13 Reports
Inspection Report — Oct 3, 2024
Complaint Investigation
Date: Oct 3, 2024
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Federal CMS-2567 health survey and Missouri State Form included in the file; the survey is described as a Recertification and Complaint survey (recertification and complaint investigation noted).
Complaint Details
Complaint numbers MO00241333 and MO00242282 are referenced; the report states no deficiencies were issued related to these intake complaints.
Findings
Ten deficiencies were cited: eight federal health deficiencies involving resident rights/self-determination, transfer and bed-hold notices, discharge preparation, post-fall neurological assessments, ostomy care, dietary staffing, and immunizations; and two Missouri state licensure deficiencies concerning the medication system and medications released upon discharge (both Class II).
Deficiencies (2)
19 CSR 30-85.042(46) Safe/Effective Medication System: See the deficiency cited at F624.
19 CSR 30-85.042(57) Meds Released Upon Discharge/Transfer: See the deficiency cited at F624.
Report Facts
residents sampled: 28
supplemental residents: 10
Inspection Report — Jun 6, 2024
Routine
Date: Jun 6, 2024
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three deficiencies were cited: one federal health deficiency for failure to provide protective oversight resulting in an elopement, and two Missouri state licensure citations referencing the failure of protective oversight and failure to notify the responsible party.
Deficiencies (2)
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: See the deficiency cited at F689.
19 CSR 30-85.042(79) Notify Responsible Party-Change in Condition: See the deficiency cited at F689.
Inspection Report — Jul 25, 2023
Life Safety
Date: Jul 25, 2023
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Federal CMS-2567 Life Safety Code survey (K-tags) and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
Fifteen deficiencies were cited: seven federal life-safety deficiencies concerning exit doors, sprinkler system maintenance, smoke barriers, door inspection/testing, portable heaters, essential electrical systems, and power strips/extension cords; and eight Missouri state licensure deficiencies referencing emergency lighting/generator, sprinkler testing/maintenance, exit door width, smoke section walls, building construction/maintenance, heating/no portable heaters, electrical wiring/equipment, and extension cords/duplex receptacles.
Deficiencies (8)
19 CSR 30-85.012(128) Emergency Lights, Generator for Life Support: Refer to K918.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K920.
19 CSR 30-85.022(18) Exit Doors-44in Wide: Refer to K233.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K372 and K761.
19 CSR 30-85.032(28) Heating System-No Portable: Refer to K781.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K920.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Refer to K920.
Report Facts
smoke compartments affected: 1
smoke compartments affected: 5
smoke compartments affected: 7
Inspection Report — Aug 17, 2022
Complaint Investigation
Date: Aug 17, 2022
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Federal health survey (CMS-2567) and Missouri State Form licensure survey; complaint investigation (MO00205196).
Complaint Details
MO00205196; substantiation not stated.
Findings
Four deficiencies were cited: two federal health deficiencies involving pressure ulcer prevention/treatment and prevention of significant medication errors, and two corresponding Missouri rule violations for safe/effective medication system and pressure sore prevention/treatment.
Deficiencies (2)
19 CSR 30-85.042(46) Safe/Effective Medication System: Refer to F760.
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: Refer to F-686.
Report Facts
residents sampled: 6
Inspection Report — Jul 15, 2021
Routine
Date: Jul 15, 2021
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
12 federal health deficiencies covering resident rights, background screening/abuse policies, care planning and services (including oxygen/nebulizer care), ADLs and activities, pressure ulcer prevention/treatment, medication labeling/storage, dental and nutrition/food safety; and 9 Missouri state licensure deficiencies addressing medication labeling, nursing care, nutrition and food service sanitation.
Deficiencies (9)
19 CSR 30-85.042(54) Medication Labeling: See the deficiency cited at F761.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Please refer to F656, F658, F677, F686, F692, F695, and F790.
19 CSR 30-85.052(1) Nutritional Needs Met, Assess Res, Inform Dr: Please refer to F804.
19 CSR 30-85.052(3) Foods-Nutritive Value/Flavor/Appearance: Please refer to F804.
19 CSR 30-87.030(41) Food Service-Dispensing Utensils Use/Storage: Please refer to F812.
19 CSR 30-87.030(62) Kitchenware/Surfaces/Pitchers-Clean/Sanitize: Please refer to F812.
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: Please refer to F812.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Please refer to F607.
19 CSR 30-88.010(29) Dignity/Privacy: Please refer to F550.
Report Facts
residents sampled: 18
Inspection Report — Jul 15, 2021
Life Safety
Date: Jul 15, 2021
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CMS-2567 federal Emergency Preparedness and Life Safety surveys and Missouri Department of Health and Senior Services State Form (state licensure) are included; the survey type is not stated.
Findings
There are 12 federal deficiencies covering emergency preparedness and life safety topics (emergency preparedness testing, building construction/fire ratings, emergency lighting, hazardous area doors, fire alarm and sprinkler systems, smoke barriers, fire drills, smoking regulation, and electrical/power strip use). There are 11 Missouri state deficiencies addressing related topics including medication room requirements, hazardous areas, oxygen storage, fire alarm/sprinkler/testing, smoke section walls/doors, fire drill documentation, electrical certification, and extension cord use.
