Inspection Reports for
John Knox Village
1001 NW Chipman Rd, Lee's Summit, MO 64081, United States, MO, 64081
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
13.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
29% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 117
Deficiencies: 1
Date: Apr 30, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for John Knox Village Care Center following a survey completed on 04/30/2025. The visit was to address a past non-compliance related to resident rights and treatment decisions.
Complaint Details
The deficiency involved an abuse allegation where a resident reported being 'sexually violated' by a CNA and felt 'assaulted' when barrier cream was applied without proper explanation. The investigation included interviews with the resident, Director of Nursing, and CNAs.
Findings
The facility failed to ensure one sampled resident was fully informed of his/her care prior to receiving it, specifically regarding the application of barrier cream without proper consent. The deficiency was corrected on 04/29/2025. The investigation included interviews and record reviews revealing a resident felt 'assaulted' by a CNA applying barrier cream without proper explanation or consent.
Deficiencies (1)
F 552 Right to be Informed/Make Treatment Decisions. The facility failed to ensure one resident was fully informed of his/her care prior to receiving it, including the application of barrier cream without proper consent or explanation.
Report Facts
Facility census: 117
Inspection Report
Plan of Correction
Census: 112
Deficiencies: 4
Date: Jan 14, 2025
Visit Reason
The inspection was conducted to assess compliance with Medicaid/Medicare coverage and liability notices, care plan timing and revision, respiratory care and suctioning, infection prevention and control, and other regulatory requirements at John Knox Village Care Center.
Findings
The facility failed to provide timely Skilled Nursing Facility Advanced Beneficiary Notices to Medicaid-eligible residents, did not review and revise care plans adequately, failed to ensure respiratory equipment was properly maintained and stored, and did not fully comply with infection prevention and control standards. The facility census was 112 residents during the survey.
Deficiencies (4)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices to two residents to inform them that skilled services may not be paid by Medicare Part A and their financial liability.
F657 Care Plan Timing and Revision: The facility failed to review and revise a resident's person-centered care plan to address a pressure injury and did not update care plans to reflect accurate health status.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure respiratory equipment such as CPAP masks and oxygen tubing were cleaned, stored properly, and covered when not in use for sampled residents.
F880 Infection Prevention & Control: The facility failed to maintain infection control standards including hand hygiene, use of enhanced barrier precautions, and proper handling of linens and wound care supplies for sampled residents.
Report Facts
Facility census: 112
Sampled residents: 23
Plan of correction completion date: Feb 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| T. H. | Administrator | Named in interviews and signed plan of correction |
| Certified Nurse Assistant (CNA) A | Responsible for reporting on care plan updates and CPAP machine storage | |
| Assistant Director of Nursing (ADON) | Responsible for education on evidence-based practices and care plan updates | |
| Director of Nursing (DON) | Responsible for education on evidence-based practices and care plan updates | |
| Licensed Practical Nurse (LPN) A | Responsible for CPAP mask storage and care plan updates | |
| Licensed Practical Nurse (LPN) B | Responsible for Foley catheter care and infection control compliance | |
| Registered Nurse (RN) B | Responsible for wound care and infection control compliance | |
| MDS Coordinator | Responsible for care plan updates and pressure injury management |
Inspection Report
Life Safety
Census: 113
Capacity: 377
Deficiencies: 3
Date: Jan 14, 2025
Visit Reason
A Life Safety Code Survey and Emergency Preparedness Survey were conducted to assess compliance with federal regulations and life safety codes.
Findings
The facility was found not to be in compliance with emergency preparedness requirements related to subsistence needs for staff and patients, and life safety code requirements including exit signage illumination and fire drills. Deficiencies had the potential to affect all 113 residents.
Deficiencies (3)
E015: The facility failed to develop policies and procedures to ensure subsistence needs of staff and residents during shelter in place, including food, water, alternate energy sources, emergency lighting, fire detection, and sewage disposal. This deficient practice could affect all 113 residents.
K293: The facility failed to ensure all exit signs were displayed with continuous illumination as required by NFPA 101. Observations showed unilluminated exit signs and missing directional arrows, potentially affecting all 113 residents.
K712: The facility failed to conduct fire drills in accordance with NFPA 101 requirements, with no documented evidence of drills during multiple quarters and no fire alarm activations recorded. This deficiency could affect all 113 residents.
Report Facts
Occupied beds: 113
Total beds: 377
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Verified policy deficiencies and lack of illuminated exit signs and fire drills | |
| Maintenance Director | Verified lack of illuminated exit signs | |
| Director of Maintenance | Verified lack of fire drills and fire alarm transmissions |
Inspection Report
Follow-Up
Census: 116
Deficiencies: 1
Date: Jul 16, 2024
Visit Reason
The visit was a follow-up inspection to verify correction of a previous deficiency related to the use of mechanical lifts and resident safety.
