Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.9 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
11% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
50% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 55
Deficiencies: 4
Date: Mar 28, 2025
Visit Reason
Routine inspection to assess compliance with Medicare and Medicaid regulations, including review of resident care, food service, infection control, and facility policies.
Findings
The facility failed to provide appropriate Medicare Non-Coverage notices for discharged residents, did not serve food according to prescribed menus and portion sizes, improperly stored food and failed to maintain proper dishwashing temperatures and procedures, and did not fully implement enhanced barrier precautions for infection control. Additionally, catheter bags were observed resting on the floor, posing infection risks.
Deficiencies (4)
F 0582: Facility staff failed to provide the required Medicare Non-Coverage notices for three residents discharged from Medicare Part A services.
F 0803: Facility staff failed to serve food in accordance with nutritionally calculated menus to 33 of 55 residents, including incorrect portion sizes and mismatched diet textures.
F 0812: Facility staff failed to store food properly to prevent contamination, including undated and uncovered food items, food stored on floors, and improper chemical storage; dishwashing machine temperatures were below required levels and dishes were not allowed to air-dry before storage.
F 0880: Facility staff failed to implement enhanced barrier precautions for residents with wounds and indwelling devices, including lack of PPE use and signage, and catheter bags were observed resting on the floor for two residents.
Report Facts
Residents affected: 3
Residents affected: 33
Facility census: 55
Dishwasher wash temperature: 153
Dishwasher rinse temperature: 169
Inspection Report
Census: 49
Deficiencies: 1
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the timely refund of resident funds upon discharge from the facility.
Findings
The facility failed to refund resident funds within 30 days of discharge for three sampled residents. The Business Office Manager was unaware of the refund timeframe and there was no audit system to ensure timely refunds.
Deficiencies (1)
F 0569: Facility staff failed to refund resident funds within 30 days of discharge for three residents. The facility lacked a policy for refunding monies owed after discharge.
Report Facts
Facility census: 49
Refund amount owed to Resident #1: 2993.25
Refund amount requested for Resident #3: 7072
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Responsible for requesting refunds and acknowledged delays | |
| Administrator | Confirmed responsibility of BOM and lack of audit system |
Inspection Report
Routine
Census: 54
Deficiencies: 6
Date: Mar 22, 2024
Visit Reason
Routine inspection of Heisinger Bluffs Rehab and Healthcare Center to assess compliance with professional standards of quality, activities programming, medication storage and labeling, food service, hand hygiene, and infection control.
Findings
The facility had multiple deficiencies including failure to ensure required PT/INR blood tests for a resident on Warfarin, inadequate activities programming for dependent residents with dementia, undated multi-dose medications, failure to serve pureed diets according to menus, poor hand hygiene practices among dietary staff, and incomplete tuberculosis screening documentation for some residents.
Deficiencies (6)
F0658: Facility staff failed to ensure one resident on Warfarin received required PT/INR blood tests to monitor medication safety.
F0679: Facility staff failed to provide an ongoing activities program meeting the interests of four dependent residents with dementia, with inadequate documentation and participation.
F0761: Facility staff failed to date multi-dose medications including inhalers, insulin pens, and nasal sprays, risking medication stability and efficacy.
F0803: Facility staff failed to serve pureed diets in accordance with nutritionally calculated recipes and menus for four residents.
F0812: Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination in food service.
F0880: Facility staff failed to ensure all residents were screened for tuberculosis with a two-step Mantoux test and lacked documentation for three residents.