Deficiencies (11)
19 CSR 30-85.012(48) Medication Room Requirements: Refer to K291.
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(10)(B) Fire Alarm System-Test/Maintain: Refer to K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K343.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372 and K374.
19 CSR 30-85.022(31) Smoking-Designated Areas/Assess Supervision: Refer to K741.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: Based on record review and interview, the facility failed to have documentation that they had requested an annual consultation from the local fire department.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K161 and K372.
19 CSR 30-85.032(31)(B) Electrical System-Certification Every 2 Years: The facility failed to have a qualified electrician certify in writing that the electrical system was being maintained and operated in accordance with applicable standards.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Refer to K920.
Inspection Report — Jul 22, 2020
Complaint Investigation
Date: Jul 22, 2020
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CMS-2567 federal health survey (COVID-19 Focused Emergency Preparedness noted in initial comments) and Missouri State Form licensure pages; complaint investigation number MO00172935 is cited in the file.
Complaint Details
MO00172935; substantiation not stated in the document.
Findings
There are 2 federal deficiencies addressing professional standards of care and infection prevention/PPE noncompliance, and 2 Missouri state deficiencies (Class II) that refer to the federal findings.
Deficiencies (2)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Please refer to F658.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Please refer to F880.
Report Facts
residents sampled: 6
residents affected: 5
Inspection Report — Jun 16, 2020
Routine
Date: Jun 16, 2020
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Federal health survey (CMS-2567) and Missouri State Form; a COVID-19 Focused Emergency Preparedness / infection control survey as stated in the Initial Comments.
Findings
Two deficiencies: one federal infection prevention and control deficiency for failures including inadequate hand hygiene, failure to follow posted contact precautions, and incomplete resident temperature documentation; and one Missouri state licensure deficiency for infection control that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
Inspection Report — Feb 11, 2020
Routine
Date: Feb 11, 2020
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 deficiencies: one federal health deficiency involving failures in meeting professional standards/comprehensive care planning including lack of a system to ensure physician-ordered appointments were processed and documented, and one Missouri state licensure Class II deficiency that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F658.
Inspection Report — Jan 8, 2020
Complaint Investigation
Date: Jan 8, 2020
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO164456).
Complaint Details
MO164456; substantiation not stated.
Findings
Four deficiencies were cited: two federal deficiencies involving alleged misappropriation/exploitation of a resident's funds and failure to perform required background checks for a contracted stylist, and two Missouri state deficiencies regarding criminal background check documentation and development/implementation of abuse/neglect policies and reporting.
Deficiencies (2)
19 CSR 30-85.042(17) Criminal Background Check Request: Refer to F606.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F602.
Inspection Report — Oct 17, 2019
Routine
Date: Oct 17, 2019
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The file contains 9 federal health deficiencies addressing resident dignity/resident rights, required postings, abuse/neglect policies/background checks, transfer/notice requirements, professional standards/medication administration, catheter/UTI care, tube-feeding care, medication error rates, and infection control; and 9 Missouri state deficiencies covering criminal background checks, communicable disease screening, safe/effective medication systems, nursing care per resident condition, infection control/communicable disease reporting, public information availability, rights postings/Alzheimer's unit info, emergency discharge notice requirements, and dignity/privacy.
Deficiencies (9)
19 CSR 30-85.042(17) Criminal Background Check Request: Refer to F607.
19 CSR 30-85.042(27) Communicable Disease-Employees: Based on record review and interview the facility failed to ensure that six of ten sampled newly hired staff received required TB testing (first-step Mantoux) prior to employment.
19 CSR 30-85.042(47) Safe/Effective Medication System: Refer to F658 and F759.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F658, F690, F693, F759 and F880.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-88.010(1) Required Info Available for Public Inspection: Refer to F575.
19 CSR 30-88.010(7) Res Rights/Rules Posted, Alz Unit Info: Refer to F575.
19 CSR 30-88.010(18) Emergency Discharges: Refer to F623.
19 CSR 30-88.010(29) Dignity/Privacy: Refer to F550.
Report Facts
residents sampled: 18
medication errors (opportunities): 6
Inspection Report — Oct 17, 2019
Life Safety
Date: Oct 17, 2019
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Federal CMS-2567 Life Safety survey (K-tag life-safety deficiencies) and Missouri Department of Health and Senior Services State Form (state licensure); the file also contains a reinspection/CMS-2567 and accompanying state form dated 2019-12-18.
Findings
Fourteen deficiencies were cited: eight federal life-safety deficiencies and six Missouri state licensure deficiencies. Main topics include delayed-egress/egress signage, cooking equipment/deep-fat fryer guard, fire alarm semi-annual testing, sprinkler maintenance and missing sprinkler wrench/sprinkler head placement, smoke barrier wall penetrations and smoke barrier door gaps, and deficiencies in conducting required fire drills; the smoke-barrier deficiency (K372) remained uncorrected at reinspection.