Findings
The facility failed to follow guidelines for using mechanical lifts, resulting in a resident slipping from a sling and sustaining injury. The deficiency was corrected with staff training and updated procedures.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. Staff used an incorrect sling on a resident, causing a fall and injury.
Report Facts
Resident census: 116
Residents using lifts list: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Witnessed resident fall and assisted with emergency response |
| Certified Nursing Assistant B | Certified Nursing Assistant (CNA) | Involved in resident transfer and witnessed incident |
| Certified Nursing Assistant C | Certified Nursing Assistant (CNA) | Involved in resident transfer and witnessed incident |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided interview about sling use and staff training |
| Restorative Aide | Restorative Aide (RA) | Provided interview about staff training on lifts and slings |
| Therapy Manager | Therapy Manager | Interviewed regarding sling size determination |
| Certified Medication Technician A | Certified Medication Technician (CMT) | Interviewed about resident care and sling use |
| Director of Nursing | Director of Nursing (DON) | Interviewed about incident and staff training |
Inspection Report
Routine
Census: 105
Capacity: 375
Deficiencies: 6
Date: Jul 5, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with federal and state regulations at John Knox Village Care Center.
Findings
The facility was found to have multiple deficiencies including failure to ensure accident hazards were minimized, improper storage and handling of medications, inadequate respiratory care, and infection control issues. The facility census was 105 residents with a licensed capacity of 375 beds at the time of the survey.
Deficiencies (6)
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure physician orders for a sit to stand transfer device were followed, resulting in a resident injury during transfer.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility failed to ensure oxygen and equipment were stored properly and physician orders were clarified for oxygen supplementation for sampled residents.
F755 Pharmacy Services/Procedures/Pharmacist/Records: Facility failed to ensure narcotic medications were accurately counted and documented by nursing staff.
F761 Label/Store Drugs and Biologicals: Facility failed to store medications in a secure, sanitary, temperature-appropriate environment.
F812 Food Procurement/Storage/Preparation/Serve-Sanitary: Facility failed to maintain sanitary conditions in dry storage, walk-in refrigerator, and freezer; food items were improperly stored and temperatures not adequately monitored.
F880 Infection Prevention & Control: Facility failed to maintain an effective infection prevention program, including hand hygiene and wound care for sampled residents.
Report Facts
Facility census: 105
Total licensed capacity: 375
Number of sampled residents: 21
Number of narcotic cards counted: 12
Inspection Report
Life Safety
Census: 105
Capacity: 375
Deficiencies: 22
Date: Jul 5, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire and life safety codes, including emergency lighting, fire alarms, sprinkler systems, and fire extinguishers.
Findings
The facility was found to be non-compliant with several Life Safety Code requirements including emergency lighting testing, fire alarm notification devices, sprinkler system installation and maintenance, fire extinguisher checks, and electrical system maintenance. The facility census was 105 residents with a licensed capacity of 375 at the time of the survey.
Deficiencies (22)
K291 Emergency lighting testing was incomplete and missing the required 90-minute generator run time for emergency light testing.
K343 Fire alarm system failed to ensure all components, including audible and visual devices, were properly installed and operable in all locations.
K351 Sprinkler system was not installed in all required areas, including a small closet without a ceiling sprinkler head, and deficiencies in maintenance and testing were noted.
K355 Portable fire extinguishers were not inspected monthly as required, with missing monthly checks on several extinguishers.
K522 Heating devices/fireplaces were found with combustibles and residents in close proximity, posing a fire hazard.
K700 Dryer lint accumulation was excessive on two commercial dryers, creating a fire hazard.
K712 Fire drills were not fully documented or conducted with required frequency and procedures.
K761 Fire doors failed to close properly and were temporarily repaired; a new fire rated door order was placed.
K914 Electrical system maintenance was incomplete with missing inspection documentation and needed repairs to receptacles.
K916 Emergency generator annunciators and monitoring were inadequate; alarms were not fully functional or monitored 24/7.
K918 Electrical system inspections were incomplete with missing documentation and needed repairs to breakers, lugs, screws, and conduits.
K920 Electrical equipment had over-amped or un-rated power strips and surge protectors not UL listed, posing safety risks.
A2003 No fire hazard was found in general requirements.
A2006 Electrical appliances must be Underwriters Laboratories or Factory Mutual approved and maintained in good repair.
A2016 Fire extinguishers must bear proper labels and have monthly pressure checks documented.
