21 Reports
Inspection Report — Feb 25, 2025
Routine
Date: Feb 25, 2025
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies: two federal deficiencies addressing failure to meet professional standards in investigating/communicating an injury and inadequate treatment/services for pressure ulcers, and two Missouri state citations mirroring nursing care per resident condition and pressure sore prevention.
Deficiencies (2)
19 CSR 30-85.042(66) Nursing Care per Res Condition: See deficiency cited at F658.
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: See deficiency cited at F686.
Report Facts
residents sampled: 4
Inspection Report — Dec 11, 2024
Routine
Date: Dec 11, 2024
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This file contains a federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure pages; the survey type is not stated.
Findings
Five deficiencies were cited: two federal health citations involving protection/management of resident funds and an insufficient surety bond, and three Missouri state licensure citations related to itemized billing, monthly interest, and bond requirements (all Class II*). The federal findings document large resident credit balances held in the facility operating account and the bond shortfall.
Deficiencies (3)
19 CSR 30-88.010(43) Resident Funds-Itemized Bill: Refer to F567.
19 CSR 30-88.020(4) Resident Fund, Monthly Interest: Refer to F567.
19 CSR 30-88.020(14) Resident Fund Bond Requirements: Refer to F570.
Report Facts
residents with untimely refunds: 26
amount of resident funds held in operating account: 164763.34
average monthly balance in Resident Trust Bank: 19158.19
approved bond amount: 30000
amount bond was insufficient by: 246000
Inspection Report — Aug 30, 2024
Routine
Date: Aug 30, 2024
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies were cited: two federal deficiencies addressing accident hazards/supervision and resident records/EMR access, and two Missouri state deficiencies addressing nursing care per resident condition and clinical records accuracy/accessibility.
Deficiencies (2)
19 CSR 30-85.042(66) Nursing Care per Res Condition: See the deficiency cited at F689.
19 CSR 30-85.042(102) Clinical Records Accurate/Accessible: See the deficiency cited at F842.
Report Facts
residents sampled: 3
Inspection Report — Jun 4, 2024
Complaint Investigation
Date: Jun 4, 2024
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation cited (MO00236799).
Complaint Details
MO00236799; substantiation not stated in the record.
Findings
Six deficiencies were cited: three federal health deficiencies concerning failure to prevent/respond to abuse or alleged violations and inadequate treatment/psychosocial documentation, and three Missouri state deficiencies addressing nursing care, abuse/neglect policy implementation, and staff training on reporting.
Deficiencies (3)
19 CSR 30-85.042(66) Nursing Care per Res Condition: See the deficiency cited at F742.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: See the deficiency cited at F600.
19 CSR 30-88.010(24) Staff Trained on Reporting A/N: See the deficiency cited at F609.
Report Facts
residents in sample: 4
facility staff employed: 74
facility staff not documented as attending in-service trainings: 30
Inspection Report — Apr 2, 2024
Life Safety
Date: Apr 2, 2024
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Federal Life Safety survey (CMS-2567) with K-tag deficiencies and a Missouri Department of Health and Senior Services State Form; the survey type is not otherwise stated.
Findings
Three deficiencies were cited: two federal life safety deficiencies addressing door maintenance/inspection and electrical receptacle maintenance/testing, and one Missouri State Form deficiency regarding the Life Safety Code edition that references those deficiencies.
Deficiencies (1)
19 CSR 30-85.012(79) LSC Edition Required per Date of Fac Plan: See the deficiencies cited at K761 and K914.
Inspection Report — Sep 22, 2023
Routine
Date: Sep 22, 2023
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Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One Missouri state licensure deficiency was cited regarding the facility's nurses' call system; the surveyor found lack of audible signals and indicating panels at nurses' stations which potentially affected all residents.
Deficiencies (1)
19 CSR 30-80.012(124) Nurses' Call System Requirements: The facility failed to provide an electrically-powered nurses' call light system with audible signals and indicating panels at the nurses' stations; observations showed no audible call light signals and no call light indicating panels on the first and second floors.
Inspection Report — Aug 9, 2023
Routine
Date: Aug 9, 2023
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Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Three deficiencies were cited: two federal deficiencies addressing failure to develop/implement complete, individualized care plans and failure to follow fall policy/document neurological assessments and post-fall interventions, and one Missouri state deficiency for protective oversight/voluntary leave referencing the fall-related federal deficiency.
Deficiencies (1)
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: See the deficiency cited at F689.
Report Facts
residents sampled for falls: 3
residents affected (for falls): 2
Inspection Report — Oct 28, 2022
Life Safety
Date: Oct 28, 2022
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CMS-2567 Life Safety Code survey (Life Safety) and Missouri Department of Health and Senior Services State Form.
Findings
Ten deficiencies were cited: six federal Life Safety deficiencies involving smoke barriers/doors, elevator certification/Firefighter's service, fire drills, electrical receptacle testing, and emergency power/generator testing and fuel; and four Missouri licensure citations referencing those same Life Safety issues.
Deficiencies (4)
19 CSR 30-85.012(79) LSC Edition Required per Date of Fac Plan: See the deficiencies cited at K531 and K918.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: See the deficiencies cited at K372 and K374.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: See the deficiency cited at K712.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: See the deficiency cited at K914.
Report Facts
smoke compartments affected: 3
smoke compartments affected: 2
quarters with missing drills: 3
Inspection Report — Feb 17, 2022
Routine
Date: Feb 17, 2022
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Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Six deficiencies were cited: three federal health deficiencies involving medication administration/security, pressure ulcer prevention/treatment, and pharmacy/controlled drug records, and three corresponding Missouri State Form deficiencies (Class II) referencing those federal findings.