Deficiencies (6)
19 CSR 30-85.022(2)(E) No Fire Hazard: 1. Please refer to K324.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: 1. Please refer to K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: 1. Please refer to K353.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Based on record review and interview, the facility failed to conduct required monthly fire drills on each shift and failed to conduct fire drills at varied times, including missing night-shift drills.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: 1. Please refer to K222, K372 and K374.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: This deficiency is uncorrected; see the Statement of Deficiencies dated 10/17/19.
Report Facts
smoke compartments affected: 8
Inspection Report — May 16, 2019
Routine
Date: May 16, 2019
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to provide ADL/nutritional assistance to sampled residents, and one Missouri licensure deficiency for nursing care per resident condition referring to the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F677.
Report Facts
residents sampled: 3
25 CMS Surveys
Inspection Report — Jan 9, 2025
Complaint Investigation
Date: Jan 9, 2025
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Federal health survey (CMS-2567); complaint investigation citing complaint number MO247374.
Complaint Details
MO247374; substantiation not explicitly stated in the document.
Findings
One federal deficiency for failure to protect a resident from abuse and neglect; the survey documents an incident where a resident was struck in the face causing a laceration and notes past noncompliance and corrective action.
Deficiencies (1)
F 600 Free from Abuse and Neglect: The facility failed to protect Resident #1 from abuse when another resident struck Resident #1 in the face, resulting in a laceration to the lower lip; facility investigation identified past noncompliance and corrective actions were implemented.
Inspection Report — Dec 2, 2024
Complaint Investigation
Date: Dec 2, 2024
Visit Reason
The inspection was conducted due to complaints regarding unsafe and disorderly discharges from the facility, specifically failures in providing proper orders, medications, home health services, dialysis services, and follow-up appointments for discharged residents.
Complaint Details
The complaint investigation revealed substantiated issues including failure to provide discharge medications, failure to arrange home health care and dialysis, failure to provide discharge instructions and education, and sending residents home with incorrect medication cards. Interviews with residents, family members, and staff confirmed these deficiencies.
Findings
The facility failed to ensure safe and orderly discharges for five of six sampled residents by not providing proper discharge orders, medications, home health services, dialysis arrangements, or follow-up care. Residents were discharged without necessary supplies, medication education, or discharge instructions, leading to confusion and lack of care continuity.
Deficiencies (1)
Failed to ensure safe and orderly discharge for five residents without proper orders, medications, home health services, dialysis services, and/or follow-up appointments.
Report Facts
Medications prescribed at discharge: 30
Medications sent home: 11
Medications prescribed: 16
Medications prescribed: 27
Medication cards sent incorrectly: 8
Follow-up cardiology appointment: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Casemanager RN | RN Casemanager | Interviewed regarding Resident #1's discharge and follow-up care failures |
| Social Services Designee | Social Services Designee | Interviewed about discharge planning responsibilities and procedures |
| Administrator | Facility Administrator | Interviewed about discharge medication review and education expectations |
| CMT A | Certified Medication Technician | Interviewed about medication review process during discharge |
Inspection Report — Oct 3, 2024
Complaint Investigation
Date: Oct 3, 2024
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Federal CMS-2567 health survey and Missouri State Form included in the file; the survey is described as a Recertification and Complaint survey (recertification and complaint investigation noted).
Complaint Details
Complaint numbers MO00241333 and MO00242282 are referenced; the report states no deficiencies were issued related to these intake complaints.
Findings
Ten deficiencies were cited: eight federal health deficiencies involving resident rights/self-determination, transfer and bed-hold notices, discharge preparation, post-fall neurological assessments, ostomy care, dietary staffing, and immunizations; and two Missouri state licensure deficiencies concerning the medication system and medications released upon discharge (both Class II).
Deficiencies (8)
F550 Resident Rights/Exercise of Rights: Based on observation, interview, and record review, the facility failed to honor a resident's request to not have certain staff provide care for one resident, potentially decreasing the resident's quality of life.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party for two residents reviewed for hospitalization.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notice of its bed-hold policy to residents or their representatives for two residents transferred or hospitalized.
F684 Quality of Care: The facility failed to perform and document required post-fall neurological assessments for residents with unwitnessed falls, potentially resulting in missed signs of head trauma for multiple residents.
F691 Colostomy, Urostomy, or Ileostomy Care: The facility failed to ensure ostomy care orders were in place and followed for a resident with an ileostomy, resulting in observed fecal matter and missing orders.
F801 Qualified Dietary Staff: The facility failed to employ a qualified director of food and nutrition services; the dietary manager did not meet required qualifications, potentially affecting residents receiving facility-prepared meals.
F883 Influenza and Pneumococcal Immunizations: The facility failed to document that residents were offered and educated about influenza and pneumococcal vaccines and failed to record immunization status or refusals for multiple residents.
F624 Preparation for Safe/Orderly Transfer/Discharge: The facility failed to ensure safe and orderly discharge planning and documentation for five of six sampled residents, including missing medication reconciliation, follow-up arrangements, and home health contact information.