A2018 Complete fire alarm systems must be installed and maintained to automatically transmit alarms to fire department.
A2032 Sprinkler systems must be complete and maintained for facilities licensed prior to August 28, 2007.
A2034 Sprinkler systems must be inspected, maintained, and tested in accordance with NFPA requirements.
A2050 Emergency lighting must provide sufficient intensity for safety of residents and staff.
A2054 Smoke section walls and doors must be fire-rated and self-closing to maintain fire separation.
A2063 Fire drill records must include time, date, personnel, duration, and narrative of special problems.
A3030 Electrical wiring and equipment must be maintained in accordance with NFPA 70 standards.
Report Facts
Facility census: 105
Licensed capacity: 375
Facility smoke zones: 36
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 2
Date: Dec 9, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an incident where a resident accessed an unsecured bottle of cleaning solution and ingested part of it, raising concerns about accident hazards and supervision.
Complaint Details
The complaint investigation found an imminent danger Class I level violation related to protective oversight and a serious jeopardy level J violation for accident hazards and supervision. The facility implemented corrective actions during the onsite visit, lowering the severity of the deficiency to level D by exit.
Findings
The facility failed to ensure the resident environment remained free of accident hazards by not keeping chemicals locked and out of reach. The facility also failed to provide adequate supervision for one sampled resident, resulting in ingestion of a hazardous cleaning solution and subsequent hospitalization.
Deficiencies (2)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to keep chemicals locked and out of reach, allowing a resident to access and drink 3/4 of a cleaning solution, resulting in hospitalization. The facility also failed to provide adequate supervision for the resident at risk.
A4073 Protective Oversight, Voluntary Leave: The facility did not provide twenty-four hour protective oversight and supervision for residents on voluntary leave, contributing to the risk of harm.
Report Facts
Census: 135
Deficiency severity level J: 1
Deficiency severity level I: 1
Inspection Report
Annual Inspection
Census: 135
Capacity: 375
Deficiencies: 15
Date: Aug 30, 2021
Visit Reason
The inspection was the comprehensive annual assessment of John Knox Village Care Center to evaluate compliance with federal and state regulations regarding resident assessments, care planning, medication management, staffing, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete required resident assessments and Minimum Data Set (MDS) submissions, incomplete baseline care plans, inadequate medication cart security, improper food safety practices, and failure to post accurate nurse staffing information. The facility submitted a plan of correction addressing these deficiencies.
Deficiencies (15)
F636 Comprehensive Assessments & Timing: The facility failed to complete an annual Minimum Data Set (MDS) for one resident and quarterly MDS for five residents, missing required assessments and submissions.
F655 Baseline Care Plan: The facility failed to develop and provide a written baseline care plan within 48 hours of admission for four residents and did not obtain signatures acknowledging receipt.
F693 Tube Feeding Management/Restore Eating Skills: The facility failed to provide appropriate gastrostomy tube care, including cleansing and dressing changes, for one resident.
F732 Posted Nurse Staffing Information: The facility failed to post accurate daily nurse staffing data including total hours worked by licensed and unlicensed staff for resident care.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure medication carts were locked and secure, with loose medications and unsecured medication carts observed.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: The facility failed to maintain sanitary food storage and preparation areas, including dirty utensils, unclean refrigerators, and improper food handling.
F838 Facility Assessment: The facility failed to complete and update a comprehensive facility-wide assessment addressing resident population, staff competencies, physical environment, and other required elements.
A4029 Communicable Disease-Employees: The facility failed to properly screen new employees for tuberculosis (TB) with required skin tests prior to hire.
A4063 Medication Storage: The facility failed to store medications securely and separately from discontinued medications, risking contamination and access by unauthorized persons.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions and accepted nursing practice.
A7003 Clean Clothing, Hair Restraints: The facility failed to ensure employees wore clean clothing and effective hair restraints to prevent contamination of food or surfaces.
A7013 Food-Safe, Obtain From Appropriate Sources: The facility failed to obtain and maintain food in sound condition, free from contamination and spoilage.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain proper temperatures during storage and service.
A7048 Safe Plastic/Rubber Items, Food Contact: The facility failed to use safe plastic or rubber materials that are resistant to damage and suitable for cleaning and sanitizing.
A7066 Grills/Griddles/Microwaves/Other-Clean Daily: The facility failed to clean cooking equipment daily to prevent accumulation of grease and soil.
Report Facts
Facility census: 135
Total licensed capacity: 375
Residents sampled for MDS review: 27
Deficiencies cited: 17
Inspection Report
Plan of Correction
Census: 157
Deficiencies: 1
Date: Jul 1, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a facility investigation of misappropriation/exploitation involving a resident's property.
