Deficiencies (last 8 years)
Deficiencies (over 8 years)
12.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
79% occupied
Based on a February 2025 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 2
Date: Feb 25, 2025
Visit Reason
The inspection was an annual survey conducted to assess compliance with professional standards of care and pressure ulcer prevention and treatment at Estates of Hidden Lake nursing facility.
Findings
The facility failed to meet professional standards of care related to investigation and notification of a resident injury and failed to provide adequate treatment and prevention for pressure ulcers. Deficiencies were documented with detailed observations and interviews.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to investigate a resident's injury properly, notify family of condition changes, and follow policies for incident investigation and notification.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to ensure a resident with pressure ulcers received necessary treatment and prevention consistent with professional standards.
Report Facts
Resident census: 53
Sample size: 4
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 5
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to the protection and management of residents' personal funds and to ensure compliance with financial security regulations.
Findings
The facility failed to maintain residents' personal funds in a separate account from the facility operating account and did not provide timely refunds for 26 residents. Additionally, the facility failed to maintain a sufficient surety bond to protect resident funds.
Deficiencies (5)
F567 Protection/Management of Personal Funds: The facility did not ensure resident funds were placed in an account separate from the facility operating account and failed to provide timely refunds for 26 residents.
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain a surety bond sufficient to ensure the protection of resident funds.
A8044 19 CSR 30-88.010(43) Resident Funds-Itemized Bill: The facility did not provide a final itemized bill for all goods and services rendered within 30 days after discharge or death of a resident.
A9004 19 CSR 30-88.020(4) Resident Fund, Monthly Interest: The facility did not maintain required separate accounts in a bank or savings and loan association and credit interest monthly to each resident's account.
A9023 19 CSR 30-88.020(14) Resident Fund Bond Requirements: The facility did not maintain the required bond amount equal to at least 1.5 times the average monthly balance of residents' personal funds.
Report Facts
Facility census: 50
Resident funds held in operating account: 164763.34
Average monthly balance: 19158.19
Approved bond amount: 30000
Bond insufficiency: 246000
Number of residents with delayed refunds: 26
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 2
Date: Aug 30, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to resident safety, accident prevention, and medical record confidentiality at Estates of Hidden Lake nursing facility.
Findings
The facility failed to ensure adequate supervision and assistance to prevent accidents, resulting in resident injuries. Additionally, the facility failed to provide timely access to electronic medical records and hospice services for residents.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure adequate supervision and assistance to prevent accidents, resulting in a resident falling off the bed and sustaining multiple injuries.
F842 Resident Records - Identifiable Information: The facility failed to grant timely access to electronic medical records and hospice services for a resident, affecting care coordination.
Report Facts
Resident census: 53
Sample size: 3
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Jun 4, 2024
Visit Reason
The inspection was conducted following allegations of abuse and neglect involving residents at the facility, triggered by a complaint and subsequent investigation.
Complaint Details
The investigation was initiated due to allegations of abuse and neglect involving residents. The complaint was substantiated as the facility failed to prevent abuse and failed to report and manage incidents appropriately.
Findings
The facility failed to ensure a resident was free from abuse when staff did not intervene during an altercation resulting in a fractured femur. The facility also failed to immediately report the incident to the administrator and responsible parties as required. Additionally, the facility did not consistently document and manage behaviors of residents with dementia and failed to provide adequate psychosocial follow-up.
Deficiencies (3)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent physical abuse when Resident #1 pushed Resident #3, causing a fractured femur. Staff did not intervene or report the incident timely.
F609 Reporting of Alleged Violations: The facility failed to immediately notify the administrator and responsible parties of a physical altercation involving residents and delayed investigation and intervention.
F742 Treatment/Services Mental/Psychosocial Concerns: The facility failed to ensure consistent documentation and follow-up of behaviors exhibited by residents with dementia, resulting in insufficient information for care planning.
Report Facts
Resident census: 51
Sample size: 4
Staff employed: 74
Staff not documented in training: 30
Inspection Report
Life Safety
Census: 48
Capacity: 67
Deficiencies: 3
Date: Apr 2, 2024
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, specifically focusing on maintenance, inspection, and testing of doors and electrical systems in the facility.
