10 Reports
Inspection Report — Feb 6, 2024
Complaint Investigation
Date: Feb 6, 2024
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation (complaint MO0231226).
Complaint Details
MO0231226; substantiation not stated in document.
Findings
Three deficiencies were cited: two federal health deficiencies addressing resident abuse/neglect and failures in safe transfer/supervision, and one Missouri state licensure deficiency referencing nursing care per resident condition.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F689.
Report Facts
Inspection Report — Jul 3, 2023
Life Safety
Date: Jul 3, 2023
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This file contains a federal CMS-2567 health and Life Safety survey (CMS-2567) and a Missouri state licensure Statement of Deficiencies (State Form); the survey type is not stated.
Findings
31 deficiencies were cited: 17 federal life-safety/emergency preparedness deficiencies addressing emergency preparedness, means of egress, exit discharge and signage, hazardous areas and smoke barriers, doors and door self-closing/latching, sprinkler/testing, electrical/generator systems, and gas/oxygen storage and training; and 14 Missouri state deficiencies citing 19 CSR provisions that refer to the federal findings.
Deficiencies (14)
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K926.
19 CSR 30-85.022(4) Hazardous Areas: Refer to K321.
19 CSR 30-85.022(6) Oxygen Storage: Refer to K923.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(12) Exit Requirements: Refer to K211 and K271.
19 CSR 30-85.022(16) Door Locks: Refer to K222.
19 CSR 30-85.022(22) Exit Sign Requirements: Refer to K293.
19 CSR 30-85.022(23) Exit Sign Placement/Letter Size: Refer to K293.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372 and K374.
19 CSR 30-85.022(40)(B) Exterior Premises-Fire Safety: Refer to K353.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K271, K325, K363, K761 and K918.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K918.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E007 and E015.
19 CSR 30-85.042(15) Personnel Informed of Policies/Duties: Refer to E007 and E015.
Report Facts
residents potentially affected: 15
residents potentially affected: 16
residents potentially affected: 35
residents potentially affected: 14
residents potentially affected: 3
residents potentially affected: 30
Inspection Report — Jul 3, 2023
Routine
Date: Jul 3, 2023
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Federal health survey (CMS-2567) and Missouri State Form; the survey type is not stated.
Findings
30 deficiencies were cited: 13 federal health deficiencies covering resident rights, privacy, bed-hold notifications, clinical care (medication/IV), safety/accident prevention, continence/catheter care, medication errors, dental and food service issues, infection control and environment; and 17 Missouri state rule deficiencies covering construction/utility areas, medication systems, protective oversight, nursing care/clinical records, infection control, food safety, sanitation/ventilation and dignity/privacy.
Deficiencies (17)
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to F921.
19 CSR 30-85.032(25) Clean/Dirty Utility Areas-Ventilated/Lighted: Refer to F921.
19 CSR 30-85.042(46) Safe/Effective Medication System: Refer to F760.
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Refer to F689.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F550, F658, F689, F690 and F880.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-85.042(83) Equip Sanitized/Stored, Prevent Contamination: Refer to F690.
19 CSR 30-85.042(91) Social Service Program: Refer to F791.
19 CSR 30-85.042(98)(B) Clinical Records - assessment/interventions: Refer to F791.
19 CSR 30-85.052(5) Hot Food Hot, Cold Food Cold: Refer to F804.
19 CSR 30-87.020(8) Sufficient Ventilation: Refer to F921.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Refer to F812.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(32) Metal Steam-Type Thermometers Used: Refer to F812.
19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below: Refer to F804.
19 CSR 30-87.030(54) Nonfood Contact Surfaces: Refer to F812.
19 CSR 30-88.010(29) Dignity/Privacy: Refer to F583.
Report Facts
residents sampled: 19
residents affected: 4
Inspection Report — Oct 29, 2021
Routine
Date: Oct 29, 2021
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Five federal CMS deficiencies were cited addressing quality of care, pharmacy/pharmacist procedures, psychotropic PRN use, medication error rates, and medication labeling/storage. Four Missouri state deficiencies were cited addressing the safe/effective medication system, medication storage, controlled substance reconciliation/records, and nursing care per resident condition.
Deficiencies (4)
19 CSR 30-85.042(47) Safe/Effective Medication System: Refer to F755, F759, and F761.
19 CSR 30-85.042(56) Medication Storage: Refer to F761.
19 CSR 30-85.042(63) Controlled Substance Reconcile/Record: Refer to F755.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F684 and F758.
Report Facts
residents sampled: 12
observed medication opportunities: 30
medication errors: 5
Inspection Report — Oct 29, 2021
Life Safety
Date: Oct 29, 2021
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CMS-2567 Life Safety survey (Emergency Preparedness portion) and Missouri Department of Health and Senior Services State Form licensure pages; Life Safety Code/Emergency Preparedness portion conducted 10/28-10/29/2021. No complaint numbers are stated.
