, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: a federal finding for failure to report a resident-to-resident physical abuse incident and a corresponding state finding for failure to report to state agencies.
Deficiencies (1)
19 CSR 30-88.01(25) Report A/N to DHSS/DMH When Needed: Refer to F609
Report Facts
residents sampled: 7
Inspection Report — Mar 22, 2018
Complaint Investigation
Date: Mar 22, 2018
Visit Reason
Federal health survey (CMS-2567) with Missouri Department of Health and Senior Services State Form pages; the file documents a complaint investigation and cites MO00140224 and MO00140227.
Findings
There are 6 deficiencies (3 federal and 3 state) addressing housekeeping/cleanliness, resident-to-resident sexual abuse and failures to protect/investigate/report, and state citations for floor surfaces, toilet room requirements, and written policies.
Deficiencies (3)
19 CSR 30-87.020(12) Floor Surfaces: Refer to F584.
19 CSR 30-87.020(41) Toilet Room Requirements: Refer to F584.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F600 and F609.
Report Facts
residents sampled: 5
24 CMS Surveys
Inspection Report — Mar 19, 2025
Routine
Date: Mar 19, 2025
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health citation for failure to ensure safe transfers and supervision related to use of a sit-to-stand mechanical lift that resulted in a resident injury, and one Missouri state citation (Class II) for failure to provide nursing care per resident referencing the federal finding.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview, and record review the facility failed to safely transfer a resident using a sit-to-stand mechanical lift, resulting in the resident's legs giving way and a severe laceration to the left lower extremity.
Inspection Report — Aug 23, 2024
Routine
Date: Aug 23, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form for licensure; the survey type is not stated.
Findings
Two deficiencies were cited: a federal health citation for inadequate pest control/rodent infestation in multiple resident rooms, and a Missouri state licensure violation for insufficient rodent control referencing the federal finding.
Deficiencies (1)
F925 Maintains Effective Pest Control Program: Based on observation, interview, and record review, the facility failed to provide an effective pest control program to address rodents in resident rooms; numerous rodent feces were observed in multiple resident rooms.
Inspection Report — May 14, 2024
Life Safety
Date: May 14, 2024
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CMS-2567 Life Safety Code survey (federal K-tag life safety findings) accompanied by Missouri Department of Health and Senior Services State Form pages (state licensure citations); life safety survey.
Findings
There are 13 federal life safety deficiencies (K-tags) addressing means of egress obstructions, egress doors/delayed egress issues, exit illumination failures, sprinkler installation and maintenance problems, unsealed vertical openings, kitchen hood/filter issues, electrical/power-strip hazards and unsecured gas cylinders. There are 12 Missouri State Form deficiencies (19 CSR citations) reflecting corresponding violations including noncombustible material/vertical openings, range hood certification and maintenance, fire alarm testing, emergency lighting, sprinkler system requirements, smoke barrier construction, smoking area provisions, dryer lint/venting, building maintenance and electrical wiring standards.
Deficiencies (13)
K100 General Requirements - Other: The facility had an accumulation of lint and debris above two of three gas dryers in the main laundry area, creating a fire hazard.
K211 Means of Egress - General: Means of egress were obstructed by trash cans, wheelchairs, equipment and other items blocking designated exit routes and exit discharges.
K222 Egress Doors: Designated emergency exit doors had impediments and delayed-egress locking hardware that failed to begin the unlocking sequence during testing, and stop signs/stickers were placed on exits.
K281 Illumination of Means of Egress: The facility failed to maintain continuous illumination at means of egress with multiple exit light fixtures burned out or not functioning.
K311 Vertical Openings - Enclosure: Vertical openings were not maintained with required fire resistance; there were unsealed penetrations and missing ceiling tiles exposing openings between floors.
K324 Cooking Facilities: Range hood baffle filters had grease buildup and gaps between filters and cooking equipment (a microwave) was found in a resident room, indicating inadequate control and maintenance of cooking facilities.
K351 Sprinkler System - Installation: The facility failed to ensure sprinkler coverage in the basement laundry/lint collection area where a sprinkler head was not installed.