Findings
The facility failed to provide complete and verifiable documentation for the annual inspection of doors equipped with panic hardware and special locking arrangements. Additionally, the facility did not ensure non-hospital grade electrical receptacles in patient sleeping areas were tested annually as required.
Deficiencies (3)
K761: The facility failed to provide complete and verifiable documentation for the annual inspection and testing of doors equipped with panic hardware, special locking arrangements, and doors in stairwells as required by NFPA 101.
K914: The facility failed to ensure non-hospital grade electrical receptacles in patient sleeping areas were tested annually, and no documentation of testing was available as required by NFPA 99.
A1086: The facility did not meet the Life Safety Code edition requirements per 19 CSR 30-85.012(79), citing deficiencies at K761 and K914.
Report Facts
Facility capacity: 67
Resident census: 48
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 1
Date: Sep 20, 2023
Visit Reason
The document is a Plan of Correction submitted in response to a deficiency found during a survey conducted on 09/20/2023 regarding the facility's nurses' call system.
Findings
The facility failed to provide an electrically-powered nurses' call light system with audible signals and indicating panels at nurses' stations, affecting all residents. The deficiency was observed on 09/20/2023 during a site visit and interviews with staff.
Deficiencies (1)
19 CSR 30-85.012(124) Nurses' Call System Requirements: The facility failed to provide an electrically-powered nurses' call light system with audible signals and indicating panels at each nurses' station. This deficiency affected all residents.
Report Facts
Census: 42
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 3
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for the Estates of Hidden Lake nursing facility.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, ensuring a safe environment free of accident hazards, and providing adequate supervision and neurological assessments following falls. The census during the survey was 44 residents.
Deficiencies (3)
F656: The facility failed to develop and implement comprehensive, person-centered care plans for three sampled residents, including timely post-fall interventions and individualized care reflecting current conditions and needs.
F689: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or neurological assessments following witnessed and unwitnessed falls for sampled residents.
A4074: The facility failed to provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, including procedures to inquire about residents' whereabouts and estimated length of absence.
Report Facts
Census: 44
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bass | Laboratory Director or Provider/Supplier Representative | Signed the statement of deficiencies and plan of correction |
| Administrator | Signed the statement of deficiencies and plan of correction | |
| Director of Nursing | Named in interview regarding responsibility for care plan updates and neurological assessments | |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding neurological assessments following falls |
Inspection Report
Life Safety
Census: 51
Capacity: 67
Deficiencies: 6
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain smoke barriers, smoke barrier doors, elevator operating certificates, fire drills, electrical receptacle testing, and generator inspections. These deficiencies had the potential to affect residents and occupants in multiple areas of the facility.
Deficiencies (6)
K372: The facility failed to maintain smoke barriers to provide the required 1/2-hour fire resistance rating. Observations showed penetrations and openings in smoke barriers near rooms 145 and 246.
K374: The facility failed to maintain smoke barrier doors in proper working order, preventing them from closing completely during fire alarm activation. The door near Room 246 did not fully close.
K531: The facility failed to obtain current state operating certificates for two elevators and did not ensure monthly firefighter service inspections were documented.
K712: The facility failed to ensure fire drills were completed on each shift quarterly and at unexpected times, with missing documentation for several drills.
K914: The facility failed to ensure annual testing and documentation of non-hospital grade electrical receptacles in resident sleeping areas.
K918: The facility failed to complete weekly or monthly inspections of the emergency generator and maintain required documentation, including load tests and circuit breaker inspections.
Report Facts
Facility capacity: 67
Resident census: 51
Deficiencies cited: 6
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 3
Date: Feb 17, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication administration, pressure ulcer prevention and treatment, and pharmacy services at The Estates of Hidden Lake.
Findings
The facility failed to meet professional standards in medication administration, including unsecured medication carts and improper handling of controlled substances. The facility also failed to properly assess, document, and treat pressure ulcers for residents, and did not maintain accurate pharmacy records for controlled substances.
Deficiencies (3)
F658 Services Provided Meet Professional Standards: The facility failed to ensure medication carts were secured and controlled substances were properly administered and documented for residents.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to identify and properly treat Stage III pressure ulcers and did not follow policy for skin assessments and wound care documentation.
F755 Pharmacy Services: The facility failed to maintain accurate records of controlled substances, including missing documentation for medication counts and discrepancies in narcotic shift change reports.