Findings
21 deficiencies were cited: 9 CMS-2567 life-safety deficiencies addressing egress/locking doors, kitchen suppression/testing and hood documentation, fire alarm testing and records, sprinkler/sprinkler escutcheon issues, corridor/door closures, fire drills, door inspection/testing, essential electrical systems and emergency call systems; and 12 Missouri State Form deficiencies that reference and cite those life-safety findings.
Deficiencies (13)
19 CSR 30-85.012(124) Nurses' Call System Requirements: Refer to K921.
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K363, K761, K918.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: Refer to K324.
19 CSR 30-85.022(10)(C) Fire Alarm System-Inspections/Certifications: Refer to K345 and K353.
19 CSR 30-85.022(10)(F) Fire Alarm System Records: Refer to K345.
19 CSR 30-85.022(10)(F) Complete Fire Alarm Systems (Records): Refer to K345.
19 CSR 30-85.022(11)(A) Inspections Completed, Certification Annually (Sprinkler System): Refer to K353.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(12) Exit Requirements: Refer to K222.
19 CSR 30-85.022(21) Corridor Requirements: Refer to K363 and K761.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Refer to K712.
19 CSR 30-85.032(27) Call System Requirements: Refer to K921.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K918.
Report Facts
residents affected: 30
residents affected: 28
residents affected: 47
Inspection Report — Oct 21, 2019
Routine
Date: Oct 21, 2019
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CMS-2567 federal health survey (health deficiencies) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 5 federal health deficiencies addressing quality of care, accident hazards/supervision (safe transfers), parenteral/IV (PICC) care and documentation, psychotropic/PRN medication use, and infection prevention and control; and 3 Missouri State Form deficiencies referencing the federal findings for medication system, nursing care, and infection control.
Deficiencies (3)
19 CSR 30-85.042(47) Safe/Effective Medication System: Refer to F758.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F684, F689, and F694.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
Report Facts
residents sampled: 19
Inspection Report — Oct 21, 2019
Life Safety
Date: Oct 21, 2019
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CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form; the survey is a Life Safety Code survey.
Findings
Seven deficiencies were cited: 3 federal Life Safety deficiencies addressing cooking equipment/fire suppression connection, annual door inspection/testing, and electrical/essential power systems testing and documentation; and 4 Missouri State Form deficiencies addressing fire hazard, complete fire alarm system requirements, corridor requirements, and electrical wiring/equipment maintenance.
Deficiencies (4)
19 CSR 30-85.022(2)(E) No Fire Hazard: See the deficiency cited at K761 and K918.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirments: See the deficiency cited at K324.
19 CSR 30-85.022(21) Corridor Requirements: See the deficiency cited at K761.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: See the deficiency cited at K918.
Inspection Report — Oct 25, 2018
Routine
Date: Oct 25, 2018
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Five federal health survey deficiencies addressed resident transfer/safety, nutrition/weight loss, medication labeling/storage, infection prevention and control (catheter/respiratory care), and environmental ventilation/dust. Six Missouri state licensure deficiencies cross-referenced the federal findings and cited rules on utility areas, medication labeling, protective oversight/voluntary leave, infection control, nutritional needs, and air duct maintenance.
Deficiencies (6)
19 CSR 30-85.032(25) Clean/Dirty Utility Areas-Ventilated/Lighted: Refer to F921.
19 CSR 30-85.042(54) Medication Labeling: Refer to F761.
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Refer to F689.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-85.052(1) Nutritional Needs Met Assess Res, Inform Dr: Refer to F692.
19 CSR 30-87.020(9) Air Ducts-Maintain: Refer to F921.
Report Facts
residents sampled: 31
residents potentially affected: 30
Inspection Report — Oct 25, 2018
Life Safety
Date: Oct 25, 2018
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CMS-2567 Life Safety (K-tags) and Emergency Preparedness (E-tags) forms and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 24 federal deficiencies (Life Safety and Emergency Preparedness) addressing building construction, means of egress, exit discharge and signage, emergency lighting and illumination, fire protection systems, cooking and laundry fire hazards, fire alarm and detection, sprinkler impairment and emergency power and electrical systems. There are 15 Missouri state licensure deficiencies mirroring many of the same topics and referring to the federal K/E findings.
Deficiencies (15)
19 CSR 30-85.022(2)(E) No Fire Hazard General Requirements: Refer to K300.
19 CSR 30-85.022(6) Oxygen Storage: Refer to K923.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: Refer to K355.
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(10)(C) Fire Alarm System - Inspections/Certifications: Refer to K345.
19 CSR 30-85.022(10)(G) Fire Alarm System - Correct Faults: Refer to K341.
19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr: Refer to K354.
19 CSR 30-85.022(12) Exit Requirements: Refer to K211 & K271.
19 CSR 30-85.022(24) Exit Sign - Maintain/Illuminate: Refer to K293.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K281.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161, K363, K372 & K918.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K914.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E001, E009, E015, E018, E022, E026 & E041.
19 CSR 30-85.042(15) Personnel Informed of Policies/Duties: Refer to E001, E009, E015, E018, E022, E026 & E041.
Report Facts
residents_potentially_affected: 89
smoke_zones_total: 16
Inspection Report — May 31, 2018
Life Safety
Date: May 31, 2018
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Federal Life Safety survey (CMS-2567 K-tag) and Missouri state licensure survey (State Form) were conducted; the survey type is not stated.