Deficiencies (3)
19 CSR 30-85.042(46) Safe/Effective Medication System: See the deficiency cited at F658.
19 CSR 30-85.042(62) Controlled Substance Reconcile/Record: See the deficiency cited at F755.
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: See the deficiency cited at F686.
Report Facts
residents sampled: 11
residents sampled for skin/wound review: 3
residents with missing controlled drug documentation: 5
medication cart shift records reviewed (total shifts): 23
Inspection Report — Dec 28, 2020
Routine
Date: Dec 28, 2020
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the forms state a COVID-19 Focused Emergency Preparedness survey was conducted.
Findings
Four deficiencies were cited: three federal deficiencies concerning infection prevention and control, the infection preventionist role/qualifications, and COVID-19 testing of residents and staff; and one Missouri state licensure deficiency related to infection control referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.042(7B) Infection Control/Communicable Disease: See the deficiency cited at F880.
Inspection Report — Feb 26, 2020
Routine
Date: Feb 26, 2020
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) were included in the file; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to ensure residents were free from accident hazards and for inadequate post-fall assessment, documentation, and timely notification; and one Missouri state licensure deficiency for nursing care per resident condition referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: See the deficiency cited at F689.
Report Facts
residents sampled: 3
Inspection Report — Oct 9, 2019
Complaint Investigation
Date: Oct 9, 2019
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation (complaint MO00161230 is cited).
Complaint Details
Complaint number MO00161230 is cited; the record does not state whether the allegation was substantiated.
Findings
2 deficiencies (1 federal and 1 state) were cited involving alleged abuse/neglect: a federal finding for failure to investigate and report a resident's fractured femur, and a state finding for failure to have required abuse/neglect policies.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: See the deficiency cited at F610.
Report Facts
working days without required investigation: 12
Inspection Report — Sep 26, 2019
Complaint Investigation
Date: Sep 26, 2019
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (complaint number MO00160792 is cited).
Complaint Details
Complaint number MO00160792 is cited; substantiation not stated in the document.
Findings
Two deficiencies were cited involving failure to timely report an injury/possible abuse and lack of written policies to prohibit and report mistreatment/abuse; the state licensure citation references the federal finding.
Deficiencies (1)
19 CSR 30-8.010(23) Develop/Implement A/N Policies: See the deficiency cited at F609.
Report Facts
residents sampled: 3
Inspection Report — Aug 27, 2019
Routine
Date: Aug 27, 2019
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 18 federal deficiencies addressing topics including missing required postings, environment/housekeeping, transfer/discharge and bed-hold notices, care plan development and revision, professional standards for services (orders/labs/oxygen), pressure ulcer prevention and treatment, accident hazards and unlocked chemicals/sharps, pain management, dialysis care and documentation, RN staffing, CNA in-service training, pharmacy/controlled substance recordkeeping, psychotropic drug use, medication storage/labeling (insulin pens), and food service sanitation. There are 16 Missouri State Form deficiencies referencing the federal findings and citing state licensure rules.
Deficiencies (15)
19 CSR 30-85.042(22) In-service Training-Nursing Personnel: See the deficiency cited at F730.
19 CSR 30-85.042(35)(A) SNF DON Must Be RN: See the deficiency cited at F727.
19 CSR 30-85.042(46) Written Orders; Restraints: See the deficiency cited at F658.
19 CSR 30-85.042(53) Drug Regimen Review-Monthly: See the deficiency cited at F758.
19 CSR 30-85.042(54) Medication Labeling: See the deficiency cited at F761.
19 CSR 30-85.042(63) Controlled Substance Reconcile/Record: See the deficiency cited at F755.
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: See the deficiency cited at F689.
19 CSR 30-85.042(67) Nursing Care per Resident Condition: See the deficiencies cited at F658, F697 and F698.
19 CSR 30-85.042(75) Pressure Sore Prevention/Treatment: See the deficiency cited at F686.
19 CSR 30-87.020(12) Floor Surfaces: See the deficiency cited at F584.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: See the deficiency cited at F584.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: See the deficiency cited at F812.
19 CSR 30-88.010(7) Resident Rights/Rules Posted, Alz Unit Info: See the deficiency cited at F575.
19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure: See the deficiency cited at F625.
19 CSR 30-88.010(17) Discharge Appeal Rights: See the deficiency cited at F623.
Report Facts
residents sampled: 13
Inspection Report — Aug 27, 2019
Life Safety
Date: Aug 27, 2019
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CMS-2567 federal health survey including emergency preparedness (E) and Life Safety (K) findings, and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
21 deficiencies were cited across federal (E/K) and Missouri state forms. Main topics include emergency preparedness planning and staff training, emergency lighting tests, fire alarm and sprinkler testing/maintenance, sprinkler escutcheon/sprinkler head issues, smoke barrier and damper maintenance, HVAC fusible link dampers, fire drills, smoking/ashtray controls near generator, electrical receptacles and generator testing, and oxygen cylinder storage.
Deficiencies (9)
19 CSR 30-85.012(79) LSC Edition Required per Date of Fac Plan LSC Edition Required per Date of Fac Plan: See the deficiencies cited at K521 and K918.
19 CSR 30-85.022(6) Oxygen Storage: See the deficiency cited at K923.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: See the deficiency cited at K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: See the deficiency cited at K353.