Report Facts
Census: 47
Deficiencies cited: 3
Completion date: Mar 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bautista | Laboratory Director or Provider/Supplier Representative | Signed the statement of deficiencies and plan of correction |
| Nurse C | Named in medication administration findings and interviews | |
| Director of Nursing | Director of Nursing | Named in wound care and medication administration findings and interviews |
| Administrator | Administrator | Interviewed regarding facility policies and procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 19, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
The complaint investigation was related to COVID-19 infection control practices and was found to have no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 5, 2021
Visit Reason
The inspection was conducted as a COVID-19 focused infection control and emergency preparedness complaint investigation from 02/04/2021 through 02/05/2021.
Complaint Details
This was a complaint investigation related to COVID-19 infection control and emergency preparedness. No deficiencies were cited.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Census: 32
Deficiencies: 4
Date: Dec 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 12/22/2020 through 12/28/2020 to assess the facility's infection prevention and control program and compliance with COVID-19 related requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness but failed to ensure an effective infection prevention and control program. Deficiencies included lack of staff education on COVID-19 status, failure to disinfect shared equipment, inadequate infection surveillance, and failure to follow CDC and CMS COVID-19 testing and infection control guidance.
Deficiencies (4)
F880 Infection Prevention & Control: The facility failed to ensure staff were educated on COVID-19 status, failed to disinfect shared gait belts, and lacked an effective infection surveillance plan and system.
F882 Infection Preventionist Qualifications/Role: The facility failed to designate an infection preventionist with specialized training and failed to ensure infection preventionist participation in quality assessment and assurance.
F886 COVID-19 Testing-Residents & Staff: The facility failed to follow CMS and CDC requirements for COVID-19 testing of residents and staff, including testing frequency and outbreak testing protocols.
A4085 Infection Control/Communicable Disease: The facility failed to meet Missouri state regulations for infection control related to communicable diseases as evidenced by the deficiencies cited at F880.
Report Facts
Census: 32
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 06/12/2020 through 06/19/2020 to assess compliance with CMS and CDC recommended practices and related regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 2
Date: Feb 26, 2020
Visit Reason
The inspection was conducted to investigate and document deficiencies related to accident hazards, supervision, and nursing care following a resident fall incident.
Findings
The facility failed to conduct a thorough assessment after a resident's fall and did not notify the physician and responsible party timely. Documentation of the fall was incomplete and late entries were noted, with no written policy for incident follow-up or neuro checks.
Deficiencies (2)
F689: The facility failed to ensure the resident environment was free of accident hazards and did not conduct a thorough assessment or timely notification after a resident fall.
A4074: The facility did not provide personal attention and nursing care consistent with the resident's condition, as evidenced by the deficiencies cited at F689.
Report Facts
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| B Stewart | RN | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Oct 9, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident with a fractured femur of unknown origin.
Complaint Details
The complaint involved allegations of abuse related to a fractured femur of unknown origin in Resident #13. The facility failed to investigate and report the incident within the required timeframe, confirming the complaint was substantiated.
Findings
The facility failed to provide evidence of an investigation into the resident's fractured femur and did not report the results of the investigation to the State Survey Agency within the required 5 working days. The investigation was not submitted within the required timeframe, with 12 working days passing without completion.
Deficiencies (2)
F610: The facility failed to provide evidence of an investigation of a fractured femur of unknown origin and did not report the investigation results to the State Survey Agency within 5 working days as required.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, and failed to require reporting to the department for any suspected abuse or neglect.
Report Facts
Census: 56
Working days delay: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stewart | RN | Signed the plan of correction |
| Director of Nurses | Mentioned in interview regarding investigation submission |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Sep 26, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident who sustained a fracture of unknown origin.
Complaint Details
The investigation was triggered by a complaint regarding a resident who sustained a fracture of unknown origin. The complaint was substantiated as the facility failed to notify the Department of Health and Senior Services within the required 2-hour timeframe.
Findings
The facility failed to notify the Department of Health and Senior Services within the required timeframe about the injury of unknown origin sustained by Resident #22. The investigation revealed that the resident had a non-displaced fracture and the facility did not report the incident immediately as required by regulations.
Deficiencies (2)
F609: The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment within the required timeframes after a resident sustained a fracture of unknown origin.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, and failed to require reports to the department for suspected abuse or neglect.