Report Facts
residents sampled: 28
supplemental residents: 10
Inspection Report — Oct 1, 2024
Life Safety
Date: Oct 1, 2024
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CMS-2567 Life Safety survey (K-tag) was conducted; Initial Comments indicate a Life Safety Code survey.
Findings
4 life-safety deficiencies were cited covering emergency lighting, sprinkler installation/spacing, low-voltage wiring protection, and essential electrical/generator testing. The surveyor indicated the deficient practices had the potential to affect all 87 residents.
Deficiencies (4)
K291 Emergency Lighting: Based on observation and interview, the facility failed to ensure emergency lighting was provided on the load side of the transfer switch of the emergency power supply (generator); emergency lighting was not present in the mechanical room where the emergency generator was located.
K351 Sprinkler System - Installation: Based on observation and interview, the facility failed to ensure sprinklers were within 1 to 12 inches from the ceiling in accordance with NFPA 13; the sprinkler in the Ansul Room for the Fireside Grill was observed approximately 2 feet down from the ceiling.
K511 Utilities - Gas and Electric: Based on observation and interview, the facility failed to ensure low-voltage wiring under seven feet was protected in conduit or within walls; low-voltage wiring was not protected in the interior walls or in conduit at the main fire alarm panel in the mechanical room.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Based on record review and interview, the facility failed to ensure monthly load tests were conducted on the emergency generator in accordance with NFPA 110; review of generator reports for 2023 and 2024 showed monthly load tests were not completed for multiple months and the Maintenance Director confirmed they were not completed.
Report Facts
residents potentially affected: 87
Inspection Report — Jun 6, 2024
Routine
Date: Jun 6, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three deficiencies were cited: one federal health deficiency for failure to provide protective oversight resulting in an elopement, and two Missouri state licensure citations referencing the failure of protective oversight and failure to notify the responsible party.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: Based on interview and record review, the facility failed to provide protective oversight to one resident with dementia who eloped from the facility and was found off property by a motorist; staff were unaware and failed to follow policy and notify the resident's representative.
Inspection Report — Jul 25, 2023
Life Safety
Date: Jul 25, 2023
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Federal CMS-2567 Life Safety Code survey (K-tags) and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
Fifteen deficiencies were cited: seven federal life-safety deficiencies concerning exit doors, sprinkler system maintenance, smoke barriers, door inspection/testing, portable heaters, essential electrical systems, and power strips/extension cords; and eight Missouri state licensure deficiencies referencing emergency lighting/generator, sprinkler testing/maintenance, exit door width, smoke section walls, building construction/maintenance, heating/no portable heaters, electrical wiring/equipment, and extension cords/duplex receptacles.
Deficiencies (7)
K233 Clear Width of Exit and Exit Access Doors: Based on observation, record review and interview, the facility failed to ensure doors with an inactive leaf had automatic flush bolts.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system, including painted sprinkler heads and incomplete inspections/testing and records.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain smoke barrier walls to ensure they were complete and provided required separation.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to properly inspect, test, maintain and document fire door assemblies and door inspections.
K781 Portable Space Heaters: The facility failed to maintain proper space heating appliances and a portable heater was observed in a nonallowed area.
K918 Electrical Systems - Essential Electric System: The facility failed to establish a program to exercise main and feeder breakers and maintain documentation for the emergency generator and related components.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to assure the safe use of power strips and power strips were used in resident rooms for medical equipment and lamps.
Report Facts
smoke compartments affected: 1
smoke compartments affected: 5
smoke compartments affected: 7
Inspection Report — Jul 25, 2023
Routine
Date: Jul 25, 2023
Visit Reason
The inspection was a routine regulatory survey of Ignite Medical Resort Kansas City, LLC to assess compliance with healthcare facility regulations including resident care, safety, and food service.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified meal service with appropriate dishware, failure to accommodate resident needs such as bed length, failure to maintain clean and comfortable environment, failure to update care plans and hold care plan meetings, failure to provide professional wound care, inadequate assistance with activities of daily living, medication pass delays, insufficient nursing staff to meet resident needs, and failure to provide palatable, timely, and temperature-appropriate meals and snacks.
Deficiencies (9)
Failure to honor residents' right to dignified existence by serving meals on Styrofoam and plastic cutlery for multiple residents.
Failure to accommodate resident needs by providing a bed sufficient in length for one resident.
Failure to maintain a clean, comfortable, and homelike environment including clean floors, toilets, and timely linen changes for residents.
Failure to update resident care plans and hold care plan meetings involving residents or their guardians.
Failure to provide professional wound care including obtaining treatment orders and timely dressing changes for a resident with a surgical site.
Failure to provide adequate assistance with activities of daily living including repositioning, incontinent care, oral care, and showers for multiple residents.
Failure to provide sufficient nursing staff to meet resident needs including timely response to call lights and timely medication administration.
Failure to ensure food and drink is palatable, attractive, and served at safe and appetizing temperatures; meals served cold and late; food substitutions without proper notification; and failure to honor resident food preferences and portions.