19 CSR 30-85.022(25) Emergency Lighting: See the deficiency cited at K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: See the deficiency cited at K372.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: See the deficiency cited at K741.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: See the deficiency cited at K712.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: See the deficiency cited at K914.
Report Facts
full oxygen tanks observed: 5
full oxygen tanks observed: 3
Inspection Report — Jun 26, 2019
Follow-Up
Date: Jun 26, 2019
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form are included; the file contains an initial survey (03/29/2019) and a follow-up/revisit (06/26/2019).
Findings
Two deficiencies were cited: one federal deficiency concerning resident records and missing medication administration documentation, and one Missouri state licensure deficiency concerning a safe/effective medication system (Class II). The federal finding remained uncorrected at follow-up.
Deficiencies (1)
19 CSR 30-85.042(47) Safe/Effective Medication System: See the deficiency cited at F842.
Report Facts
sampled residents affected: 2
sampled residents affected: 5
Inspection Report — May 2, 2019
Routine
Date: May 2, 2019
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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 deficiency for failure to provide treatment, monitoring and documentation to prevent and heal pressure ulcers, and one Missouri licensure deficiency for pressure sore prevention/treatment which references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(75) Pressure Sore Prevention/Treatment: See the deficiency cited at F686.
Report Facts
residents sampled: 5
Inspection Report — Nov 20, 2018
Life Safety
Date: Nov 20, 2018
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CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form (state licensure) were included; the survey type is not otherwise stated.
Findings
There are 6 federal life-safety deficiencies concerning means of egress, cooking range hood certification/inspections, portable fire extinguishers, combustible decorations, portable space heaters, and oxygen/cylinder storage; there are 6 Missouri State Form deficiencies concerning heating/space heaters, combustible materials, oxygen storage, monthly fire extinguisher checks, range hood certification, and exit requirements.
Deficiencies (6)
19 CSR 30-85.012(90) Heating System, Space Heaters: This regulation is not met as evidenced by: Class III. Refer to K781.
19 CSR 30-85.022(5) Combustible Materials, Unnecessary: This regulation is not met as evidenced by: Class II. Refer to K753.
19 CSR 30-85.022(6) Oxygen Storage: This regulation is not met as evidenced by: Class III. Refer to K923.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: This regulation is not met as evidenced by: Class III. Refer to K355.
19 CSR 30-85.022(9) Range Hood Certification: This regulation is not met as evidenced by: Class III. Refer to K324.
19 CSR 30-85.022(12) Exit Requirements: This regulation is not met as evidenced by: Class II. Refer to K211.
Inspection Report — Nov 20, 2018
Routine
Date: Nov 20, 2018
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Federal health survey (CMS-2567) with Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 16 federal health deficiencies covering topics including surety bond/financial security, resident access to survey results, abuse/neglect policy and reporting, care plan timing and revision, professional standards of care (physician orders, oxygen, consults), ADL/perineal care, mechanical lift safety, dialysis oversight, CNA in-service training and staffing postings, pharmacy/medication procedures and medication error rates, hospice coordination, QAA committee meetings, infection prevention and antibiotic stewardship. It also contains 7 Missouri state licensure deficiencies citing corresponding 19 CSR rules.
Deficiencies (7)
19 CSR 30-85.042(22) In-service Training Personnel: See the deficiency cited at F730.
19 CSR 30-85.042(45) Written Orders; Restraints: See the deficiencies cited at F658 and F759.
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: See the deficiency cited at F689.
19 CSR 30-85.042(67) Nursing Care per Res Condition: See the deficiencies cited at F677, F689, F698, F755 and F759.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F880.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: See the deficiency cited at F607.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: See the deficiency cited at F607.
Report Facts
residents receiving dialysis: 4
certified nurse aides employed for more than one year: 7
Inspection Report — Jan 19, 2018
Routine
Date: Jan 19, 2018
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Federal health survey (CMS-2567) and Missouri state licensure (State Form); the survey type is not stated.
Findings
Seven deficiencies were cited: four federal deficiencies addressing notice and conveyance of personal funds, admissions policy, accident hazards/safe transfers, and infection prevention and control; and three Missouri state licensure citations that reference the federal deficiencies.
Deficiencies (3)
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: See the deficiency cited at F689.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F880.
19 CSR 30-88.020(11) Death of Resident, Contact DSS: See the deficiency cited at F569.
Report Facts
residents sampled: 13
residents with expired resident trust funds noted: 4
Inspection Report — Jan 19, 2018
Life Safety
Date: Jan 19, 2018
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Federal CMS-2567 Life Safety (K-tag) form and Missouri Department of Health and Senior Services State Form are included; K-tag life safety deficiencies were cited.
Findings
Nine deficiencies were cited: 4 federal life safety deficiencies addressing delayed-egress doors, fire alarm testing/maintenance, smoke barrier/damper issues, and fire drills; and 5 Missouri state deficiencies addressing fire alarm testing/maintenance, smoke section walls/doors, fire drill plans and requirements, and building construction/maintenance.
Deficiencies (5)
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: See the deficiency cited at K345.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: See the deficiency cited at K372.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: Based on interview and record review, facility staff failed to request consultation from the local fire authority for review of the facility's fire and evacuation plans annually.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: See the deficiency cited at K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: See the deficiency cited at K222.