Findings
Two deficiencies were cited: one federal life safety deficiency regarding the facility's evacuation/relocation plan and failure to include an hourly fire watch procedure after a fire, and one Missouri state deficiency for failure to perform/document 24-hour hourly fire-monitoring checks.
Deficiencies (1)
19 CSR 30-85.022(2)(G) Fire-24hr Monitor, Hourly Checks: Refer to K711.
22 CMS Surveys
Inspection Report — Oct 22, 2025
Complaint Investigation
Date: Oct 22, 2025
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The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure accurate documentation and administration of narcotic medication for a sampled resident.
Complaint Details
Complaint number 2634694 triggered the investigation into narcotic medication administration and documentation discrepancies.
Findings
The facility failed to ensure the physician's orders for narcotic medication matched the narcotic sheet and Medication Administration Record (MAR), failed to accurately document narcotic administration on the MAR, and failed to follow policy for corrections on the narcotic sheet. Discrepancies were found in medication counts and documentation, including altered records and missing signatures.
Deficiencies (3)
Failure to ensure physician's order for narcotic medication was accurately shown on the narcotic sheet and MAR.
Failure to ensure nurse accurately documented narcotic medications administered on the MAR.
Failure to follow policy and procedure for corrections made on the narcotic sheet.
Report Facts
Residents Affected: 8
Medication tablets delivered: 30
Medication tablets documented: 20
Medication tablets administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Described narcotic medication administration process and discrepancies |
| Registered Nurse A | Registered Nurse | Described in-service training and narcotic administration documentation requirements |
| Director of Nursing | Director of Nursing | Provided expectations for narcotic order verification and documentation, and discussed audit findings |
| Administrator | Administrator | Discussed narcotic sheet and MAR discrepancies and corrective expectations |
Inspection Report — Jan 10, 2025
Routine
Date: Jan 10, 2025
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Federal health survey (CMS-2567); a standard survey was conducted and no complaint number is cited.
Findings
Seven federal health deficiencies were cited addressing representative rights and decision-making, Medicaid/Medicare notice procedures, safety/cleanliness and homelike environment, timeliness of care plan revision, accident hazards and supervision (unsecured treatment cart), kitchen/food sanitation, and quality assessment/assurance committee participation.
Deficiencies (7)
F551 Rights Exercised by Representative: Based on interviews and record review the facility failed to ensure a resident not determined by a physician to lack the ability to make informed healthcare decisions was provided opportunities to participate in the Care Plan process; this was evidenced for one resident sampled (Resident #64).
F582 Medicaid/Medicare Coverage/Liability Notice: Based on interviews and record review the facility failed to ensure the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by the resident; this was evidenced for one resident sampled (Resident #64).
F584 Safe/Clean/Comfortable/Homelike Environment: Based on observations, interviews, and review of cleaning documentation the facility failed to maintain a clean, safe, and homelike environment on multiple halls and common areas, including accumulated debris, dust, trash on floors, cobwebs, dirty ice machine, and missing door hardware.
F657 Care Plan Timing and Revision: Based on interviews and record review the facility failed to develop or revise a comprehensive care plan within the required timeframe after a significant change in a resident's condition; this was evidenced for one resident sampled (Resident #10).
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview and record review the facility failed to ensure an environment free from accident hazards when an unattended, unlocked treatment cart containing medications and supplies was stored in a lounge accessible to residents.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observations and interviews the facility failed to maintain kitchen and food preparation areas in a clean and sanitary condition, with food debris, grease, and dried residues observed on floors, equipment, ovens, and preparation surfaces.
F868 QAA Committee: Based on interviews and record review the facility failed to maintain required participation on the Quality Assessment and Assurance/Performance Improvement committee, with required members not present or signatures missing for several quarterly meetings.
Report Facts
residents sampled for care plan participation: 3
residents sampled for Notice of Medicare Non-Coverage: 3
Inspection Report — Jan 9, 2025
Life Safety
Date: Jan 9, 2025
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CMS-2567 Life Safety Code recertification survey (federal); Emergency Preparedness initial comments/pages are also present.
Findings
Three life safety (K-tag) deficiencies were cited related to sprinkler supervisory signaling, sprinkler system maintenance/testing (lack of required full flow trip testing), and improper use of electrical equipment/power cords (relocatable power tap). Emergency Preparedness observations indicated compliance.
Deficiencies (3)
K 352 Sprinkler System - Supervisory Signals: Based on observation and interview, the facility failed to install electronic supervisory devices on all sprinkler control valves. The deficient practice affected two (2) of six (6) smoke compartments, staff, and 24 residents.
K 353 Sprinkler System - Maintenance and Testing: Based on records review and interview, the facility failed to maintain required sprinkler system testing documentation and did not provide documentation of a full flow trip test within the last three years. The deficient practice affected six (6) of six (6) smoke compartments, staff, and all residents.