Failure to ensure meals and snacks are served at times in accordance with resident needs and preferences, including failure to provide nourishing bedtime snacks and allowing excessive time between evening meal and breakfast.
Report Facts
Residents sampled: 18
Meal service start times: 7
Meal service start times: 11
Meal service start times: 16
Meal temperature: 127
Meal temperature: 120
Meal temperature: 149
Pressure ulcer size: 6.3
Pressure ulcer size: 4.3
Pressure ulcer size: 0.1
Braden score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided expectations on meal service, wound care, call light response, and resident care |
| Administrator | Administrator | Provided expectations on meal service, staffing, resident care, and facility operations |
| Dietary Manager | Dietary Manager | Provided information on food service, ordering, and meal preparation |
| Licensed Practical Nurse B | Licensed Practical Nurse | Provided information on resident bed length and care |
| Physical Therapist A | Physical Therapist | Provided information on resident bed length and mobility |
| Charge Nursing Officer | Charge Nursing Officer | Provided information on care plan meetings and resident care |
| Registered Nurse B | Registered Nurse | Provided information on medication passes and staffing |
| Certified Nurse Aide A | Certified Nurse Aide | Provided information on shower schedule and resident care |
| Certified Nurse Aide E | Certified Nurse Aide | Observed assisting resident with repositioning and care |
Inspection Report — Jul 25, 2023
Routine
Date: Jul 25, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, facility operations, and safety.
Findings
The facility was found deficient in multiple areas including failure to honor resident dignity related to meal service with plastic cutlery and Styrofoam, inadequate wound care and failure to obtain timely treatment orders, insufficient assistance with activities of daily living, inadequate staffing leading to delayed call light response and medication administration, and failure to meet resident dietary preferences and timely meal/snack service.
Deficiencies (6)
Failure to honor residents' dignity by serving meals with plastic cutlery and Styrofoam containers for six sampled residents.
Failure to obtain timely wound care treatment orders and provide appropriate dressing changes for one resident with a surgical site.
Failure to provide adequate assistance with activities of daily living including repositioning, incontinent care, oral care, and showers for four sampled residents.
Failure to provide sufficient nursing staff to meet residents' needs, resulting in delayed call light response and medication administration for multiple residents.
Failure to accommodate resident dietary preferences, provide meal choices, and follow posted menus, resulting in residents receiving substituted or unavailable food items and inadequate portions.
Failure to provide bedtime snacks and maintain no more than 14 hours between evening meal and breakfast for five sampled residents.
Report Facts
Deficiency count: 6
Deficiency count: 1
Deficiency count: 4
Deficiency count: 6
Deficiency count: 5
Pressure ulcer size: 6.3
Pressure ulcer size: 4.3
Pressure ulcer size: 0.1
Braden score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in relation to food shortages, meal substitutions, and kitchen ordering practices | |
| Director of Nursing | DON | Provided expectations on meal service, wound care, call light response, and staffing |
| Administrator | Provided expectations on meal service, staffing, and resident care | |
| Nurse Practitioner A | NP | Provided wound care encounter note for Resident #181 |
| LPN C | Licensed Practical Nurse | Observed wound condition and provided care instructions for Resident #181 |
| RN A | Registered Nurse | Obtained wound care orders late for Resident #181 |
| CNA E | Certified Nurse Aide | Observed assisting Resident #2 with pressure relieving cushion and care |
| RN B | Registered Nurse | Described medication pass timing and staffing |
| LPN D | Licensed Practical Nurse | Described medication pass and new admit medication process |
| CNA A | Certified Nurse Aide | Described shower and snack provision practices |
| CNA B | Certified Nurse Aide | Described call light response and snack provision |
Inspection Report — Dec 14, 2022
Routine
Date: Dec 14, 2022
Visit Reason
Federal CMS-2567 health survey (F tags) and federal Emergency Preparedness (E tags); the Initial Comments state this was a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey.
Findings
No deficiencies were cited; the facility was found in compliance with CMS and CDC recommended COVID-19 infection control practices and in compliance with 42 CFR 483.73 emergency preparedness requirements.
Inspection Report — Nov 2, 2022
Routine
Date: Nov 2, 2022
Visit Reason
CMS-2567 federal health (infection control) and federal emergency preparedness surveys. The forms state this was a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey.
Findings
No health or emergency preparedness deficiencies were cited; the facility was found in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 emergency preparedness.
Inspection Report — Aug 17, 2022
Complaint Investigation
Date: Aug 17, 2022
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Federal health survey (CMS-2567) and Missouri State Form licensure survey; complaint investigation (MO00205196).
Complaint Details
MO00205196; substantiation not stated.
Findings
Four deficiencies were cited: two federal health deficiencies involving pressure ulcer prevention/treatment and prevention of significant medication errors, and two corresponding Missouri rule violations for safe/effective medication system and pressure sore prevention/treatment.
Deficiencies (2)
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on observation, interview and record review, the facility failed to ensure staff followed required pressure ulcer wound care treatment and change-of-condition policies for one sampled resident, resulting in a necrotic/unable-to-stage pressure ulcer found on the resident's right heel.