Report Facts
exits affected: 1
smoke compartments affected: 3
23 CMS Surveys
Inspection Report — Feb 25, 2025
Routine
Date: Feb 25, 2025
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies: two federal deficiencies addressing failure to meet professional standards in investigating/communicating an injury and inadequate treatment/services for pressure ulcers, and two Missouri state citations mirroring nursing care per resident condition and pressure sore prevention.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to investigate and properly document and communicate an injury to Resident #1 after a right foot fracture, including not notifying the family and not transcribing/clarifying hospital/ER orders.
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: The facility failed to ensure a resident with pressure ulcers received necessary treatment and services per physician orders and facility policy, including inconsistent dressing application and lack of prescribed protective/pressure-relief measures for Resident #4.
Report Facts
residents sampled: 4
Inspection Report — Dec 11, 2024
Routine
Date: Dec 11, 2024
Visit Reason
This file contains a federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure pages; the survey type is not stated.
Findings
Five deficiencies were cited: two federal health citations involving protection/management of resident funds and an insufficient surety bond, and three Missouri state licensure citations related to itemized billing, monthly interest, and bond requirements (all Class II*). The federal findings document large resident credit balances held in the facility operating account and the bond shortfall.
Deficiencies (2)
F567 Protection/Management of Personal Funds: Based on record review and interview the facility failed to ensure resident funds were placed in an account separate from the facility operating account and did not provide timely refunds for numerous residents; review showed resident funds held in the facility operating account totaling $164,763.34.
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain a surety bond sufficient to ensure protection of resident funds; review showed an average monthly Resident Trust Bank balance of $19,158.19 and $164,763.34 held in the accounts receivable/operating account while the approved bond was $30,000, making the bond insufficient.
Report Facts
residents with untimely refunds: 26
amount of resident funds held in operating account: 164763.34
average monthly balance in Resident Trust Bank: 19158.19
approved bond amount: 30000
amount bond was insufficient by: 246000
Inspection Report — Aug 30, 2024
Routine
Date: Aug 30, 2024
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four deficiencies were cited: two federal deficiencies addressing accident hazards/supervision and resident records/EMR access, and two Missouri state deficiencies addressing nursing care per resident condition and clinical records accuracy/accessibility.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview and record review the facility failed to ensure adequate supervision and assistance to prevent accidents, resulting in a resident fall with serious injuries and failures in safe gait belt transfer practices.
F842 Resident Records - Identifiable Information: Based on observation, interview and record review the facility failed to grant timely access to the facility's electronic medical records and failed to provide hospice providers access to a resident's EMR.
Report Facts
residents sampled: 3
Inspection Report — Jun 4, 2024
Complaint Investigation
Date: Jun 4, 2024
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation cited (MO00236799).
Complaint Details
MO00236799; substantiation not stated in the record.
Findings
Six deficiencies were cited: three federal health deficiencies concerning failure to prevent/respond to abuse or alleged violations and inadequate treatment/psychosocial documentation, and three Missouri state deficiencies addressing nursing care, abuse/neglect policy implementation, and staff training on reporting.
Deficiencies (3)
F600 Free from Abuse and Neglect: Based on interview and record review, staff failed to ensure a resident was free from abuse when staff did not appropriately intervene and separate Residents #1 and #3 during an escalating argument over a walker; Resident #1 grabbed Resident #3's walker and pushed him/her to the ground, resulting in a fractured femur to Resident #3.
F609 Reporting of Alleged Violations: Based on interview and record review, facility staff failed to follow policy to immediately notify the Administrator and other responsible parties of a physical altercation between residents and failed to timely report the incident, resulting in delayed investigation and implementation of interventions.
F742 Treatment/Srvcs Mental/Psychosocial Concerns: Based on interview and record review, the facility failed to ensure staff consistently documented detailed behaviors and provide psychosocial follow-up for residents (including one resident who expressed fear after an incident that resulted in another resident's fractured femur), resulting in insufficient information for the interdisciplinary team to determine resident-specific interventions.
Report Facts
residents in sample: 4
facility staff employed: 74
facility staff not documented as attending in-service trainings: 30
Inspection Report — Apr 2, 2024
Life Safety
Date: Apr 2, 2024
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Federal Life Safety survey (CMS-2567) with K-tag deficiencies and a Missouri Department of Health and Senior Services State Form; the survey type is not otherwise stated.
Findings
Three deficiencies were cited: two federal life safety deficiencies addressing door maintenance/inspection and electrical receptacle maintenance/testing, and one Missouri State Form deficiency regarding the Life Safety Code edition that references those deficiencies.
Deficiencies (2)
K 761 Maintenance, Inspection & Testing - Doors: Facility failed to provide complete and verifiable documentation of annual inspections for doors with panic hardware and other exit/stairwell doors. Observation found a detached panic bar and a detached arm of the door closing device on an exit door.
K 914 Electrical Systems - Maintenance and Testing: Facility failed to ensure non-hospital grade electrical receptacles in resident sleeping areas were tested and maintained, and review of maintenance records showed no documentation of annual receptacle testing. Observations showed non-hospital grade receptacles installed in sleeping rooms.
Inspection Report — Aug 9, 2023
Routine
Date: Aug 9, 2023
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Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Three deficiencies were cited: two federal deficiencies addressing failure to develop/implement complete, individualized care plans and failure to follow fall policy/document neurological assessments and post-fall interventions, and one Missouri state deficiency for protective oversight/voluntary leave referencing the fall-related federal deficiency.
Deficiencies (2)
F656 Develop/Implement Comprehensive Care Plan: The facility failed to ensure sampled residents had complete, accurate, and timely individualized care plans that included post-fall interventions.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to follow its policy after unwitnessed falls and did not document required neurological assessments or develop baseline care plans and post-fall interventions for sampled residents.