K 920 Electrical Equipment - Power Cords and Extens: Based on observation and interview, the facility failed to prohibit improper use of electrical equipment when a relocatable power tap was observed powering a therapy table. The deficient practice affected one (1) of six (6) smoke compartments, staff, and one (1) resident.
Report Facts
residents affected: 24
residents affected: 1
smoke compartments affected: 6
Inspection Report — Jul 9, 2024
Routine
Date: Jul 9, 2024
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Federal health (CMS-2567) survey; the survey type is not stated.
Findings
One CMS-2567 health deficiency cited involving failure to notify a resident's responsible party/DPOA of a new medication for one sampled resident; the survey notes past noncompliance.
Deficiencies (1)
F580 Notify of Changes (Injury/Decline/Room, etc.): Based on interview and record review, the facility failed to notify the resident's responsible party to obtain consent prior to starting a new medication for one sampled resident (Resident #2) out of three sampled residents.
Report Facts
residents sampled: 3
residents affected: 1
Inspection Report — Feb 6, 2024
Complaint Investigation
Date: Feb 6, 2024
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation (complaint MO0231226).
Complaint Details
MO0231226; substantiation not stated in document.
Findings
Three deficiencies were cited: two federal health deficiencies addressing resident abuse/neglect and failures in safe transfer/supervision, and one Missouri state licensure deficiency referencing nursing care per resident condition.
Deficiencies (2)
F600 Free from Abuse and Neglect: Based on observation, interview, and record review, staff forced a resident to shower after the resident refused, resulting in visible bruising and emotional distress; the facility failed to protect the resident from intimidation and physical abuse.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide safe transfer assistance for one resident, transferring the resident without a gait belt and lifting the resident by staff arms which resulted in bruising; policies and documentation regarding gait/transfer belt use were not provided or followed.
Report Facts
Inspection Report — Jul 3, 2023
Life Safety
Date: Jul 3, 2023
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This file contains a federal CMS-2567 health and Life Safety survey (CMS-2567) and a Missouri state licensure Statement of Deficiencies (State Form); the survey type is not stated.
Findings
31 deficiencies were cited: 17 federal life-safety/emergency preparedness deficiencies addressing emergency preparedness, means of egress, exit discharge and signage, hazardous areas and smoke barriers, doors and door self-closing/latching, sprinkler/testing, electrical/generator systems, and gas/oxygen storage and training; and 14 Missouri state deficiencies citing 19 CSR provisions that refer to the federal findings.
Deficiencies (17)
E007 EP Program Patient Population: The facility failed to include a plan for how licensed personnel would access the automated medication dispenser in the event of a power outage, potentially affecting all residents.
E015 Subsistence Needs for Staff and Patients: The facility failed to include the method of monitoring ambient air temperatures in the facility during an HVAC failure, potentially affecting all residents.
K211 Means of Egress - General: The facility failed to ensure required egress areas were kept free of obstructions, including items left in front of kitchen exit doors, potentially placing residents and staff at risk during egress.
K222 Egress Doors: The facility allowed locking arrangements (padlocks/locked cages) on doors/areas that could be entered by a person, preventing required egress without reliable means of release.
K271 Discharge from Exits: The facility failed to ensure exit discharges were unobstructed and maintained (damaged walkways, mats obstructing doors), which could impede evacuation; this practice potentially affected at least 15 residents in the ALF.
K293 Exit Signage: The facility failed to provide required NO EXIT and EXIT signage in several locations between the kitchen and dining areas, creating potential confusion about egress routes for residents and staff.
K321 Hazardous Areas - Enclosure: The facility failed to ensure doors to hazardous areas were self-closing or automatic-closing (multiple utility/storage/training rooms), affecting resident safety in those smoke zones.
K324 Cooking Facilities: The facility failed to ensure the range hood/flue was properly oriented and free of excessive grease buildup, creating a fire/grease hazard in kitchen smoke zones.
K325 Alcohol Based Hand Rub Dispenser (ABHR): The facility installed ABHR dispensers in locations that did not meet placement requirements (above electrical receptacles), creating a potential hazard.
K353 Sprinkler System - Maintenance and Testing: The facility failed to provide required signage/clear path and marking for fire hydrants and fire department access, leaving hydrants and related areas without appropriate markings.
K363 Corridor - Doors: The facility failed to ensure corridor and fire/smoke doors closed and latched (many doors held open or difficult to close), potentially affecting residents in multiple smoke zones.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier continuity (gaps, temporary plastic sheeting and inadequate sealing), compromising smoke separation between zones.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to ensure smoke barrier doors closed during fire alarm tests (doors did not fully close), impacting safe compartmentation during alarm conditions.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to ensure fire resistance rating (FRR) labels were present and documented on required doors, limiting the ability to verify door fire ratings.
K918 Electrical Systems - Essential Electric System: The facility failed to ensure required inspections/testing of the essential electrical system (including circuit breaker inspection/records), affecting power reliability for life-safety systems.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure oxygen/carbon-dioxide cylinders were stored and secured appropriately (some cylinders unsupported and combustible materials stored nearby), with cylinders observed stored without proper support.