F760 Residents are Free of Significant Med Errors: Based on observation, interview, and record review, the facility failed to prevent a significant medication error when staff administered hydrocodone to a resident with a documented allergy, affecting one sampled resident.
Report Facts
residents sampled: 6
Inspection Report — Jul 15, 2021
Life Safety
Date: Jul 15, 2021
Visit Reason
CMS-2567 federal Emergency Preparedness and Life Safety surveys and Missouri Department of Health and Senior Services State Form (state licensure) are included; the survey type is not stated.
Findings
There are 12 federal deficiencies covering emergency preparedness and life safety topics (emergency preparedness testing, building construction/fire ratings, emergency lighting, hazardous area doors, fire alarm and sprinkler systems, smoke barriers, fire drills, smoking regulation, and electrical/power strip use). There are 11 Missouri state deficiencies addressing related topics including medication room requirements, hazardous areas, oxygen storage, fire alarm/sprinkler/testing, smoke section walls/doors, fire drill documentation, electrical certification, and extension cord use.
Deficiencies (12)
E039 EP Testing Requirements: The facility failed to analyze and document the facility's response to its annual emergency preparedness exercises, with drills documented but no evidence the facility analyzed the responses.
K161 Building Construction Type and Height: The facility failed to maintain the one-hour fire rating of the ceiling due to unsealed penetrations in multiple ceiling locations.
K291 Emergency Lighting: The facility did not provide emergency lighting in the medication rooms as required and documentation did not show emergency illumination in those rooms.
K321 Hazardous Areas - Enclosure: The facility failed to ensure hazardous area doors were free of obstructions and able to fully close; hazardous storage and propping of doors were observed.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to provide and maintain complete documentation of sensitivity testing and testing/maintenance records for the fire alarm system.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain its sprinkler system (missing escutcheon plates and storage within 18 inches of the ceiling were observed).
K372 Subdivision of Building Spaces - Smoke Barrie: The facility failed to maintain smoke barrier walls continuous and without unsealed penetrations, with multiple gaps and holes observed in smoke barrier walls.
K374 Subdivision of Building Spaces - Smoke Barrie Doors: The facility failed to maintain self-closing hardware on smoke barrier doors and ensure doors were smoke-tight, with missing hardware and doors not fully latching.
K712 Fire Drills: The facility failed to conduct fire drills at varied times on each shift as required, with drill times not varied as required by policy.
K741 Smoking Regulations: The facility failed to ensure cigarette butts were properly disposed of and to maintain required smoking precautions on the property.
K920 Electrical Equipment - Power Cords and Extens: The facility failed to assure the safe use of power strips and extension cords, with multi-plug adapters and unsecured power strips observed.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to store oxygen cylinders in a safe manner and left cylinders unsecured on the floor in multiple locations.
Inspection Report — Jul 15, 2021
Routine
Date: Jul 15, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
12 federal health deficiencies covering resident rights, background screening/abuse policies, care planning and services (including oxygen/nebulizer care), ADLs and activities, pressure ulcer prevention/treatment, medication labeling/storage, dental and nutrition/food safety; and 9 Missouri state licensure deficiencies addressing medication labeling, nursing care, nutrition and food service sanitation.
Deficiencies (12)
F550 Resident Rights/Exercise of Rights: The facility failed to ensure one resident was treated in a dignified manner and did not provide activities or television programming in the resident's primary language during personal activity time.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to develop and implement a policy for background screening and failed to ensure Family Care Safety Registry (FCSR) checks were completed for sampled employees.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive, person-centered care plans for sampled residents and omitted necessary measurable objectives and interventions related to health conditions and treatments.
F658 Services Provided Meet Professional Standards: The facility failed to follow professional standards by not obtaining orders or appropriate nurse oversight for oxygen and nebulizer treatments for affected residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide or document activities of daily living (bathing/showering and grooming) per resident preference for sampled dependent residents.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide activities in accordance with resident choice and preferences, including language-appropriate activities and calendars for a resident who speaks another language.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to follow care plans, complete assessments, and implement interventions to prevent and manage pressure ulcers for a sampled resident.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure proper respiratory care and maintenance of oxygen and nebulizer equipment, including missing/dated tubing, humidifier bottles, and absence of orders for oxygen therapy for affected residents.
F761 Label/Store Drugs and Biologicals: The facility failed to discard expired medications and had loose pills and unsecured/expired items in medication carts and storage areas.
F790 Routine/Emergency Dental Services in SNFs: The facility failed to assist a resident with routine or emergency dental care, resulting in untreated broken/decayed teeth and related eating/weight problems.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to provide meals with appropriate consistency, appearance, temperature and preferences for residents on mechanically altered diets and other sampled residents.
F812 Food Procurement,Store,Prepare,Serve-Sanitary: The facility failed to ensure safe food handling and sanitary meal preparation/serving practices, including improper glove use, hand hygiene and direct hand contact with plated food.