K353 Sprinkler System - Maintenance and Testing: Sprinkler heads were dirty or covered, escutcheon plates were missing in locations, storage was too close to heads, and monthly visual inspections were not documented.
K363 Corridor - Doors: Corridor doors failed to positively latch, had unsealed gaps at the top or sides, and had impediments preventing proper closing and smoke resistance.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Smoke barriers had unsealed conduit and other penetrations and some dampers/motors failed during testing, allowing the passage of smoke.
K741 Smoking Regulations: Designated and surrounding smoking areas were not properly equipped or maintained; cigarette butts and combustible debris were observed and a self-closing receptacle failed to close properly.
K920 Electrical Equipment - Power Cords and Extension Cords: Numerous power strips, extension cords and multi-plug adapters were observed in resident rooms and facility areas, including motorized equipment and medical devices plugged into power strips.
K923 Gas Equipment - Cylinder and Container Storage: A compressed gas cylinder (helium) was observed unsecured and standing on the floor in an activity storage room.
Report Facts
smoke compartments: 21
gas clothes dryers observed: 2
Inspection Report — May 14, 2024
Annual Inspection
Date: May 14, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, infection control, medication management, food service, and facility safety.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, call light accessibility, medication administration, nutritional care, infection control practices, medication storage and disposal, food service safety and preparation, equipment maintenance, and vaccination compliance.
Deficiencies (16)
Failure to treat residents with dignity and respect, including verbal abuse and inappropriate staff comments.
Call lights were not accessible to residents, resulting in delayed assistance and skin irritation.
Failure to provide written notice of bed hold policy to residents transferred to hospital.
Failure to follow physician orders for thickened liquids, resulting in residents receiving incorrect liquid consistency.
Failure to obtain weekly weights as ordered and failure to notify physician of weight loss or supplement refusals.
Failure to provide adequate assistance with activities of daily living including showers, nail care, shaving, oral care, and incontinence care.
Unsafe transfer technique used with gait belt, placing hands under resident's arms instead of on gait belt.
Resident served food on Styrofoam despite care plan prohibiting it; resident ingested Styrofoam.
Failure to provide appropriate catheter care including improper handling of drainage tubing and catheter bags touching floor.
Failure to provide food according to diet orders including serving incorrect diet textures, missing menu items, incorrect portion sizes, and food served at improper temperatures.
Failure to follow proper infection control practices including hand hygiene, glove use, gown use, and storage of respiratory equipment.
Failure to properly store, label, date, and discard food items; failure to maintain sanitary conditions in food preparation and storage areas; failure to clean and maintain ice machines and food service equipment; failure to follow hygienic practices during food preparation and serving.
Failure to prime insulin pens and hold dose knob for required time during insulin administration, risking incorrect dosing.
Failure to secure controlled medications and failure to properly dispose of controlled medications per policy.
Failure to offer and administer pneumococcal vaccines according to CDC guidelines for eligible residents.
Failure to maintain equipment in good repair including frayed power cord on food processor and non-functioning refrigerator compartment.
Report Facts
Residents affected: 3
Residents affected: 12
Residents affected: 35
Weight loss: 11.4
Weight loss percentage: 5.9
Weight loss: 23
Weight loss percentage: 14.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN W | Licensed Practical Nurse | Administered insulin without priming pen or holding dose knob; failed to wash hands and change gloves properly during wound care and catheter care |
| CNA UU | Certified Nurse Aide | Failed to follow enhanced barrier precautions, hand hygiene, and glove use during catheter care |
| LPN TT | Licensed Practical Nurse | Failed to wash hands and change gloves properly during incontinence care |
| Dietary Aide H | Dietary Aide | Prepared mechanical soft broccoli salad incorrectly and served incorrect pudding portion size |
| Dietary Manager | Dietary Manager | Unaware of some food safety issues and equipment malfunctions; expected staff to follow diet orders and maintain food safety |
| CNA GG | Certified Nurse Aide | Failed to wash hands and change gloves properly during incontinence care |
| CMT HH | Certified Medication Technician | Failed to wash hands and change gloves properly during incontinence care |
| LPN Z | Licensed Practical Nurse | Failed to wash hands and change gloves properly during wound care and incontinence care |
| CNA BBB | Certified Nurse Aide | Unaware of enhanced barrier precautions and failed to wear gown when required |
| Dietary Aide G | Dietary Aide | Handled food with soiled gloves and touched eating surfaces of plates |
| Dietary Aide J | Dietary Aide | Handled food with bare hands and touched face and hair without hand hygiene |
| Dietary Aide I | Dietary Aide | Handled toast with bare hands and did not wash hands after touching face and hair |
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) are included in the file; a complaint number MO232779 is cited in the record.