K926 Gas Equipment - Qualifications and Training of Personnel: The facility failed to ensure personnel (including contract staff) were trained and informed about safe handling and removal of oxygen cylinders and related procedures.
Report Facts
residents potentially affected: 15
residents potentially affected: 16
residents potentially affected: 35
residents potentially affected: 14
residents potentially affected: 3
residents potentially affected: 30
Inspection Report — Jul 3, 2023
Routine
Date: Jul 3, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; the survey type is not stated.
Findings
30 deficiencies were cited: 13 federal health deficiencies covering resident rights, privacy, bed-hold notifications, clinical care (medication/IV), safety/accident prevention, continence/catheter care, medication errors, dental and food service issues, infection control and environment; and 17 Missouri state rule deficiencies covering construction/utility areas, medication systems, protective oversight, nursing care/clinical records, infection control, food safety, sanitation/ventilation and dignity/privacy.
Deficiencies (13)
F550 Resident Rights/Exercise of Rights: Based on observation, interview and record review the facility failed to provide supporting documentation for the use or consent for a wandering safety device and did not have required documentation of resident notification/consent for its placement for sampled residents.
F583 Personal Privacy/Confidentiality of Records: The facility failed to ensure resident privacy during a blood glucose test and insulin administration by performing these procedures in a common area without obtaining privacy or consent for the resident.
F625 Notice of Bed Hold Policy Before/Upon Trnsfr: The facility failed to ensure bed-hold forms were completed and provided for residents transferred to the hospital for three sampled residents.
F658 Services Provided Meet Professional Standards: The facility failed to follow professional standards when flushing/aspirating IV catheters prior to medication administration for one sampled resident and did not verify catheter patency as required.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure wheels on mobile devices (beds/wheelchairs) were locked prior to transferring and repositioning a sampled resident and staff left devices unlocked.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure appropriate care and monitoring of a suprapubic catheter and to perform required assessments, cleaning and supplies checks for one sampled resident.
F757 Drug Regimen is Free from Unnecessary Drugs: Based on record review and interview the facility failed to ensure one sampled resident was free from unnecessary medications and had transcription/medication order issues that put residents at risk.
F760 Residents are Free of Significant Med Errors: The facility failed to prevent a significant medication error for one sampled resident by transcribing/administering an incorrect antibiotic regimen.
F791 Routine/Emergency Dental Srvcs in NFs: The facility failed to provide or document dental services for one sampled resident and did not provide a copy of their dental policy at exit.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to maintain hot foods at safe/acceptable temperatures and residents reported cold or unpalatable food; observed hot trays below expected temperatures for room trays.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to follow food safety practices in the kitchen including use of undated frozen items, unclean equipment/nozzle debris, and failure to date or refrigerate opened items, placing residents at risk.
F880 Infection Prevention & Control: The facility failed to use adequate hand hygiene and aseptic technique for IV care and did not follow infection prevention practices during resident care events for sampled residents.
F921 Safe/Functional/Sanitary/Comfortable Environ: The facility failed to maintain clean vents, secure outdoor vent screening, maintain negative air flow in shower/restroom vents, and had heavy dust buildups and other environmental deficiencies in multiple non-resident and resident areas.
Report Facts
residents sampled: 19
residents affected: 4
Inspection Report — Nov 29, 2022
Complaint Investigation
Date: Nov 29, 2022
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Federal health survey (CMS-2567); complaint investigation (MO00209885).
Complaint Details
MO00209885; substantiation not stated.
Findings
One federal deficiency was cited for staff licensure and supervision issues. The surveyor found the facility employed a graduate practical nurse who lacked required licensure/certification and administered medications without an approval letter; past noncompliance was noted.
Deficiencies (1)
F 836 License/Comply w/ Fed/State/Local Law/Prof Std: The facility allowed a graduate practical nurse to pass medications without an approval letter and the nurse did not have the required certification or proof of passing nursing licensing boards; facility records and interviews showed failures to verify staff qualifications.
Inspection Report — Nov 29, 2021
Routine
Date: Nov 29, 2021
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CMS-2567 federal health survey; the initial comments state a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies were cited on this federal health survey. The survey found the facility in compliance with COVID-19 emergency preparedness and infection control requirements as stated in the initial comments.
Inspection Report — Oct 29, 2021
Routine
Date: Oct 29, 2021
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Five federal CMS deficiencies were cited addressing quality of care, pharmacy/pharmacist procedures, psychotropic PRN use, medication error rates, and medication labeling/storage. Four Missouri state deficiencies were cited addressing the safe/effective medication system, medication storage, controlled substance reconciliation/records, and nursing care per resident condition.
Deficiencies (5)
F 684 Quality of Care: Based on interview and record review, the facility failed to ensure coordination of care with hospice for one sampled resident. The resident's care plan and the unit hospice documentation did not show a coordinated hospice care plan or schedule.