Report Facts
residents sampled: 18
Inspection Report — Jan 22, 2021
Routine
Date: Jan 22, 2021
Visit Reason
CMS-2567 federal health (F) and emergency preparedness (E) forms; the Initial Comments state 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 surveys found the facility to be in compliance with the infection control and emergency preparedness requirements.
Inspection Report — Dec 30, 2020
Routine
Date: Dec 30, 2020
Visit Reason
Federal CMS-2567 pages for an infection control (F) and emergency preparedness (E) survey; both were COVID-19 focused and no complaint number is stated.
Findings
No deficiencies were cited; the facility was found in compliance with COVID-19 infection control practices and applicable emergency preparedness requirements.
Inspection Report — Nov 30, 2020
Routine
Date: Nov 30, 2020
Visit Reason
Federal CMS-2567 forms for a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control/Health survey; the survey was COVID-19 focused.
Findings
No deficiencies were cited in either the emergency preparedness or infection control portions of the survey.
Inspection Report — Jul 22, 2020
Complaint Investigation
Date: Jul 22, 2020
Visit Reason
CMS-2567 federal health survey (COVID-19 Focused Emergency Preparedness noted in initial comments) and Missouri State Form licensure pages; complaint investigation number MO00172935 is cited in the file.
Complaint Details
MO00172935; substantiation not stated in the document.
Findings
There are 2 federal deficiencies addressing professional standards of care and infection prevention/PPE noncompliance, and 2 Missouri state deficiencies (Class II) that refer to the federal findings.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: Based on record review and interview, the facility failed to provide appropriate professional care for a sampled resident after a fall, including failure to follow up with a neurosurgeon appointment and to assure monitoring and treatment for head lacerations.
F880 Infection Prevention & Control: Based on observation, interview, and record review during the COVID-19 pandemic, the facility failed to maintain proper infection control practices, including failures in hand hygiene and appropriate use of PPE when providing care which affected multiple sampled residents.
Report Facts
residents sampled: 6
residents affected: 5
Inspection Report — Jun 16, 2020
Routine
Date: Jun 16, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; a COVID-19 Focused Emergency Preparedness / infection control survey as stated in the Initial Comments.
Findings
Two deficiencies: one federal infection prevention and control deficiency for failures including inadequate hand hygiene, failure to follow posted contact precautions, and incomplete resident temperature documentation; and one Missouri state licensure deficiency for infection control that references the federal finding.
Deficiencies (1)
F 880 Infection Prevention & Control: Based on observation, interview, and record review, the facility failed to properly plan for and implement infection prevention related to COVID-19, including not documenting resident temperatures and dietary staff failing to sanitize or wash hands between rooms and not following posted contact precautions.
Inspection Report — Feb 11, 2020
Routine
Date: Feb 11, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 deficiencies: one federal health deficiency involving failures in meeting professional standards/comprehensive care planning including lack of a system to ensure physician-ordered appointments were processed and documented, and one Missouri state licensure Class II deficiency that references the federal finding.
Deficiencies (1)
F 658 Services Provided Meet Professional Standards: The facility failed to ensure staff followed professional standards and comprehensive care plan processes, including failure to ensure physician-ordered appointments were processed, documented, and placed on the resident event calendar, resulting in a missed dialysis appointment and lack of documentation of refusals and transport arrangements.
Inspection Report — Jan 8, 2020
Complaint Investigation
Date: Jan 8, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO164456).
Complaint Details
MO164456; substantiation not stated.
Findings
Four deficiencies were cited: two federal deficiencies involving alleged misappropriation/exploitation of a resident's funds and failure to perform required background checks for a contracted stylist, and two Missouri state deficiencies regarding criminal background check documentation and development/implementation of abuse/neglect policies and reporting.
Deficiencies (2)
F602 Free from Misappropriation/Exploitation: Facility staff failed to prevent the misappropriation of a resident's credit card information resulting in an unauthorized $63.32 charge and the contracted beautician had access to the resident's credit card information.
F606 Not Employ/Engage Staff w/ Adverse Actions: The facility failed to perform required criminal background checks, check the federal marker, Employee Disqualification List (EDL) and the Certified Nurse Assistant (CNA) registry prior to allowing a contracted hair stylist to work in the facility.
Inspection Report — Oct 17, 2019
Routine
Date: Oct 17, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The file contains 9 federal health deficiencies addressing resident dignity/resident rights, required postings, abuse/neglect policies/background checks, transfer/notice requirements, professional standards/medication administration, catheter/UTI care, tube-feeding care, medication error rates, and infection control; and 9 Missouri state deficiencies covering criminal background checks, communicable disease screening, safe/effective medication systems, nursing care per resident condition, infection control/communicable disease reporting, public information availability, rights postings/Alzheimer's unit info, emergency discharge notice requirements, and dignity/privacy.
Deficiencies (9)
F550 Resident Rights/Exercise of Rights: Based on observations, record review and interviews the facility failed to ensure staff treated residents with dignity; staff spoke disrespectfully to residents which affected three of 18 sampled residents.
F575 Required Postings: Based on observation and interviews the facility failed to post required state agency and ombudsman contact information and other required postings in conspicuous, accessible locations.