Complaint Details
MO232779; substantiation not stated in the document.
Findings
2 deficiencies were cited: one federal health deficiency for failure to consistently complete skin assessments and implement timely interventions/treatment for a sampled resident related to pressure ulcers, and one Missouri State citation for pressure sore prevention/treatment (Class II) that references the federal finding.
Deficiencies (1)
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on interview and record review, the facility failed to consistently follow their policy to complete skin assessments to identify areas of concern and ensure timely implementation of interventions and treatment for one sampled resident (Resident #2) of six sampled residents.
Report Facts
residents sampled: 6
Inspection Report — Apr 25, 2023
Routine
Date: Apr 25, 2023
Visit Reason
This file contains a federal health survey (CMS-2567) statement of deficiencies and a Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency related to free of accident hazards/supervision/devices concerning transfer and bed mobility methods, and one Missouri state deficiency for nursing care per resident condition; both reference failure to follow required transfer methods/policy.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview, and record review, the facility failed to employ appropriate methods for transferring one resident when staff did not follow the resident's recommended transfer method and technique per the plan of care.
Report Facts
residents sampled: 4
residents affected: 1
Inspection Report — Oct 27, 2022
Annual Inspection
Date: Oct 27, 2022
Visit Reason
Federal health survey (CMS-2567) - recertification survey; facility Plan of Correction included.
Findings
Six federal health survey deficiencies were cited addressing environmental cleanliness and vent maintenance, untimely quarterly MDS assessments, failure to provide resident activities, inadequate behavioral health services, unsecured/improper medication storage, and unsanitary food service/kitchen practices.
Deficiencies (6)
F584 Safe/Clean/Comfortable/Homelike Environment: Based on observation and interview, the facility failed to maintain ceiling vents and ceilings in a clean condition; numerous exhaust and ceiling vents in resident rooms, hall housekeeping/utility rooms, kitchen and other areas were covered with a thick layer of dust and some closet areas had a black mold-like substance.
F638 Qrtly Assessment at Least Every 3 Months: Based on record review and interviews, the facility failed to timely complete and submit required quarterly Minimum Data Set (MDS) assessments for several residents.
F679 Activities Meet Interest/Needs Each Resident: Based on record review, observation, and interview, the facility failed to ensure one sampled resident was provided an activity calendar, invited to activities, and otherwise supported to participate in activities per the resident's preferences.
F740 Behavioral Health Services: Based on observation, interview, and record review, the facility failed to ensure behavioral health services were provided for a sampled resident whose records and observations showed ongoing depressive behavior, crying, and need for behavioral health follow-up.
F761 Label/Store Drugs and Biologicals: Based on observations and interviews, the facility failed to ensure medication carts and treatment carts were secured when unattended; medication cart was observed unlocked between rooms and treatment cart in nurses station area was unlocked with insulin pens accessible.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observation, interview, and record review, the facility failed to maintain the kitchen and food storage in a sanitary manner, including broken soap dispenser at handwashing sink, expired and undated food items, inadequate labeling/dating, incomplete temperature logs, dirty equipment, and other deficiencies in food handling and storage.
Report Facts
sample_size: 41
supplemental_residents: 5
residents_with_incomplete_quarterly_MDS_assessments: 6
Inspection Report — Jun 24, 2022
Complaint Investigation
Date: Jun 24, 2022
Visit Reason
CMS-2567 federal health survey and Missouri state licensure survey (State Form); a complaint investigation is cited (MO 202962).
Complaint Details
Complaint number MO 202962 cited; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal health citation involving resident rights related to staff conduct and one Missouri state licensure citation for dignity/privacy that refers to the federal finding.