F 755 Pharmacy Srvs/Procedures/Pharmacist/Records: The facility failed to ensure controlled substance/narcotic counts were completed and signed by two staff each shift for multiple medication carts and medication rooms. Numerous narcotic count records showed missing or unsigned on-coming or off-going nurse signatures across multiple dates and units.
F 758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure behavioral documentation and non-pharmacological interventions were completed prior to administration of a PRN anti-anxiety psychotropic for one sampled resident. Records lacked documentation of behaviors and of non-pharmacologic interventions used prior to PRN lorazepam.
F 759 Free of Medication Error Rts 5 Prcnt or More: The facility failed to ensure medication error rates were less than 5 percent; out of 30 observed medication opportunities five errors occurred (an error rate of 16.67%). Errors included crushing medications and improper administration techniques for eye drops.
F 761 Label/Store Drugs and Biologicals: The facility failed to ensure multi-dose and opened medications were dated and stored according to policy. Observations and record review identified opened/undated vials, bottles and pens and inconsistent dating practices for medications.
Report Facts
residents sampled: 12
observed medication opportunities: 30
medication errors: 5
Inspection Report — Oct 29, 2021
Life Safety
Date: Oct 29, 2021
Visit Reason
CMS-2567 Life Safety survey (Emergency Preparedness portion) and Missouri Department of Health and Senior Services State Form licensure pages; Life Safety Code/Emergency Preparedness portion conducted 10/28-10/29/2021. No complaint numbers are stated.
Findings
21 deficiencies were cited: 9 CMS-2567 life-safety deficiencies addressing egress/locking doors, kitchen suppression/testing and hood documentation, fire alarm testing and records, sprinkler/sprinkler escutcheon issues, corridor/door closures, fire drills, door inspection/testing, essential electrical systems and emergency call systems; and 12 Missouri State Form deficiencies that reference and cite those life-safety findings.
Deficiencies (9)
K222 Egress Doors: Based on observation, interview and record review, the facility failed to provide release of locking mechanisms on two of three egress doors, and the doors did not disengage during fire alarm tests, potentially preventing rapid exit for occupants in the 800 (SCU) unit.
K324 Cooking Facilities: The facility failed to provide complete and verifiable inspection and testing documentation for the kitchen range hood fire suppression and associated components, and records did not show required items such as connection to the building fire alarm.
K345 Fire Alarm System - Testing and Maintenance: The facility did not provide complete and current documentation of required semi-annual and annual fire alarm inspections and testing, and did not demonstrate testing of all three fire alarm systems after a lightning/storm-related electrical event.
K353 Sprinkler System - Maintenance and Testing: Observations showed missing or improperly positioned sprinkler escutcheon plates at multiple locations and record review revealed gaps in required sprinkler inspection/maintenance documentation.
K363 Corridor - Doors: The facility had smoke barrier/corridor doors blocked open with wedges and chairs and the doors would not close properly, which could prevent containment of smoke and affect residents in adjacent smoke compartments.
K712 Fire Drills: The facility failed to conduct fire drills with complete documentation on varying dates/shifts and the drill records lacked required details, limiting assurance staff familiarity with emergency procedures.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to perform and document complete visual and functional door inspections and testing on the required schedule and did not maintain adequate records of door condition and maintenance.
K918 Electrical Systems - Essential Electric System: The facility did not provide complete, comprehensive, verifiable documentation of maintenance and testing of the facility's electrical main and branch circuit breaker panels, and records of required periodic testing were missing.
K921 Electrical Equipment - Testing and Maintenance: The facility failed to ensure the emergency call/call light audible signals in resident bath/shower areas on the 200 corridor and in the SCU were functioning or audible to staff, and staff could not hear those signals.
Report Facts
residents affected: 30
residents affected: 28
residents affected: 47
Inspection Report — Dec 29, 2020
Routine
Date: Dec 29, 2020
Visit Reason
CMS-2567 federal health survey; the form states a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted.
Findings
No deficiencies were cited; the facility was found in compliance with emergency preparedness and infection control requirements.
Inspection Report — Nov 13, 2020
Routine
Date: Nov 13, 2020
Visit Reason
CMS-2567 (federal health) COVID-19 Focused Emergency Preparedness and COVID-19 Focused Infection Control survey; the survey type is stated on the form and no complaint number is provided.
Findings
No health survey deficiencies were cited; Initial Comments state the facility was found in compliance with emergency preparedness and infection control requirements.
Inspection Report — Aug 24, 2020
Routine
Date: Aug 24, 2020
Visit Reason
CMS-2567 federal health survey (Statement of Deficiencies) containing Initial Comments for a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey.
Findings
No survey deficiencies were cited. Initial Comments state the facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6) and with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Aug 4, 2020
Routine
Date: Aug 4, 2020
Visit Reason
CMS-2567 federal health survey (COVID-19 Focused Emergency Preparedness and COVID-19 Focused Infection Control Survey) as indicated in the Initial Comments.
Findings
No deficiencies were cited; the survey found the facility in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS/CDC recommended practices for COVID-19 infection control.