Report Facts
Facility census: 54
Residents affected: 1
Residents affected: 4
Residents affected: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding missing PT/INR orders and tuberculosis documentation, and activities programming |
| Assisted Living Activities Director | Activities Director (AD) | Interviewed regarding activities programming and documentation |
| Certified Medication Technician D | CMT | Interviewed about medication expiration and dating practices |
| Certified Medication Technician E | CMT | Interviewed about medication expiration and dating practices |
| Pharmacy Nurse Consultant | Pharmacy Nurse Consultant | Interviewed about medication dating requirements |
| Kitchen Supervisor | Kitchen Supervisor | Interviewed about pureed diet preparation and menu adherence |
| Certified Dietary Manager | CDM | Interviewed about food service practices and hand hygiene |
| Dietary Aide G | Dietary Aide | Observed and interviewed regarding hand hygiene failures |
| Dietary Aide H | Dietary Aide | Observed and interviewed regarding hand hygiene failures |
| Cook | Cook | Observed and interviewed regarding hand hygiene failures |
| Infection Preventionist | Infection Preventionist | Interviewed regarding tuberculosis screening procedures and documentation |
| Administrator | Administrator | Interviewed regarding activities programming, medication cart checks, food service, and hand hygiene |
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 8
Date: Mar 3, 2023
Visit Reason
The document is a Plan of Correction submitted by Heisinger Bluffs Senior Living following a survey conducted on March 3, 2023, addressing deficiencies found during the inspection.
Findings
The facility was cited for multiple deficiencies including failure to complete Employee Disqualification List (EDL) checks for staff, unsigned physician orders for residents, incomplete medication regimen reviews, unsanitary kitchen environment, inadequate hand hygiene among staff, improper food storage and labeling, ice machine contamination risk, and failure to ensure resident rights were reviewed annually.
Deficiencies (8)
19 CSR 30-86.047(13)(B) EDL Inquiry: Facility staff failed to complete Employee Disqualification List checks for three staff members prior to resident contact.
19 CSR 30-86.047(47)(B) Physicians Orders Requirements: Physician's orders were not signed for three of five sampled residents.
19 CSR 30-86.047(54) Drug Regimen Review: Facility staff failed to ensure a pharmacist, physician, or registered nurse reviewed medication regimens for three of five sampled residents.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Facility failed to maintain the kitchen environment in a clean and sanitary manner.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: Facility staff failed to perform hand hygiene as often as necessary.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility staff failed to properly store open food to prevent cross contamination and outdated usage.
19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap: Facility failed to ensure the ice bin drained through an air gap, risking contamination.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: Facility failed to ensure resident rights were reviewed upon admission and annually for three of five sampled residents.
Report Facts
Facility census: 47
Sampled residents: 5
Staff sampled for EDL check: 9
Staff failed EDL check: 3
Inspection Report
Routine
Census: 48
Deficiencies: 7
Date: Mar 3, 2023
Visit Reason
Routine inspection to evaluate compliance with regulatory requirements including employee background checks, medication administration, infection control, food safety, hospice care coordination, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete required employee background checks, failure to follow physician orders for wound care and medication administration, improper medication storage and monitoring, inadequate infection control practices, failure to maintain kitchen sanitation and food safety, and lack of documented coordination with hospice providers.
Deficiencies (7)
F 0607: Facility failed to complete required Employee Disqualification List, Family Care Safety Registry, Criminal Background Check, and Certified Nurse Aide Registry checks for several employees.
F 0658: Facility staff failed to follow physician orders for wound care treatments for four residents, with multiple missed treatments documented.
F 0758: Facility failed to ensure psychotropic medications were used only with appropriate diagnoses for three residents.
F 0761: Facility failed to implement procedures to ensure controlled medications were monitored and stored safely; loose pills and unmonitored medications were observed.
F 0812: Facility failed to maintain kitchen sanitation including ice machine drainage, ceiling cleanliness, hand hygiene, glove use, and proper food storage with expired and unsealed food items.
F 0849: Facility failed to document collaboration and coordinated care plans with hospice providers for four residents receiving hospice services.
F 0880: Facility failed to maintain infection control practices including hand hygiene, glove changes, catheter care, wound care equipment cleaning, and employee tuberculosis screening.