Report Facts
residents sampled for falls: 3
residents affected (for falls): 2
Inspection Report — Oct 28, 2022
Life Safety
Date: Oct 28, 2022
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CMS-2567 Life Safety Code survey (Life Safety) and Missouri Department of Health and Senior Services State Form.
Findings
Ten deficiencies were cited: six federal Life Safety deficiencies involving smoke barriers/doors, elevator certification/Firefighter's service, fire drills, electrical receptacle testing, and emergency power/generator testing and fuel; and four Missouri licensure citations referencing those same Life Safety issues.
Deficiencies (6)
K 372 Subdivision of Building Spaces - Smoke Barrie: Based on observation, interview and record review, the facility failed to maintain smoke barriers to provide the required fire resistance rating; these deficient practices had the potential to affect occupants in three of seven smoke compartments in resident use areas.
K 374 Subdivision of Building Spaces - Smoke Barrie Doors: Based on observation and interview, the facility failed to maintain a smoke barrier door in proper working order, preventing it from closing completely during activation of the fire alarm; this had the potential to affect all residents in two of seven smoke compartments.
K 531 Elevators: Based on observation, interview and record review, the facility failed to obtain a current state operating certificate for two elevators and failed to ensure Firefighter's Service testing/records were maintained for the elevators.
K 712 Fire Drills: Based on interview and record review, the facility failed to ensure fire drills were completed on each shift, quarterly, and at unexpected times for three of four quarters reviewed.
K 914 Electrical Systems - Maintenance and Testing: Based on observation, interview and record review, the facility failed to ensure annual testing/documentation of non-hospital grade electrical receptacles in resident sleeping areas was properly completed and recorded.
K 918 Electrical Systems - Essential Electric Syste: Based on observation, interview and record review, the facility failed to complete required weekly/monthly inspections, testing, and documentation for the emergency generator and associated equipment and failed to ensure required fuel supply, with potential to affect all residents.
Report Facts
smoke compartments affected: 3
smoke compartments affected: 2
quarters with missing drills: 3
Inspection Report — Feb 17, 2022
Routine
Date: Feb 17, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Six deficiencies were cited: three federal health deficiencies involving medication administration/security, pressure ulcer prevention/treatment, and pharmacy/controlled drug records, and three corresponding Missouri State Form deficiencies (Class II) referencing those federal findings.
Deficiencies (3)
F 658 Services Provided Meet Professional Standards: Based on observation, interview and record review the facility left an unattended, unlocked medication cart with pre-prepared medication cups and allowed a certified medication technician to administer controlled substances to residents, contrary to facility policy.
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on observation, interview and record review the facility failed to identify/treat a Stage III pressure ulcer and failed to complete and document required skin/wound assessments and physician notifications for affected residents.
F 755 Pharmacy Svcs/Procedures/Pharmacist/Records: Based on interview and record review the facility failed to establish accurate records of receipt and disposition of controlled drugs; controlled substance shift change count sheets and resident controlled drug records were missing or inaccurate for multiple residents.
Report Facts
residents sampled: 11
residents sampled for skin/wound review: 3
residents with missing controlled drug documentation: 5
medication cart shift records reviewed (total shifts): 23
Inspection Report — Jan 19, 2022
Complaint Investigation
Date: Jan 19, 2022
Visit Reason
Federal CMS-2567 health (infection control) and emergency preparedness statements; the documents state a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey and reference a complaint investigation.
Complaint Details
A complaint investigation is referenced in the F 000 initial comments; no complaint number is provided. The F 000 states: 'No deficiencies were cited as a result of this complaint investigation.'
Findings
No deficiencies were cited (0 deficiencies). The surveys addressed COVID-19 infection control and emergency preparedness and found the facility in compliance.
Inspection Report — Feb 5, 2021
Complaint Investigation
Date: Feb 5, 2021
Visit Reason
CMS-2567 federal health (infection control) and emergency preparedness survey; the file documents a COVID-19 focused complaint investigation.
Complaint Details
Complaint investigation is stated in the report; no complaint number is provided and no deficiencies were cited as a result of the investigation.
Findings
Zero deficiencies were cited. The federal health (COVID-19 focused infection control) and emergency preparedness portions both report the facility was found to be in compliance.
Inspection Report — Dec 28, 2020
Routine
Date: Dec 28, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the forms state a COVID-19 Focused Emergency Preparedness survey was conducted.
Findings
Four deficiencies were cited: three federal deficiencies concerning infection prevention and control, the infection preventionist role/qualifications, and COVID-19 testing of residents and staff; and one Missouri state licensure deficiency related to infection control referencing the federal finding.
Deficiencies (3)
F 880 Infection Prevention & Control: The facility failed to ensure an infection surveillance plan was in place and staff did not consistently implement COVID-19 policies, including proper PPE use and disinfection of shared equipment.
F 882 Infection Preventionist Qualifications/Role: The facility failed to designate one or more individuals with specialized infection prevention training and the infection preventionist had not started required training.
F 886 COVID-19 Testing-Residents & Staff: The facility failed to follow CMS/CDC testing requirements and did not implement a testing plan based on county positivity rates, including facility-wide staff testing as indicated.
Inspection Report — Jun 19, 2020
Routine
Date: Jun 19, 2020
Visit Reason
CMS-2567 federal health survey (COVID-19 Focused Infection Control) and CMS-2567 federal emergency preparedness survey (COVID-19 Focused); no complaint number is stated in the file.