Deficiencies (1)
F550 Resident Rights/Exercise of Rights: Based on observation, interview, and record review the facility failed to ensure Resident #1 was treated with dignity and respect; staff RN A made inappropriate retaliatory comments and residents reported the exchange.
Report Facts
residents sampled: 5
residents to be interviewed: 3
Inspection Report — Mar 10, 2022
Complaint Investigation
Date: Mar 10, 2022
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form licensure survey; the file contains a complaint investigation (MO#197568).
Complaint Details
Complaint number MO#197568; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal health deficiency for inadequate supervision and accident hazards, and one Missouri state licensure deficiency for protective oversight/voluntary leave that refers to the federal finding.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision for residents, allowing Resident #2 to repeatedly assist or attempt to assist Resident #1, change Resident #1's clothing, and expose Resident #1's genitalia without timely staff intervention.
Inspection Report — Sep 15, 2021
Complaint Investigation
Date: Sep 15, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; complaint investigation. Complaint numbers cited: MO190569, MO190112, MO190055, MO190044.
Complaint Details
MO190569, MO190112, MO190055, MO190044; substantiation not stated in the report.
Findings
Ten deficiencies were cited: five federal health deficiencies concerning resident abuse/neglect, failure to report and investigate alleged abuse, deficiencies in urinary catheter care documentation, and fall/accident prevention; and five Missouri State Form deficiencies that reference and cross‑reference those federal findings.
Deficiencies (5)
F600 Free from Abuse and Neglect: The facility failed to ensure residents were free from abuse and neglect as evidenced by multiple resident-to-resident altercations including a resident who stabbed another resident and other incidents of verbal and physical abuse that were not prevented or adequately managed by staff.
F609 Reporting of Alleged Violations: The facility failed to report incidents of resident-to-resident verbal abuse for one resident involving three other residents in a review of 15 sampled residents.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate allegations of resident verbal abuse and did not implement or document appropriate corrective actions to prevent further abuse while investigations were in progress.
F658 Services Provided Meet Professional Standards: The facility failed to follow professional standards for urinary catheter care and consistently document catheter output for Resident #15 across multiple shifts and dates.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate oversight and interventions to prevent falls, resulting in multiple falls and injuries to a resident and insufficient follow-up, documentation, and prevention measures.
Report Facts
residents sampled: 15
Inspection Report — Jan 29, 2021
Routine
Date: Jan 29, 2021
Visit Reason
CMS-2567 federal health and emergency preparedness forms; a COVID-19 Focused Emergency Preparedness survey and an Infection Control survey were conducted as stated on the form.
Findings
No federal health or emergency preparedness deficiencies were cited; the facility was found in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report — Dec 24, 2020
Routine
Date: Dec 24, 2020
Visit Reason
Federal CMS-2567 health and emergency preparedness forms; a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted.
Findings
No health or emergency preparedness deficiencies were cited. The facility was found in compliance with requirements related to COVID-19 infection control and emergency preparedness.
Inspection Report — Dec 1, 2020
Routine
Date: Dec 1, 2020
Visit Reason
CMS-2567 federal health and emergency preparedness (COVID-19 Focused Infection Control and Emergency Preparedness) survey; the survey type is COVID-19 focused infection control/emergency preparedness.
Findings
No federal health or emergency preparedness deficiencies were cited; the survey found the facility 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 — Nov 11, 2020
Routine
Date: Nov 11, 2020
Visit Reason
Federal CMS-2567 health survey (COVID-19 Focused Emergency Preparedness and Infection Control survey) as stated on the form; no complaint number reported.
Findings
No deficiencies were cited; the facility was found in compliance with emergency preparedness and infection control practices related to COVID-19 as noted in the initial comments.
Inspection Report — Jun 25, 2020
Routine
Date: Jun 25, 2020
Visit Reason
CMS-2567 (federal health statement of deficiencies) — a COVID-19 Focused Emergency Preparedness and a COVID-19 Focused Infection Control survey as stated on the form.
Findings
No health survey deficiencies were cited on the CMS-2567. Initial Comments state the facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6) and with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Feb 11, 2020
Complaint Investigation
Date: Feb 11, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure form are included in this file; the survey references a complaint number MO166043 indicating a complaint investigation.