Report Facts
Resident census: 58
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 16
Date: Aug 27, 2019
Visit Reason
Annual inspection survey conducted from 08/22/2019 to 08/27/2019 to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found non-compliant in multiple areas including required postings, safe and homelike environment, notice requirements before transfer/discharge, care plan timing and revision, medication labeling, pain management, accident hazards, and quality assurance. Deficiencies were cited with corrective actions planned.
Deficiencies (16)
F575 Required Postings. The facility failed to post the state abuse/neglect hotline phone number in a prominent location accessible to all residents and visitors.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a safe, clean, comfortable, and homelike environment with issues including dirty and damaged walls, floors, and carpets on the first and second floors.
F623 Notice Requirements Before Transfer/Discharge. The facility failed to provide written transfer/discharge notices to residents or their legal representatives for four of 13 sampled residents transferred to hospitals.
F625 Notice of Bed Hold Policy Before/Upon Transfer. The facility failed to provide written notice of the bed-hold policy to residents or their legal representatives at the time of transfer for four of 13 sampled residents.
F657 Care Plan Timing and Revision. The facility failed to ensure care plans reflected residents' current needs and failed to remove hospice information for one resident discharged from hospice.
F658 Services Provided Meet Professional Standards. The facility failed to ensure all physician orders were followed, including notification of weight gain, discontinuation of hospice care, and obtaining laboratory tests for residents.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to prevent resident access to harmful chemicals and razors in unlocked spa and laundry rooms.
F697 Pain Management. The facility failed to adequately assess and manage pain for two residents, resulting in severe discomfort and inadequate pain control.
F727 RN 8 Hrs/7 Days/Wk, Full Time DON. The facility failed to provide a registered nurse for eight consecutive hours a day, seven days a week.
F730 Nurse Aide Perform Review-12hr/yr In-Service. The facility failed to ensure certified nurse aides received required 12 hours of in-service training.
F755 Pharmacy Services/Procedures/Pharmacist/Records. The facility failed to maintain accurate records of controlled substances and narcotics, including counts and signatures.
F758 Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to ensure appropriate use and documentation of psychotropic medications for residents.
F761 Label/Store Drugs and Biologicals. The facility failed to label and store medications in accordance with accepted professional standards, including expired insulin pens.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to maintain cleanliness of vents in the dish room, resulting in dust accumulation.
F867 QAPI/QAA Improvement Activities. The facility failed to implement an effective quality assurance and performance improvement program.
F868 QAA Committee. The facility failed to maintain a functioning quality assurance committee and provide requested documentation.
Report Facts
Census: 49
Sampled residents: 13
Deficiency citations: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stewart | Executive Director | Named in plan of correction and interview regarding signage and compliance |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including care plan, pain management, medication administration, and staffing |
| Certified Nurse Aide A | CNA | Mentioned in observations related to resident care and skin assessment |
| Licensed Practical Nurse B | LPN | Mentioned in observations related to resident care and skin assessment |
| Licensed Practical Nurse C | LPN | Mentioned in observations related to resident care and skin assessment |
Inspection Report
Life Safety
Census: 49
Capacity: 67
Deficiencies: 12
Date: Aug 27, 2019
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code survey to assess compliance with federal, state, and local emergency preparedness requirements and the 2012 Existing Edition of the Life Safety Code.
Findings
The facility failed to update its emergency preparedness plan annually and did not provide emergency preparedness training to staff on an annual basis. Deficiencies were also found in emergency lighting, fire alarm system maintenance, sprinkler system maintenance, smoke barriers, HVAC maintenance, fire drills, smoking regulations, electrical systems, oxygen storage, and other life safety code requirements.
Deficiencies (12)
E004: The facility failed to update their emergency preparedness plan annually, lacking documentation and necessary procedures affecting all occupants.
E037: The facility failed to provide emergency preparedness training to staff annually and maintain documentation, affecting all occupants.
K291: The facility failed to conduct monthly tests of battery-powered emergency lighting, impacting residents, staff, and visitors.
K345: The facility failed to maintain the fire alarm system with semi-annual inspections, affecting all residents and staff.
K353: The facility failed to inspect, test, and maintain sprinkler systems and maintain documentation, risking system failure.