Findings
No deficiencies were cited on the federal health (infection control) and federal emergency preparedness CMS-2567 forms; both surveys were COVID-19 focused.
Inspection Report — Feb 26, 2020
Routine
Date: Feb 26, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) were included in the file; the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to ensure residents were free from accident hazards and for inadequate post-fall assessment, documentation, and timely notification; and one Missouri state licensure deficiency for nursing care per resident condition referencing the federal finding.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2): Based on observation, interview and record review, staff failed to conduct a thorough assessment and document it after a resident's fall for one of three sampled residents. Staff also failed to notify the next shift, the physician, and the responsible party in a timely manner.
Report Facts
residents sampled: 3
Inspection Report — Oct 9, 2019
Complaint Investigation
Date: Oct 9, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; complaint investigation (complaint MO00161230 is cited).
Complaint Details
Complaint number MO00161230 is cited; the record does not state whether the allegation was substantiated.
Findings
2 deficiencies (1 federal and 1 state) were cited involving alleged abuse/neglect: a federal finding for failure to investigate and report a resident's fractured femur, and a state finding for failure to have required abuse/neglect policies.
Deficiencies (1)
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to provide evidence of an investigation of a fractured femur of unknown origin (Resident #13) and did not report the results to the State Survey Agency within the required time frame.
Report Facts
working days without required investigation: 12
Inspection Report — Sep 26, 2019
Complaint Investigation
Date: Sep 26, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (complaint number MO00160792 is cited).
Complaint Details
Complaint number MO00160792 is cited; substantiation not stated in the document.
Findings
Two deficiencies were cited involving failure to timely report an injury/possible abuse and lack of written policies to prohibit and report mistreatment/abuse; the state licensure citation references the federal finding.
Deficiencies (1)
F609 Reporting of Alleged Violations: Based on observation, interview and record review, the facility failed to notify the Department of Health and Senior Services about an injury of unknown origin for one of three sampled residents (Resident #22).
Report Facts
residents sampled: 3
Inspection Report — Aug 27, 2019
Routine
Date: Aug 27, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 18 federal deficiencies addressing topics including missing required postings, environment/housekeeping, transfer/discharge and bed-hold notices, care plan development and revision, professional standards for services (orders/labs/oxygen), pressure ulcer prevention and treatment, accident hazards and unlocked chemicals/sharps, pain management, dialysis care and documentation, RN staffing, CNA in-service training, pharmacy/controlled substance recordkeeping, psychotropic drug use, medication storage/labeling (insulin pens), and food service sanitation. There are 16 Missouri State Form deficiencies referencing the federal findings and citing state licensure rules.
Deficiencies (18)
F575 Required Postings: The facility failed to ensure the state abuse/neglect hotline phone number was posted in a prominent and accessible location for residents, visitors and staff.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a safe, clean, comfortable and homelike environment by not ensuring walls, carpets and floors were clean and in good repair (numerous gouges, chips, darkened/dirty carpet, cobwebs and visible dirt).
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written transfer/discharge notices to residents or their representatives for sampled residents transferred to the hospital for medical reasons.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notice of the facility's bed-hold policy to residents or their representatives at the time of transfer for sampled residents.
F657 Care Plan Timing and Revision: The facility failed to ensure care plans reflected residents' current needs and included timely updates and new interventions for identified problems (falls/hospice information not removed for discharged resident).
F658 Services Provided Meet Professional Standards: The facility failed to ensure physician orders were followed and timely obtained (laboratory tests, orders for oxygen and other physician communications) for multiple sampled residents.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to prevent and appropriately treat a resident's unstageable pressure ulcer and failed to follow the facility wound policy and obtain timely treatment orders.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to prevent resident access to harmful chemicals and razors in multiple unlocked spa and laundry closets, creating potential hazards for residents.
F697 Pain Management: The facility failed to adequately assess, document and treat pain, resulting in inadequate pain management and inconsistent pain assessment and documentation for sampled residents.
F698 Dialysis: The facility failed to routinely assess, monitor and document dialysis access/shunt assessments and communication with dialysis providers for residents receiving dialysis.
F727 RN 8 Hrs/7 days/Wk, Full Time DON: The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours during the day shift on weekends as required.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to ensure certified nurse assistants (CNAs) received required in-service training based on performance reviews for staff who had worked at the facility more than one year.
F755 Pharmacy Svcs/Procedures/Pharmacist/Records: The facility failed to maintain accurate and reconciled controlled drug records and a system of receipt/disposition for controlled drugs on multiple shifts.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure appropriate use and documentation of psychotropic medications and PRN orders were limited and properly monitored for residents.
F761 Label/Store Drugs and Biologicals: The facility failed to properly label and discard insulin flex/pen products and failed to follow appropriate storage/labeling practices for drugs and biologics.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain cleanliness of the dish room vent, which could allow dust and contamination to reach clean utensils, glassware and cookware.
F867 QAPI/QAA Improvement Activities: The facility failed to implement an effective quality assurance and performance improvement (QAPI) program with appropriate actions to correct ongoing systemic deficiencies.
F868 QAA Committee: The facility failed to maintain a functioning quality assessment and assurance (QAA) committee that met and implemented corrective actions for identified quality issues.