F607 Develop/Implement Abuse/Neglect Policies: Based on record review and interview the facility failed to perform required criminal background (CBC) and employee disqualification (EDL/NA Registry) checks for multiple newly hired staff prior to direct resident contact.
F623 Notice Requirements Before Transfer/Discharge: Based on observation, interview and record review the facility failed to ensure residents or their responsible parties received written notice of transfer or discharge, affecting two of 18 sampled residents.
F658 Services Provided Meet Professional Standards: Based on observations, interviews and record review the facility failed to ensure staff administered nasal sprays, eye drops and inhalers per professional/manufacturer guidelines, affecting multiple residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Based on observations, interviews and record review the facility failed to provide appropriate catheter and perineal care and securement for a resident with an indwelling catheter, contributing to a urinary tract infection for one sampled resident.
F693 Tube Feeding Mgmt/Restore Eating Skills: Based on observation, interview and record review the facility failed to follow policy and physician orders for care and medication administration via a percutaneous endoscopic gastrostomy (PEG) tube, affecting a sampled resident with a feeding tube.
F759 Free of Medication Error Rts 5 Prcnt or More: Based on observations, interviews and record review facility staff made six medication errors out of 25 opportunities, resulting in a medication error rate above 5% and affecting three of 18 sampled residents.
F880 Infection Prevention & Control: Based on observation, interview and record review the facility failed to ensure infection prevention and isolation practices were followed (including meal service and communication to dietary), affecting at least one resident on isolation precautions.
Report Facts
residents sampled: 18
medication errors (opportunities): 6
Inspection Report — Oct 17, 2019
Life Safety
Date: Oct 17, 2019
Visit Reason
Federal CMS-2567 Life Safety survey (K-tag life-safety deficiencies) and Missouri Department of Health and Senior Services State Form (state licensure); the file also contains a reinspection/CMS-2567 and accompanying state form dated 2019-12-18.
Findings
Fourteen deficiencies were cited: eight federal life-safety deficiencies and six Missouri state licensure deficiencies. Main topics include delayed-egress/egress signage, cooking equipment/deep-fat fryer guard, fire alarm semi-annual testing, sprinkler maintenance and missing sprinkler wrench/sprinkler head placement, smoke barrier wall penetrations and smoke barrier door gaps, and deficiencies in conducting required fire drills; the smoke-barrier deficiency (K372) remained uncorrected at reinspection.
Deficiencies (7)
K 222 Egress Doors: Based on observation and interview, the facility failed to provide a durable sign with a contrasting background indicating how to operate the delayed egress locking mechanism and failed to place "This is not an EXIT" signs on doors going into the enclosed courtyards.
K 324 Cooking Facilities: Based on observation and interview, the facility failed to install a deep fat fryer guard/baffle or provide the required 18 inches between the deep fat fryer and adjacent gas grill.
K 345 Fire Alarm System - Testing and Maintenance: Based on record review and interview, the facility failed to perform the required semi-annual inspection of the automatic fire alarm system.
K 353 Sprinkler System - Maintenance and Testing: Based on observation, record review and interview, the facility failed to maintain their sprinkler system, including missing sprinkler head wrench in the replacement box, a sprinkler head touching the smoke barrier, and delayed or incomplete quarterly inspections.
K 372 Subdivision of Building Spaces - Smoke Barrier: Based on record review, observation and interview, the facility failed to maintain smoke barrier walls; multiple penetrations and holes were observed in smoke barrier walls affecting eight of ten smoke compartments.
K 374 Subdivision of Building Spaces - Smoke Barrier Doors: Based on observation and interview, the facility failed to properly install smoke barrier doors, resulting in gaps between double-leaf doors that did not allow the door to maintain the required fire protection rating.
K 712 Fire Drills: Based on record review and interview, the facility failed to conduct required fire drills monthly on each shift and failed to conduct drills at varied times, including missing night-shift drills.
Report Facts
smoke compartments affected: 8
Inspection Report — May 16, 2019
Routine
Date: May 16, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency for failure to provide ADL/nutritional assistance to sampled residents, and one Missouri licensure deficiency for nursing care per resident condition referring to the federal finding.
Deficiencies (1)
F 677 ADL Care Provided for Dependent Residents: Based on observations, interviews, and record review the facility failed to provide assistance with nutrition to three sampled residents, including staff not offering assistance or monitoring during meals.
Report Facts
residents sampled: 3
Inspection Report — Nov 9, 2018
Routine
Date: Nov 9, 2018
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form licensure inspection; the state form indicates a Licensure Inspection and no complaint numbers are cited.
Findings
No federal health survey deficiencies were cited on the CMS-2567. No state licensure deficiencies were cited on the Missouri State Form.
Inspection Report — Nov 9, 2018
Life Safety
Date: Nov 9, 2018
Visit Reason
CMS-2567 Life Safety (K) and Emergency Preparedness (E) pages and a Missouri Department of Health and Senior Services licensure State Form; the survey is a Life Safety Code survey.
Findings
No federal health, life safety, emergency preparedness, or state licensure deficiencies were cited (zero deficiencies).
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