Report Facts
Facility census: 48
Employee sample size: 10
Residents affected by wound care deficiencies: 4
Residents affected by psychotropic medication deficiencies: 3
Residents affected by medication storage deficiencies: 1
Residents affected by hospice care coordination deficiencies: 4
Residents affected by infection control deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration and infection control findings |
| CMT K | Certified Medication Technician | Named in medication storage and handling findings |
| CNA I | Certified Nursing Assistant | Named in infection control glove use findings |
| CNA J | Certified Nursing Assistant | Named in infection control glove use findings |
| LPN D | Licensed Practical Nurse | Named in wound care infection control findings |
| DON | Director of Nursing | Named in multiple interviews regarding findings and policies |
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 1
Date: Apr 1, 2021
Visit Reason
This document is a plan of correction related to a licensure inspection focusing on fire safety and sprinkler system compliance at Heisinger Bluffs Senior Living.
Findings
The facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. Observations showed missing sprinkler heads under porch roofs and decks, and sprinkler heads installed too close to light fixtures, violating minimum distance requirements.
Deficiencies (1)
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13: The facility failed to install and maintain a complete sprinkler system as required by NFPA 13, 1999 edition. Sprinkler heads were missing under porch roofs and decks, and some were installed less than the minimum allowable distance from obstructions.
Report Facts
Facility census: 35
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 1
Date: Mar 13, 2020
Visit Reason
The inspection was conducted to assess compliance with sanitation and utensil air drying regulations at Heisinger Lutheran Home.
Findings
The facility failed to allow sanitized kitchenware to air dry prior to stacking, resulting in wet utensils being stored and potential growth of food-borne pathogens. Multiple observations showed food preparation pans stacked wet in various locations, and the facility lacked a written dishwashing policy.
Deficiencies (1)
19 CSR 30-87.030(84) Equip/Utensils Air Dried, Self-Drain Utensils: Facility staff failed to allow sanitized kitchenware to air dry before stacking, leading to wet utensils stored in a self-draining position.
Report Facts
Facility census: 64
Inspection Report
Life Safety
Census: 68
Deficiencies: 1
Date: Jan 13, 2020
Visit Reason
The inspection was conducted as a fire safety portion of the licensure inspection to verify compliance with fire alarm system testing requirements.
Findings
The facility failed to have the Fire Alarm System tested annually in accordance with the National Fire Protection Association 72. The deficiency affected all 68 residents present during the inspection.
Deficiencies (1)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to have the Fire Alarm System tested annually as required by NFPA 72, 1999 edition. This affected all 68 residents present on January 13, 2020.
Report Facts
Facility census: 68
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 3
Date: Jan 15, 2019
Visit Reason
The inspection was conducted as part of the fire safety portion of the licensure inspection on January 15, 2019.
Findings
The facility failed to conduct a full evacuation fire drill within a twelve-month period and failed to ensure hazardous areas were properly separated by construction and self-closing doors. Additionally, there was an excessive accumulation of combustible materials in Resident Room #291.
Deficiencies (3)
19 CSR 30-86.022(5)(D) Fire Drill Requirements. The facility failed to conduct one full evacuation fire drill within a twelve-month period as required. The facility census on January 15, 2019 was ninety-one residents.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to ensure hazardous areas were separated by construction and doors were self-closing as required during the fire safety inspection.
19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of. The facility failed to ensure rooms were neat and free of unnecessary combustible materials, with excessive accumulation observed in Resident Room #291.
Report Facts
Facility census: 91
Memory Care Unit census: 18
Memory Care Unit capacity: 24
Inspection Report
Plan of Correction
Census: 58
Deficiencies: 2
Date: Dec 21, 2018
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements for residents and staff, and to evaluate the proper storage of toxic materials in the facility.
Findings
The facility failed to screen two of three sampled employees for tuberculosis as required, and toxic materials were found stored out of reach of residents but not properly secured in locked cabinets. Multiple chemical containers were observed with precautionary labels but stored unlocked in various locations.
Deficiencies (2)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to screen two of three sampled employees for tuberculosis as required by regulation. The facility census was 58.
19 CSR 30-87.020(5) Toxic Material Storage: The facility failed to ensure chemicals and toxic materials were stored in locked cabinets or similar secure locations inaccessible to residents. Multiple unlocked chemical containers were observed in various areas.
Report Facts
Facility census: 58
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