Report Facts
residents sampled: 13
Inspection Report — Aug 27, 2019
Life Safety
Date: Aug 27, 2019
Visit Reason
CMS-2567 federal health survey including emergency preparedness (E) and Life Safety (K) findings, and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
21 deficiencies were cited across federal (E/K) and Missouri state forms. Main topics include emergency preparedness planning and staff training, emergency lighting tests, fire alarm and sprinkler testing/maintenance, sprinkler escutcheon/sprinkler head issues, smoke barrier and damper maintenance, HVAC fusible link dampers, fire drills, smoking/ashtray controls near generator, electrical receptacles and generator testing, and oxygen cylinder storage.
Deficiencies (12)
E004 Develop EP Plan, Review and Update Annually: The facility failed to update their emergency preparedness plan annually and the annual review sheet had no signatures or dates; the plan lacked documented community resources protocols and notification procedures.
E037 EP Training Program: The facility failed to provide and document annual emergency preparedness training for staff and could not locate documentation of prior training.
K291 Emergency Lighting: The facility failed to conduct monthly tests of battery-powered emergency lighting and had no documented monthly testing of the battery-powered emergency lights.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain and document semi-annual inspections of the fire alarm system as required, with no documented semi-annual alarm inspections in 2018 or 2019.
K353 Sprinkler System - Maintenance and Testing: The facility failed to inspect, test, and maintain sprinkler systems or keep complete and verifiable documentation of routine inspections and testing; observations included exposed gaps at escutcheon plates and rusty or loaded sprinkler heads.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to ensure smoke barriers were maintained to provide the required fire resistance rating and to maintain required smoke dampers, including conduit penetrations and a smoke damper that did not close.
K521 HVAC: The facility failed to maintain fusible link dampers with documented exercise and lubrication, with no documentation of inspection or testing of dampers.
K712 Fire Drills: The facility failed to ensure fire drills were completed on each shift, quarterly, and under varying conditions as required; records showed missing drills for some quarters and shifts.
K741 Smoking Regulations: The facility failed to maintain smoking areas in accordance with NFPA, with observations of a gasoline container and numerous cigarette butts near the emergency generator area.
K914 Electrical Systems - Maintenance and Testing: The facility failed to assess and document electrical receptacles in resident rooms for grounding and other required checks, and non-hospital grade receptacles were observed at resident bed locations.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to document weekly checks, monthly load tests, and annual inspections of the generator and did not have records of required generator inspections and testing.
K923 GAS Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage in accordance with NFPA, with full and empty cylinders stored together in patient care area oxygen rooms.
Report Facts
full oxygen tanks observed: 5
full oxygen tanks observed: 3
Inspection Report — Jun 26, 2019
Follow-Up
Date: Jun 26, 2019
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form are included; the file contains an initial survey (03/29/2019) and a follow-up/revisit (06/26/2019).
Findings
Two deficiencies were cited: one federal deficiency concerning resident records and missing medication administration documentation, and one Missouri state licensure deficiency concerning a safe/effective medication system (Class II). The federal finding remained uncorrected at follow-up.
Deficiencies (1)
F842 Resident Records - Identifiable Information: The facility failed to ensure staff documented administration of medications as ordered; medication administration records (MARs) contained blank entries without documented reasons for multiple sampled residents.
Report Facts
sampled residents affected: 2
sampled residents affected: 5
Inspection Report — May 2, 2019
Routine
Date: May 2, 2019
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 deficiency for failure to provide treatment, monitoring and documentation to prevent and heal pressure ulcers, and one Missouri licensure deficiency for pressure sore prevention/treatment which references the federal finding.
Deficiencies (1)
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on interview and record review, the facility failed to provide treatment, monitor effectiveness of physician-ordered treatment, document assessments and update physicians when a resident's pressure ulcer deteriorated, resulting in hospitalization for one resident with a Stage IV pressure ulcer.
Report Facts
residents sampled: 5
Inspection Report — Nov 20, 2018
Life Safety
Date: Nov 20, 2018
Visit Reason
CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form (state licensure) were included; the survey type is not otherwise stated.
Findings
There are 6 federal life-safety deficiencies concerning means of egress, cooking range hood certification/inspections, portable fire extinguishers, combustible decorations, portable space heaters, and oxygen/cylinder storage; there are 6 Missouri State Form deficiencies concerning heating/space heaters, combustible materials, oxygen storage, monthly fire extinguisher checks, range hood certification, and exit requirements.
Deficiencies (6)
K211 Means of Egress - General: The facility failed to maintain exit pathways free from obstructions and an exit access door by the kitchen was locked.
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood to NFPA requirements and records/interview showed no monthly inspections since 8/2018.
K355 Portable Fire Extinguishers: The facility failed to maintain portable fire extinguishers; monthly inspection tags were missing for several extinguishers and a K-class extinguisher had not been serviced since 12/2016.
K753 Combustible Decorations: The facility failed to prohibit combustible decorations; five candles with wicks were observed in the conference room.
K781 Portable Space Heaters: The facility failed to prohibit portable space heaters; a space heater was observed at the front receptionist desk.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage to NFPA code; oxygen tanks on the first and second floor storage areas were not labeled and separated.
Inspection Report — Nov 20, 2018
Routine
Date: Nov 20, 2018
Visit Reason
Federal health survey (CMS-2567) with Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 16 federal health deficiencies covering topics including surety bond/financial security, resident access to survey results, abuse/neglect policy and reporting, care plan timing and revision, professional standards of care (physician orders, oxygen, consults), ADL/perineal care, mechanical lift safety, dialysis oversight, CNA in-service training and staffing postings, pharmacy/medication procedures and medication error rates, hospice coordination, QAA committee meetings, infection prevention and antibiotic stewardship. It also contains 7 Missouri state licensure deficiencies citing corresponding 19 CSR rules.