Complaint Details
MO166043; substantiation not stated in the document.
Findings
Two deficiencies were cited: a federal health citation for failure to follow professional standards related to wound care and medication/treatment administration resulting in treatments not completed, and a Missouri state licensure citation for nursing care per resident condition (Class I) referencing the federal finding.
Deficiencies (1)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i): The facility failed to follow professional standards of practice for two residents in a review of sampled residents when facility staff failed to follow physician orders during wound care; record reviews, observations, and interviews showed multiple instances of treatments not completed due to unavailable medications or supplies and staff not completing ordered treatments.
Report Facts
residents sampled: 5
Inspection Report — Jan 23, 2020
Complaint Investigation
Date: Jan 23, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form were included; a complaint investigation is cited (Complaint #MO165136).
Complaint Details
Complaint MO165136 is cited in the file. The facility's Plan of Correction states there was no evidence to suggest abuse occurred to Resident #1 and that the allegations have been unsubstantiated.
Findings
Four deficiencies were cited: two federal F-tags involving failure to promptly report and to investigate an allegation of sexual abuse, and two Missouri state citations addressing policy development/implementation and reporting to DHSS/DMH.
Deficiencies (2)
F609 Reporting of Alleged Violations: Based on interview and record review, the facility failed to promptly report an allegation of sexual abuse involving one resident (Resident #1) to the State Survey Agency and did not report the allegation until 1/6/20.
F610 Investigate/Prevent/Correct Alleged Violation: Based on interview and record review, the facility failed to conduct a timely and thorough investigation and allowed the alleged staff member to continue working after the allegation, failing to protect the resident and prevent potential harm.
Report Facts
residents sampled: 5
Inspection Report — Oct 16, 2019
Routine
Date: Oct 16, 2019
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 12 federal health survey deficiencies covering resident dignity/rights, resident choice/self-determination, assistance with activities of daily living and personal care, pressure ulcer prevention/treatment, accident hazards and supervision, catheter/urinary care, sufficient staffing, psychotropic medication practices, nutrition/meal service and food safety, and infection prevention and control. It also contains 11 Missouri State Form deficiencies addressing nursing staffing/qualifications, protective oversight/leave, nursing care/resident condition, repositioning/body alignment, infection control/communicable disease, nutrition, food protection/temperature/food storage, dignity/privacy and resident personal rights.
Deficiencies (12)
F557 Respect, Dignity/Right to have Personal Property: The facility failed to ensure residents were treated with dignity and respect, as evidenced by observations and interviews documenting staff actions and comments that humiliated or disrespected residents.
F561 Self-Determination/Participation in Activities of Daily Living: The facility failed to honor residents' rights to make choices and follow preferences, including preferred waking/bedtime and participation in activities, as shown by care plan reviews and observations.
F677 Personal Care/Activities of Daily Living (perineal care, shaving, nail care): The facility failed to provide consistent and appropriate personal care and grooming for residents, with multiple observations and interviews documenting incomplete or improper perineal care, shaving, and nail/skin care.
F686 Treatment/Services to Prevent/Heal Pressure Sores: The facility failed to provide timely and effective pressure ulcer prevention and treatment, including repositioning and appropriate skin care, as evidenced by resident assessments, care plans, and observations.
F689 Free from Accident Hazards/Supervision/Devices: The facility failed to ensure residents were free from accident hazards and adequately supervised, as shown by reviews and observations of unsafe transfer/transfer device use and inconsistent staff supervision.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to maintain appropriate catheter and urinary drainage practices and failed to ensure urinary drainage bags and tubing were kept off the floor and covered, increasing risk to residents.
F725 Sufficient Nursing Staff: The facility failed to provide sufficient nursing staff to meet residents' needs, as evidenced by staffing reviews, observations of missed or delayed care, and interviews reporting insufficient staff at key times.
F758 Psychotropic Drugs: The facility failed to ensure appropriate use and monitoring of psychotropic medications, including PRN use and documentation, with records and interviews showing lack of required reviews and monitoring.
