Inspection Reports for Independence Manor Care Center
1600 SOUTH KINGS HIGHWAY, INDEPENDENCE, MO, 64055-1853
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
54 residents
Based on a December 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 54
Deficiencies: 8
Date: Dec 11, 2023
Visit Reason
The inspection was a routine survey to assess compliance with professional standards of quality, infection control, staffing, medication management, activities programming, hospice care, respiratory care, food and nutrition services, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including medication order clarity and monitoring parameters, inadequate activities programming for residents, lack of documentation of hospice visits, improper respiratory care practices, insufficient RN staffing coverage, improper medication storage and labeling, inadequate food service sanitation and staffing, and failure to implement effective infection prevention and control measures including COVID-19 isolation protocols.
Deficiencies (8)
Failed to include parameters for monitoring a resident's pulse and clarify physician's orders for as needed blood pressure medication.
Failed to provide an ongoing program of activities to meet residents' interests and needs.
Failed to ensure documentation of hospice visits for a resident on hospice care.
Failed to ensure resident's oxygen tubing and nebulizer were not on the floor and tubing was changed weekly with date written on storage bag.
Failed to ensure a Registered Nurse worked eight consecutive hours per day, seven days a week for multiple days over the past year.
Failed to ensure medications were stored properly, opened medications were dated, and non-medical items were not stored with medications.
Failed to maintain sanitary food service equipment and utensils, retain operable thermometers in refrigerators/freezers, and document dishwasher chemical testing.
Failed to implement an effective infection prevention and control program including proper COVID-19 isolation precautions and hand hygiene during incontinence care.
Report Facts
Residents sampled: 14
Residents affected: 54
RN coverage missing days: 38
Oxygen tubing date: Nov 7, 2023
Hospice documentation missing days: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication order clarification, oxygen tubing, and incontinence care |
| Director of Nursing | Director of Nursing | Interviewed regarding medication orders, hospice documentation, RN staffing, medication storage, and infection control |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding resident activities and infection control practices |
| Dietary Manager | Dietary Manager | Interviewed regarding dietary staffing and food service deficiencies |
| Administrator | Administrator | Interviewed regarding hospice documentation and RN staffing |
| Physical Therapist A | Physical Therapist | Observed and interviewed regarding PPE use in COVID-19 isolation room |
| Certified Nursing Assistant A | Certified Nursing Assistant | Observed and interviewed regarding incontinence care and infection control |
| Certified Nursing Assistant B | Certified Nursing Assistant | Observed and interviewed regarding incontinence care and infection control |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding medication storage |
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding medication storage and infection control |
| Day Dishwasher | Dishwasher | Interviewed regarding dishwasher chemical testing |
| Day Cook | Cook | Interviewed regarding food service staffing and meal service |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding RN staffing schedules |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 7
Date: May 17, 2022
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to employee background checks, medication administration, psychotropic medication use, medication storage security, food safety, hospice services, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to complete timely background checks prior to hiring, improper medication administration practices especially with Levothyroxine, lack of documented diagnoses for psychotropic medications, unsecured medication carts on the memory care unit, unsanitary food preparation equipment and surfaces, incomplete hospice visit documentation, and inadequate infection control practices during feeding and catheter care.
Deficiencies (7)
Failed to ensure timely completion of Employee Disqualification List and background checks prior to hire for two staff.
Failed to ensure proper medication administration of Levothyroxine including diagnosis, timing, and avoiding co-administration with interfering substances for multiple residents.
Failed to ensure diagnoses were listed on Physician Order Summary and Medication Administration Record for psychotropic medications for one resident.
Failed to ensure medication cart was locked on secured unit during medication administration.
Failed to maintain sanitary conditions and cleaning of food and non-food contact surfaces in the kitchen.
Failed to ensure hospice staff documented visits and designate a direct contact from the interdisciplinary team for hospice coordination.
Failed to use proper infection control practices by blowing on and touching resident's food and failing to implement infection control during Foley catheter care.
Report Facts
Residents sampled: 18
Staff sampled: 10
Days late for background check: 41
Medication administration time delay: 7
Medication administration time delay: 39
Hospice nurse visits missed: 1
Hospice CNA visits missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee D | Named in background check deficiency for late screening | |
| Employee J | Named in background check deficiency for delayed EDL check | |
| CMT B | Certified Medication Technician | Named in medication administration deficiencies related to Levothyroxine |
| LPN C | Licensed Practical Nurse | Named in medication administration deficiencies and interview about Levothyroxine |
| CMT A | Certified Medication Technician | Named in medication administration deficiencies and resident medication refusal |
| LPN A | Licensed Practical Nurse | Named in medication administration and infection control interviews |
| Dietary Supervisor | Named in food sanitation deficiency interview | |
| CNA B | Certified Nursing Assistant | Named in infection control deficiency for blowing on and touching resident's food |
| CNA C | Certified Nursing Assistant | Named in infection control deficiency for improper catheter care |
| Administrator | Named in multiple interviews regarding deficiencies | |
| Acting DON | Director of Nursing | Named in multiple interviews regarding deficiencies |
Inspection Report
Routine
Census: 58
Capacity: 99
Deficiencies: 10
Date: Jul 12, 2019
Visit Reason
Routine inspection of Independence Manor Care Center to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including timely delivery of mail to residents, completion of Medicare beneficiary notices, notification of transfers and bed-hold policies, PASARR screening, medication destruction documentation, medication storage temperature monitoring, kitchen sanitation, food brought in by visitors policy education, and infection prevention and control practices related to a C. diff outbreak and waterborne pathogen risk management.
Deficiencies (10)
Failed to ensure incoming mail received on Saturdays was delivered to residents within 24 hours.
Failed to complete Skilled Nursing Facility Advanced Beneficiary Notice for discharged residents.
Failed to send discharge or transfer letters to residents and their representatives.
Failed to provide written bed-hold information prior to hospital transfer/discharge.
Failed to ensure PASARR Level I screening was completed for residents with mental disorders or intellectual disabilities.
Failed to maintain a medication destruction log verifying two nurses destroyed used narcotic patches.
Failed to monitor and document refrigerator temperatures for medication and vaccines properly.
Failed to maintain kitchen sanitation including clean floors, equipment, utensils, and proper hair hygiene.
Failed to educate staff on policy regarding use and storage of foods brought by family and visitors.
Failed to adequately document resident diarrhea, timely contact physician on positive C. diff lab results, implement contact isolation precautions, maintain personal protective equipment availability, and have an infection prevention program addressing waterborne pathogens.
Report Facts
Facility census: 58
Licensed capacity: 99
Missing temperature log signatures: 11
Medication administration: 4
Days antibiotic treatment: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed medication pass and destruction of narcotic patch; interviewed about medication destruction procedures |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding mail delivery, medication destruction, refrigerator temperature monitoring, and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding mail delivery, beneficiary notices, bed hold policies, PASARR screening, medication destruction, refrigerator temperature monitoring, and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation, food brought in by visitors policy, and cleaning procedures |
| LPN B | Licensed Practical Nurse | Interviewed regarding food brought in by visitors policy and medication destruction procedures |
| Social Services Director | Social Services Director | Interviewed regarding completion of Skilled Nursing Facility Advanced Beneficiary Notices and bed hold policies |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding water system monitoring and Legionella risk management |
| Resident's Nurse Practitioner | Nurse Practitioner | Involved in treatment and communication regarding resident with C. diff infection |
| Administrator | Facility Administrator | Interviewed regarding Legionella risk assessment and CDC toolkit requirements |
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