Findings
The facility failed to protect a resident from financial exploitation by a Health Services Associate who accepted a blank signed check and gave it to a friend who cashed it for $5,000. The facility conducted an investigation, notified appropriate parties, and terminated the employee involved.
Deficiencies (1)
CFR 483.12: The resident was not free from misappropriation of property as a Health Services Associate accepted a blank signed check and gave it to a friend who cashed it for $5,000. The facility failed to assure the resident's protection from exploitation.
Report Facts
Facility census: 157
Amount misappropriated: 5000
Number of sampled residents: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HSA A | Health Services Associate | Employee involved in misappropriation of resident's property |
| Administrator | Administrator | Signed the plan of correction and involved in notification |
| Director of Nursing | Director of Nursing | Notified of the incident and involved in investigation |
Inspection Report
Routine
Deficiencies: 0
Date: Mar 9, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 1
Date: Jan 11, 2021
Visit Reason
The inspection was conducted following a complaint investigation into an allegation of physical abuse by a Certified Nurse Aide (CNA) against a resident.
Complaint Details
The complaint was substantiated. The investigation found that CNA B physically abused Resident #1 by pushing the resident into a chair, resulting in bruises and blood. The CNA was terminated and the facility took corrective actions including staff education and policy review.
Findings
The facility failed to ensure one resident was free from physical abuse when a CNA pushed the resident into a chair causing bruising and blood on the resident's lip. The facility staff investigated, suspended, and terminated the CNA involved and reviewed abuse and neglect policies with all employees.
Deficiencies (1)
F 600: The facility failed to prevent physical abuse of a resident by a CNA who pushed the resident into a chair causing bruising and blood on the resident's lip. The resident had multiple bruises and skin discolorations noted during the investigation.
Report Facts
Facility census: 151
Date of incident: Jan 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Named in physical abuse finding against resident |
| LPN C | Licensed Practical Nurse | Witnessed abuse incident and intervened |
| RN A | Registered Nurse | House Supervisor involved in investigation |
| Director of Nursing | Notified per policy about the abuse incident |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 15, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 229
Deficiencies: 1
Date: Jan 28, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident by a Certified Nurses Aide (CNA) at John Knox Village Care Center.
Complaint Details
The complaint was substantiated. The Administrator was notified on 01/28/20 of the past noncompliance which occurred on 01/26/20. The CNA was suspended and placed on do not return status. The resident's physician and family were notified. The investigation was ongoing and turned over to a detective.
Findings
The facility failed to keep one sampled resident free from physical abuse, resulting in bruising to multiple body areas. The investigation confirmed that a CNA forcibly handled the resident, causing injuries and the CNA was suspended and placed on do not return status.
Deficiencies (1)
F 600: The facility failed to keep one resident free from physical abuse when a staff member forced the resident to bed, causing bruising to the left upper arm, left lower flank, and right outer arm. The facility census was 229 residents at the time.
Report Facts
Facility census: 229
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Witnessed CNA forcibly handling the resident and reported the incident |
| CNA A | Certified Nurses Aide | Staff member who physically abused the resident |
| LPN B | Licensed Practical Nurse | Assisted in assessing the resident and notified House Supervisor |
| RN A | Registered Nurse, House Supervisor | Notified about the incident and involved in investigation |
| Director of Nursing | Director of Nursing | Interviewed and confirmed police report and investigation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 3, 2019
Visit Reason
The visit was conducted as the facility's annual survey and licensure inspection, including a complaint investigation.
Findings
No health deficiencies or state licensure deficiencies were cited as a result of the annual survey and complaint investigation.
Inspection Report
Life Safety
Census: 201
Capacity: 430
Deficiencies: 23
Date: May 3, 2019
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with federal, state, and local emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with several emergency preparedness and life safety code requirements, including deficiencies in emergency lighting, fire extinguishers, fire drills, fire alarm systems, smoke barriers, electrical systems, and fire door assemblies. The facility census was 201 residents with a licensed capacity of 430.
Deficiencies (23)
E001 Emergency Preparedness program failed to establish and maintain a comprehensive plan addressing evacuation of bariatric residents, monitoring extreme temperatures, facility roles under federal waivers, and staff training processes.
K291 Emergency lighting was not inspected and tested per NFPA standards, with missing itemized lists and non-illuminating exit lights during testing.
K300 Smoke penetrations were found in multiple locations including kitchen, mechanical rooms, and resident rooms, with unsealed pipes and offset sprinkler head escutcheons.
K355 Portable fire extinguishers lacked documented quick inspections for April 2019 and failed to ensure monthly inspections and fire drills were conducted and documented properly.