F803 Menus and Nutritional Adequacy/Food Service: The facility failed to ensure residents' nutritional needs were met and that menus/food service followed orders and standards, with observations of incorrect portions and meal service practices.
F809 Frequency of Meals/Snack Availability: The facility failed to provide adequate evening snacks and/or access to snacks for residents as evidenced by interviews and observations of residents not being offered or able to obtain snacks on request.
F812 Food Procurement/Store/Prepare/Serve-Sanitary (Food safety requirements): The facility failed to maintain safe food storage and preparation practices, including freezer/refrigerator temperature control and dated/stored food items, as shown by temperature logs and observations.
F880 Infection Prevention & Control: The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by lack of written procedures, inadequate implementation, and gaps in staff knowledge and documentation.
Report Facts
residents sampled: 25
Inspection Report — Oct 16, 2019
Life Safety
Date: Oct 16, 2019
Visit Reason
Federal CMS-2567 life safety pages (K-tags) and Missouri Department of Health and Senior Services State Form pages; Life Safety Code survey (K-tags present).
Findings
Six deficiencies were cited in this survey: three federal life safety deficiencies involving means of egress, exit signage/emergency illumination testing, and cooking facility suppression/hood inspection; and three Missouri state licensure deficiencies referencing range hood certification, exit requirements, and exit sign maintenance/illumination.
Deficiencies (3)
K211 Means of Egress - General: The facility failed to maintain exit pathways to a public way; an outside exit path from the 500 hall dining room had a 6-inch step down to the finished asphalt creating a hazardous exit pathway.
K293 Exit Signage: The facility failed to ensure emergency illumination lighting was tested in accordance with NFPA code; record review showed no documentation of required 90-minute annual testing.
K324 Cooking Facilities: The facility failed to inspect the kitchen range hood wet chemical suppression system in accordance with NFPA standards; records showed the system was inspected in May 2019 but no monthly inspections had been ensured since that date.
Report Facts
smoke compartments: 21
required emergency illumination test duration (minutes): 90
Inspection Report — Oct 30, 2018
Abbreviated Survey
Date: Oct 30, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form licensure survey; the survey is an abbreviated survey.
Findings
Two deficiencies were cited: one federal health deficiency for failure to report an injury/allegation of abuse and one state licensure deficiency for failure to develop and implement abuse/neglect policies.
Deficiencies (1)
F 609 Reporting of Alleged Violations: Based on observation, interview, and record review the facility failed to report an injury of unknown origin for one resident in a sample of nine residents.
Report Facts
residents sampled: 9
Inspection Report — Sep 13, 2018
Routine
Date: Sep 13, 2018
Visit Reason
The file contains a federal health survey (CMS-2567) and a Missouri state licensure survey (State Form); the survey type is not stated in the forms.
Findings
22 deficiencies were cited. Federal findings addressed resident funds management, baseline care plans and care plan revisions, perineal/personal hygiene, pressure ulcer prevention and treatment, supervision/transfers and safe handling, incontinence and catheter care, food service/temperature and sanitation issues, infection prevention and control practices, and pneumococcal/immunization documentation. State licensure findings reference related violations of nursing care, pressure sore prevention, infection control, food service, resident funds procedures, and environmental/housekeeping standards.
Deficiencies (10)
F567 Protection/Management of Personal Funds: Based on record review and staff interview, the facility failed to ensure residents' personal funds were accurately accounted for and secured; resident trust/operating account records lacked required authorizations and documentation and multiple resident monetary items were not properly inventoried.
F655 Comprehensive Person-Centered Care Plans/Baseline Care Plans: The facility failed to initiate baseline care plans within 48 hours of admission and did not have complete baseline care plan information for sampled residents.
F657 Care Plan Timing and Revision/Comprehensive Care Plans: The facility failed to timely revise or develop comprehensive care plans to address changes in residents' conditions, including missing documentation for urinary catheter care and wound issues.
F677 Personal Hygiene/Oral Care/Perineal Care: The facility failed to provide consistent perineal and personal care for residents, resulting in observed soiled linens, odor, and lack of routine hygiene care for several residents.