Deficiencies (16)
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain a surety bond sufficient to assure the security of residents' personal funds; bond documentation was inconsistent with DHSS approvals.
F577 Right to Survey Results/Advocate Agency Info: The facility failed to post the results of the most recent survey in a place readily accessible to residents and family; the survey binder location was not clearly posted and residents were unaware of how to view prior surveys.
F607 Develop/Implement Abuse/Neglect Policies: The facility's abuse and neglect policies and procedures did not identify when, how, and by whom determinations of capacity to consent to sexual contact would be made and recorded and failed to ensure timely reporting requirements were clearly implemented.
F657 Care Plan Timing and Revision: The facility failed to give one resident the opportunity to participate in the development, review and revision of his/her care plan as required.
F658 Services Provided Meet Professional Standards: The facility failed to ensure physician orders were followed for compression stockings, timely psychiatric and eye consultations, and consistent oxygen management for sampled residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide adequate perineal care for dependent residents; observations showed incomplete cleansing technique and inconsistent practices by staff.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to follow safety precautions during the operation of a mechanical lift and did not ensure proper technique by staff during transfers.
F698 Dialysis: The facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis center for residents receiving dialysis, resulting in incomplete oversight of dialysis care.
F730 Nurse Aide Perform Review-12 hrly In-Service: The facility failed to ensure certified nurse aides received required annual in-service training hours and dementia training as required.
F732 Posted Nurse Staffing Information: The facility failed to post daily nurse staffing data for the shifts observed and did not maintain required posted staffing information.
F755 Pharmacy Srvs/Procedures/Pharmacist/Records: The facility failed to follow procedures to ensure accurate acquiring, receiving, dispensing and administering of drugs to meet residents' needs and to ensure medication records and reconciliation processes were adequate.
F759 Free of Medication Error Rts 5 Prcnt or More: The facility failed to ensure a medication error rate below 5%; observed errors included insulin pen priming and missed or incorrect administrations resulting in an error rate above the threshold.
F849 Hospice Services: The facility failed to collaborate adequately with hospice providers, ensure hospice orders matched facility orders, and maintain required hospice documentation and coordination for residents receiving hospice.
F868 QAA Committee: The facility failed to provide documentation showing the quality assurance and performance improvement (QAPI/QAA) committee met quarterly as required.
F880 Infection Prevention & Control: The facility failed to ensure staff followed standard infection control procedures, including appropriate hand hygiene and safe medication handling, as observed during medication preparation.
F881 Antibiotic Stewardship Program: The facility failed to establish an antibiotic stewardship program with protocols and a system to monitor antibiotic use.
Report Facts
residents receiving dialysis: 4
certified nurse aides employed for more than one year: 7
Inspection Report — Jan 19, 2018
Routine
Date: Jan 19, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure (State Form); the survey type is not stated.
Findings
Seven deficiencies were cited: four federal deficiencies addressing notice and conveyance of personal funds, admissions policy, accident hazards/safe transfers, and infection prevention and control; and three Missouri state licensure citations that reference the federal deficiencies.
Deficiencies (4)
F 569 Notice and Conveyance of Personal Funds: The facility failed to disburse remaining resident trust account funds and convey funds within 30 days for multiple residents who expired, with review showing amounts remaining for Residents #303, #301, #304 and #302.
F 620 Admissions Policy: The facility failed to ensure the admissions policy and resident handbook did not require residents to waive potential facility liability for losses of personal property and failed to ensure the admission policy met regulatory requirements.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure safe resident transfers; staff tipped a Broda chair back on two wheels during the transfer of Resident #30, creating potential harm and demonstrating inadequate supervision/transfer techniques.
F 880 Infection Prevention & Control: The facility failed to ensure staff utilized infection control measures and proper hand hygiene during personal care, observed when a CNA performed perineal care and changed gloves without properly washing hands, affecting one of 13 sampled residents.
Report Facts
residents sampled: 13
residents with expired resident trust funds noted: 4
Inspection Report — Jan 19, 2018
Life Safety
Date: Jan 19, 2018
Visit Reason
Federal CMS-2567 Life Safety (K-tag) form and Missouri Department of Health and Senior Services State Form are included; K-tag life safety deficiencies were cited.
Findings
Nine deficiencies were cited: 4 federal life safety deficiencies addressing delayed-egress doors, fire alarm testing/maintenance, smoke barrier/damper issues, and fire drills; and 5 Missouri state deficiencies addressing fire alarm testing/maintenance, smoke section walls/doors, fire drill plans and requirements, and building construction/maintenance.
Deficiencies (4)
K222 Egress Doors: Based on observation and interview, the facility failed to assure doors with delayed egress devices that operated in excess of 15 seconds were approved by the Authority Having Jurisdiction; this affected one exit on the second floor.
K345 Fire Alarm System - Testing and Maintenance: Based on record review and interview, the facility failed to maintain and test the fire alarm system in accordance with NFPA requirements and did not conduct required inspections beyond the annual inspection.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Based on observation and interview, the facility failed to maintain smoke barriers and smoke dampers on the second floor, including gaps in barrier walls and dampers that did not close, potentially affecting occupants in three of six smoke compartments.
K712 Fire Drills: Based on record review and interview, the facility failed to ensure required fire drills were conducted on the second (evening) shift and under varying conditions; staff conducted no second shift fire drills for the second quarter of 2017.
Report Facts
exits affected: 1
smoke compartments affected: 3
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