K372: The facility failed to maintain smoke barriers with required fire resistance and proper damper maintenance, affecting residents in six smoke compartments.
K521: The facility failed to maintain fusible link dampers with required inspections and lubrication, affecting all occupants.
K712: The facility failed to ensure fire drills were completed quarterly on each shift, affecting all occupants.
K741: The facility failed to maintain smoking regulations, allowing smoking in prohibited areas and presence of cigarette butts near gas containers.
K914: The facility failed to assess and maintain electrical receptacles in resident rooms, risking physical integrity and safety.
K918: The facility failed to document weekly checks, monthly load tests, and annual inspections of the emergency power system, affecting all residents.
K923: The facility failed to maintain oxygen cylinder storage in accordance with NFPA standards, risking safety in two resident-use compartments.
Report Facts
Census: 49
Total Capacity: 67
Inspection Report
Plan of Correction
Census: 58
Deficiencies: 2
Date: May 2, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations related to pressure ulcer prevention and treatment at Aperion Care Hidden Lake.
Findings
The facility failed to provide adequate treatment and monitoring for a resident with a Stage IV pressure ulcer, resulting in hospitalization. Documentation and wound care assessments were incomplete or missing, and staff did not follow policies for wound measurement and condition changes.
Deficiencies (2)
F686: The facility failed to provide treatment consistent with professional standards to prevent and heal pressure ulcers. The resident with a Stage IV pressure ulcer did not receive adequate wound care, monitoring, or documentation, leading to deterioration and hospitalization.
A4082: The facility did not meet the regulation requiring residents to be free from avoidable pressure sores and to receive adequate treatment if sores exist, as evidenced by the deficiency cited at F686.
Report Facts
Census: 58
Deficiencies cited: 2
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 2
Date: Mar 29, 2019
Visit Reason
The inspection was conducted to evaluate compliance with federal and state regulations regarding resident records and medication administration following a prior deficiency.
Findings
The facility failed to ensure staff documented administration of medications as ordered, with missing reasons for medication administration times left blank for multiple residents. The plan of correction was submitted to address these issues and prevent recurrence.
Deficiencies (2)
F842 Resident Records - The facility failed to ensure medical records were complete, accurately documented, readily accessible, and systematically organized. Staff did not document reasons for medication administration times left blank for multiple residents.
A4054 Safe/Effective Medication System - There was no safe and effective system of medication distribution, administration, control, and use as evidenced by the deficiency cited at F842.
Report Facts
Resident census: 44
Number of residents with medication administration time left blank: 5
Number of residents reviewed for medication administration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nurses | Interviewed regarding medication administration documentation |
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 16
Date: Nov 20, 2018
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Aperion Care Hidden Lake following a survey conducted on 11/20/2018. It addresses regulatory compliance issues identified during the inspection.
Findings
The facility was found deficient in multiple areas including financial security, posting survey results, abuse and neglect policies, care plan timing and revision, professional standards of care, accident hazards, dialysis care, nurse aide training, nurse staffing information, pharmacy services, medication error rates, quality assurance, infection control, and hospice services. The census during the survey was consistently reported as 48.
Deficiencies (16)
F570: The facility failed to maintain a surety bond sufficient to protect resident funds as required by regulation.
F577: The facility failed to post the results of the most recent survey in a place accessible to residents and family members.
F607: The facility failed to develop and implement adequate abuse and neglect policies and procedures, including timely reporting and documentation.
F657: The facility failed to ensure residents and their representatives had the opportunity to participate in care plan development, review, and revision.
F658: The facility failed to meet professional standards of care, including following physician orders for compression stockings, psychiatric and eye consults, and oxygen therapy.
F677: The facility failed to provide adequate ADL care for dependent residents requiring total assistance.
F689: The facility failed to follow safety precautions during operation of a mechanical lift, risking resident safety.
F698: The facility failed to provide thorough assessments, orders, monitoring, and communication for residents receiving dialysis.
F730: The facility failed to ensure certified nurse aides received required annual in-service training, including dementia training.
F732: The facility failed to post nurse staffing information daily as required by regulation.
F755: The facility failed to follow procedures ensuring accurate acquiring, receiving, dispensing, and administering of drugs for one resident.
F759: The facility failed to maintain a medication error rate below 5%, with multiple medication errors observed.