F686 Treatment/Pressure Ulcer Care and Prevention: The facility failed to provide appropriate prevention and treatment for pressure ulcers, including inconsistent wound assessments, failure to reposition, and incomplete documentation of wound care.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure safe transfers and appropriate supervision/assistance for residents with weight-bearing restrictions, with staff not consistently following transfer protocols and resulting in unsafe transfer practices.
F690 Incontinence/Urinary/Bowel/Indwelling Catheter Care: The facility failed to provide appropriate incontinence and catheter care, including observations of catheter tubing/bags contacting the floor and inconsistent perineal care practices.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to maintain safe food service practices and sanitary conditions in the kitchen and food service areas, including grease and food debris on equipment and temperature/handling deficiencies.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program, including improper glove and glucometer use, inadequate cleaning and disinfection practices, and inconsistent staff hand hygiene.
F883 Influenza and Pneumococcal Immunizations: The facility failed to follow policies and procedures to ensure pneumococcal vaccination status and documentation for residents, with numerous resident records lacking documented vaccination or consent.
Report Facts
residents sampled: 27
total resident funds found in operating account: 47542.53
Inspection Report — Sep 13, 2018
Life Safety
Date: Sep 13, 2018
Visit Reason
CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form are present in the file; the survey type is not stated.
Findings
Seven deficiencies were cited: four federal Life Safety deficiencies concerning egress doors, kitchen/cooking equipment and grease accumulation, corridor door latching, and smoking area hazards; and three Missouri state deficiencies addressing door locks, ashtray/disposal in designated smoking areas, and building construction/maintenance (state items refer to the related K-tag findings).
Deficiencies (4)
K222 Egress Doors: Based on observation and interview, the facility failed to maintain exits free of locks so they were readily available in the event of an emergency; staff were unable to open a set of gates at the Division 300 dining room and training on operation of the gates was lacking.
K324 Cooking Facilities: Based on observation, interview, and record review, the facility failed to ensure cooking equipment was in compliance with NFPA 96, with buildup of grease observed on and under equipment and no documentation showing inspection or professional cleaning by a qualified person.
K363 Corridor - Doors: Based on observation and interview, the facility failed to ensure the doors to the main kitchen were positive latching; observations showed doors that directly accessed the main dining room did not have means to positive latch in the frame.
K741 Smoking Regulations: Based on observation and interview, the facility failed to maintain smoking areas so as not to present a fire hazard, with observations of large numbers of cigarette butts and inadequate mulch maintenance in/outside designated smoking areas.
Report Facts
smoke compartments: 21
residents in certified beds: 136
Inspection Report — Jun 4, 2018
Routine
Date: Jun 4, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: a federal finding for failure to report a resident-to-resident physical abuse incident and a corresponding state finding for failure to report to state agencies.
Deficiencies (1)
F 609 Reporting of Alleged Violations CFP(s): 483.12(c)(1)(4): Based on interview and record review the facility failed to report a witnessed incident of resident-to-resident physical abuse when one resident (Resident #20) slapped another resident (Resident #6).
Report Facts
residents sampled: 7
Inspection Report — Mar 22, 2018
Complaint Investigation
Date: Mar 22, 2018
Visit Reason
Federal health survey (CMS-2567) with Missouri Department of Health and Senior Services State Form pages; the file documents a complaint investigation and cites MO00140224 and MO00140227.
Findings
There are 6 deficiencies (3 federal and 3 state) addressing housekeeping/cleanliness, resident-to-resident sexual abuse and failures to protect/investigate/report, and state citations for floor surfaces, toilet room requirements, and written policies.
Deficiencies (3)
F584 Safe/Clean/Comfortable/Homelike Environment: Based on observation and interview, housekeeping failed to maintain a clean, comfortable environment; multiple resident rooms and bathrooms were observed with dried fecal matter, soiled floors, and strong odors.
F600 Free from Abuse and Neglect: Based on interview and record review, the facility failed to ensure one resident remained free from sexual abuse by another resident on known occasions and did not provide timely protective assessment and interventions.
F609 Reporting of Alleged Violations: Based on interview and record review, the facility failed to report and investigate a witnessed resident-to-resident sexual abuse incident and failed to report investigation results as required.
Report Facts
residents sampled: 5
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