Inspection Report — Jul 16, 2020
Routine
Date: Jul 16, 2020
Visit Reason
CMS-2567 federal health and emergency preparedness/infection control survey; a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted.
Findings
No deficiencies were cited. The facility was found in compliance with 42 CFR 483.73 related to E-0024(b)(6) and with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — May 22, 2020
Routine
Date: May 22, 2020
Visit Reason
CMS-2567 federal health (infection control) and federal emergency preparedness forms; a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted.
Findings
No federal health (F) or emergency preparedness (E) deficiencies were cited; the facility was found in compliance with CDC recommended practices and 42 CFR 483.73 related requirements.
Inspection Report — Oct 21, 2019
Routine
Date: Oct 21, 2019
Visit Reason
CMS-2567 federal health survey (health deficiencies) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
The file contains 5 federal health deficiencies addressing quality of care, accident hazards/supervision (safe transfers), parenteral/IV (PICC) care and documentation, psychotropic/PRN medication use, and infection prevention and control; and 3 Missouri State Form deficiencies referencing the federal findings for medication system, nursing care, and infection control.
Deficiencies (5)
F684 Quality of Care: Based on observation, interview, and record review, the facility failed to notify the physician of a significant weight gain and to obtain physician orders for a specialized arm sleeve for edema for one sampled resident.
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview and record review, the facility failed to ensure a safe transfer by not ensuring required two-person assist and proper wheelchair checks during a transfer for one sampled resident.
F694 Parenteral/IV Fluids: Based on observation, interview and record review, the facility failed to document PICC external catheter length, compare measurements, and secure the PICC during dressing changes as required for a sampled resident.
F758 Free from Unnec Psychotropic Meds/PRN Use: Based on observation, interview and record review, the facility failed to ensure PRN psychotropic orders were limited to 14 days with clinical justification and documented duration when extended, resulting in deficient PRN psychotropic use for multiple sampled residents.
F880 Infection Prevention & Control: Based on observation, interview and record review, the facility failed to ensure proper transmission-based precautions, PPE use, and aseptic technique for PICC and wound dressing changes, resulting in contaminated practice and infection control lapses for one sampled resident.
Report Facts
residents sampled: 19
Inspection Report — Oct 21, 2019
Life Safety
Date: Oct 21, 2019
Visit Reason
CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form; the survey is a Life Safety Code survey.
Findings
Seven deficiencies were cited: 3 federal Life Safety deficiencies addressing cooking equipment/fire suppression connection, annual door inspection/testing, and electrical/essential power systems testing and documentation; and 4 Missouri State Form deficiencies addressing fire hazard, complete fire alarm system requirements, corridor requirements, and electrical wiring/equipment maintenance.
Deficiencies (3)
K324 Cooking Facilities: Based on interview and record review, the facility's kitchen range hood fire suppression system was not documented as being connected to the facility's main fire alarm system.
K761 Maintenance, Inspection & Testing - Doors: Based on interview and record review, the facility failed to conduct annual visual and functional line-item assessments and maintain required inspection/testing documentation for corridor and egress door assemblies.
K918 Electrical Systems - Essential Electric System: Based on interview and record review, the facility failed to complete comprehensive testing and provide complete, verifiable documentation of the electrical main and circuit breaker panels and associated testing.
Inspection Report — Oct 25, 2018
Routine
Date: Oct 25, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Five federal health survey deficiencies addressed resident transfer/safety, nutrition/weight loss, medication labeling/storage, infection prevention and control (catheter/respiratory care), and environmental ventilation/dust. Six Missouri state licensure deficiencies cross-referenced the federal findings and cited rules on utility areas, medication labeling, protective oversight/voluntary leave, infection control, nutritional needs, and air duct maintenance.
Deficiencies (5)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure safe transfers with a mechanical lift when staff did not lock a resident's wheelchair during transfer for one sampled resident.
F692 Nutrition/Hydration Status Maintenance: The facility failed to provide new dietary interventions and update the plan of care to prevent further weight loss for one sampled resident who lost 26 pounds in one month.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure proper labeling of opened medications and controlled substances (including inhalers, nasal sprays, insulin and liquid controlled substances) with multiple opened containers lacking dates or resident names.
F880 Infection Prevention & Control: The facility failed to ensure infection control practices to prevent cross contamination during transfers and to maintain catheter drainage bags and oxygen/respiratory supplies off the floor, placing residents at risk.
F921 Other Environmental Conditions/Safe/Functional/Sanitary/Comfortable Environ: The facility failed to ensure required negative airflow in specified utility/soiled areas and had heavy dust buildup in ceiling vents in multiple resident areas, potentially affecting residents who used those areas.
Report Facts
residents sampled: 31
residents potentially affected: 30
Inspection Report — Oct 25, 2018
Life Safety
Date: Oct 25, 2018
Visit Reason
CMS-2567 Life Safety (K-tags) and Emergency Preparedness (E-tags) forms and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 24 federal deficiencies (Life Safety and Emergency Preparedness) addressing building construction, means of egress, exit discharge and signage, emergency lighting and illumination, fire protection systems, cooking and laundry fire hazards, fire alarm and detection, sprinkler impairment and emergency power and electrical systems. There are 15 Missouri state licensure deficiencies mirroring many of the same topics and referring to the federal K/E findings.