F849: The facility failed to ensure hospice services met professional standards and failed to collaborate with hospice providers in care planning.
F868: The facility failed to maintain a quality assessment and assurance committee that met regularly and addressed deficiencies.
F880: The facility failed to establish and maintain an effective infection prevention and control program.
F881: The facility failed to establish an antibiotic stewardship program to monitor and control antibiotic use.
Report Facts
Census: 48
Bond amount: 5000
Bond amount: 7500
Medication error rate: 7.32
Medication error rate threshold: 5
Annual training hours: 12
Annual training hours completed: 6
Annual training hours completed: 8.5
Inspection Report
Life Safety
Census: 48
Deficiencies: 6
Date: Nov 20, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain exit pathways free from obstructions, maintain kitchen range hood inspections, maintain fire extinguisher inspections, prohibit combustible decorations and portable space heaters, and properly label and separate oxygen storage tanks. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (6)
K211 Means of Egress - The facility failed to maintain exit pathways free from obstructions, including a locked exit access door by the kitchen.
K324 Cooking Facilities - The facility failed to maintain monthly inspections of the kitchen range hood as required by NFPA code.
K355 Portable Fire Extinguishers - The facility failed to maintain monthly inspections of fire extinguishers, with missing inspections for several months and a fire extinguisher not serviced since 2016.
K753 Combustible Decorations - The facility failed to prohibit the use of flammable decorations, including candles with wicks found in the conference room.
K781 Portable Space Heaters - The facility failed to prohibit the use of portable space heaters, with a space heater observed at the front receptionist desk.
K923 Gas Equipment - Cylinder and Container Storage - The facility failed to maintain proper labeling and separation of oxygen tanks in storage areas.
Report Facts
Facility census: 48
Inspection date: Nov 20, 2018
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 7
Date: Jan 19, 2018
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for nursing home operations, including resident rights, safety, infection control, and financial management.
Findings
The facility was found deficient in multiple areas including improper handling and conveyance of resident personal funds, inadequate admissions policy, failure to protect residents from accidents during transfers, and insufficient infection prevention and control practices.
Deficiencies (7)
F569 Notice and Conveyance of Personal Funds: The facility failed to disburse resident trust account funds within 30 days of death and did not provide final accounting as required by state law.
F620 Admissions Policy: The facility did not ensure the admissions policy prohibited waiving liability for loss of personal property and did not properly disclose service limitations to residents.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to protect a resident from harm during transfer by not securing the base of a mechanical lift chair, risking injury.
F880 Infection Prevention & Control: The facility failed to ensure staff properly cleansed hands during personal care, increasing risk of infection transmission among residents.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave.
A4085 Infection Control/Communicable Disease: The facility did not follow acceptable infection control procedures to prevent spread of communicable diseases.
A9011 Death of Resident, Contact DSS: The facility failed to contact the Department of Social Services upon a resident's death as required.
Report Facts
Resident census: 49
Deficiencies cited: 7
Inspection Report
Life Safety
Census: 49
Capacity: 67
Deficiencies: 4
Date: Jan 19, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents, including fire alarm system testing, smoke barriers, fire drills, and emergency preparedness.
Findings
The facility failed to meet several Life Safety Code requirements, including delayed egress locking arrangements, fire alarm system testing and maintenance, smoke barrier construction and maintenance, and fire drill scheduling. Deficient practices had the potential to affect all residents in the building.
Deficiencies (4)
K222: The facility failed to assure doors with delayed egress devices that operated in excess of 15 seconds were approved by the Authority Having Jurisdiction. One door unlocked after 30 seconds of applied pressure.
K345: The facility failed to maintain and test the fire alarm system in accordance with NFPA 72. Only annual inspections were conducted, with no additional or semi-annual inspections documented.
K372: The facility failed to ensure smoke barriers were maintained to provide the required fire resistance rating and maintain smoke dampers. Gaps and unsealed conduits were observed in smoke barriers.
K712: The facility failed to ensure fire drills were conducted on the second shift at expected and unexpected times at least quarterly. Some drills were not conducted and some were conducted simultaneously.
Report Facts
Resident census: 49
Total capacity: 67
Delayed egress unlocking time: 30
Fire alarm inspection date: Mar 3, 2017
Fire drill dates: 2
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