Deficiencies (24)
K161 Building Construction Type and Height: Based on observation, interview and record review, the facility failed to ensure there were penetrations in walls and/or ceilings in multiple locations (dining office, 200 Hall janitor's closet, resident rooms 213, 814, 313, the 400 Hall hot water heater room and the ALF medication room).
K211 Means of Egress - General: The facility failed to ensure one exit door from the dining room would open easily during the fire alarm test, affecting residents who use that dining area.
K271 Discharge from Exits: The facility failed to ensure exit discharge paths from the kitchen and other areas were maintained free of obstructions and damaged walkway areas that could hinder evacuation.
K281 Illumination of Means of Egress: The facility failed to provide sufficient emergency lighting at exit discharge locations outside the Atrium area and other exits, leaving some exit paths without adequate emergency illumination.
K293 Exit Signage: The facility failed to place EXIT signs at both entrances into the facility from within the courtyard between the Health Care Center and the Assisted Living Facility to inform users of that courtyard how to re-enter the facility.
K300 Protection - Other: The facility failed to prevent a buildup of lint in the firebox (chambers at top of dryers) in the laundry area, creating a combustible hazard.
K324 Cooking Facilities: The facility failed to ensure range hood components (baffle vents) were maintained in good repair, with damaged/slatted baffle vents observed in the kitchen hood.
K341 Fire Alarm System - Installation: The facility failed to ensure a heat detector in the 600 Hall employee kitchenette was properly attached to the ceiling, and other initiating device installation/attachment issues were observed.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to ensure a semi-annual fire alarm inspection had been conducted in accordance with NFPA 72 (records showed only an annual test).
K354 Sprinkler System - Out of Service: The facility's fire watch plan and documentation did not include required elements when sprinkler systems are impaired and lacked procedures required for extended impairments.
K355 Portable Fire Extinguishers: The facility failed to ensure a Class K fire extinguisher for the kitchen was not obscured (hidden by frying pans) and lacked required signage indicating activation before use.
K363 Corridor - Doors: Corridor and resident room doors were observed that did not resist passage of smoke (doors not latching, gaps, wedged open or otherwise not closing as required).
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to ensure smoke barrier walls were continuous and had gaps between barrier wall and attic/ceiling areas over the 300 East Hall and 500 Hall attic areas.
K914 Electrical Systems - Maintenance and Testing: The facility did not assess receptacles in resident rooms and associated resident use areas for integrity, grounding continuity, polarity and retention force as required by testing procedures.
K918 Electrical Systems - Essential Electric System: The facility failed to have a 90-minute fire-rated door at the generator room and other essential electrical system arrangements required for emergency power.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly label and segregate the two oxygen storage rooms and to mark full versus empty cylinder storage as required.
K926 Gas Equipment - Qualifications and Training: The facility failed to ensure staff had completed required training and in-services regarding the handling and transfill procedures for liquid oxygen and oxygen cylinders.
E001 Establishment of the Emergency Program (EP): The facility's disaster plan lacked the Communications Plan and the Training and Testing components required as part of the emergency preparedness program.
E009 Local, State, Tribal Collaboration Process: The facility failed to include phone numbers for emergency management agencies (FEMA, SEMA, CMS) and documentation of collaborative planning efforts in its emergency preparedness materials.
E015 Subsistence Needs for Staff and Patients: The facility's disaster plan lacked a backup sewage plan and a policy to monitor temperatures in the event of climate control failure affecting subsistence needs and sanitary storage.
E018 Procedures for Tracking of Staff and Patients: The facility failed to include a plan to track residents and staff locations after evacuation so records would follow residents to receiving locations.
E022 Policies/Procedures for Sheltering in Place: The facility's disaster manual did not include procedures for implementing shelter-in-place actions if the call light system failed.
E026 Roles Under a Waiver Declared by Secretary: The facility failed to include a policy describing how it would operate under an 1135 waiver and the facility's role under waivers declared during emergencies.
E041 Hospital CAH and LTC Emergency Power: The facility failed to include required emergency generator information in the manual and lacked a letter documenting reliability of natural gas supply; generator power documentation was incomplete.
Report Facts
residents_potentially_affected: 89
smoke_zones_total: 16
Inspection Report — May 31, 2018
Life Safety
Date: May 31, 2018
Visit Reason
Federal Life Safety survey (CMS-2567 K-tag) and Missouri state licensure survey (State Form) were conducted; the survey type is not stated.
Findings
Two deficiencies were cited: one federal life safety deficiency regarding the facility's evacuation/relocation plan and failure to include an hourly fire watch procedure after a fire, and one Missouri state deficiency for failure to perform/document 24-hour hourly fire-monitoring checks.
Deficiencies (1)
K711 Evacuation and Relocation Plan: The facility failed to include a requirement to conduct hourly fire watches of areas affected by a fire.
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