K711 Evacuation and relocation plan lacked comprehensive policy and documentation for fire watches, with missing notifications and incomplete procedures.
K712 Fire drills were not thoroughly documented with missing drill types, sizes, scenarios, and successful transmission confirmations.
K761 Fire doors failed to be inspected and tested annually, with missing smoke barrier and fire resistive rating assessments and missing FRR labels on doors.
K914 Electrical systems failed to maintain complete records of testing and inspections, with missing documentation for receptacles and failure to replace broken outlets in resident rooms.
K918 Generator and emergency power systems lacked complete documentation and testing records, with missing monthly test times and incomplete maintenance records.
K920 Electrical equipment had unsafe power cords and extension cords, with surge protectors missing or improperly used, posing potential hazards.
K923 Gas equipment storage areas lacked proper fire resistive ratings and signage, with missing FRR labels and inadequate separation of oxygen storage room.
A1036 Oxygen storage room lacked required one-hour rated construction with powered or gravity vent to outside.
A1135 Emergency lighting for life support areas was not provided as required by NFPA standards.
A2003 No fire hazard was present in the building.
A2016 Fire extinguisher monthly checks were not documented as required.
A2019 Fire alarm system testing and maintenance were incomplete and not fully documented.
A2020 Fire alarm inspections and certifications were incomplete.
A2025 Fire alarm system was out of service for more than four hours without proper notification and fire watch.
A2054 Smoke section walls and doors lacked required fire-rated construction and self-closing mechanisms.
A2063 Fire drill records were incomplete with missing times, dates, personnel, and narrative notations.
A3001 Building was not substantially constructed and maintained per construction standards.
A3030 Electrical wiring and equipment were not maintained according to NFPA standards.
A4013 Policies and procedures for operational safety, infection control, and emergency preparedness were not fully developed or implemented.
Report Facts
Facility census: 201
Total licensed capacity: 430
Smoke zones: 36
Fire extinguishers: 36
Fire drills missing: 1
Fire alarm transmission confirmations missing: 11
Broken or missing receptacles: 6
Fire alarm out of service duration: 4
Fire drills per year: 12
Generator exercise frequency: 12
Inspection Report
Complaint Investigation
Census: 235
Deficiencies: 1
Date: Jun 7, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly transcribe physician oxygen orders and ensure adequate oxygen delivery to a resident in need of supplemental oxygen.
Complaint Details
The visit was complaint-related, investigating allegations that the facility failed to provide ordered oxygen therapy to a resident, resulting in hypoxia and potential harm. The complaint was substantiated based on record reviews and staff interviews.
Findings
The facility failed to transcribe physician orders for oxygen and did not ensure continuous oxygen supply to a resident, resulting in hypoxia and low oxygen saturation levels. Interviews and record reviews revealed multiple lapses in oxygen management and documentation.
Deficiencies (1)
F684 Quality of care: The facility failed to transcribe physician admission comfort care oxygen orders to the physician order sheet, medication administration record, and treatment administration record, resulting in a resident going without supplemental oxygen and being found hypoxic with low oxygen saturation levels.
Report Facts
Resident census: 235
Oxygen saturation levels: 70
Respiration rate: 22
Inspection Report
Annual Inspection
Census: 197
Capacity: 239
Deficiencies: 14
Date: Mar 23, 2018
Visit Reason
Annual inspection of John Knox Village Care Center to assess compliance with emergency preparedness, life safety, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including emergency preparedness plan updates, emergency communication plans, fire drills documentation, HVAC system operation, electrical system maintenance, and surge protector usage. Deficiencies potentially affected all residents, visitors, and staff.
Deficiencies (14)
E004: The facility failed to develop, review, and update an emergency preparedness plan annually as required by federal and state regulations.
E031: The facility failed to maintain an emergency preparedness communication plan including contact information for state and federal emergency preparedness staff.
E039: The facility failed to conduct required emergency preparedness exercises including full-scale and tabletop exercises.
K521: The HVAC system did not operate properly in restrooms of 10 resident rooms, potentially affecting 14 residents in one smoke zone.
K712: The facility failed to ensure fire drills were thoroughly documented with varying simulated conditions for staff education and resident safety.
K914: The facility failed to maintain records for electrical system maintenance and testing including hospital-grade receptacles in resident rooms.
K918: The facility failed to maintain and test electrical main and circuit breaker panels annually with proper documentation.
K920: The facility failed to prevent unsafe use of extension cords and surge protectors in multiple resident rooms and common areas, creating potential electrical hazards.
K921: The facility failed to perform required testing and maintenance of patient-care related electrical equipment including surge protectors.
A2063: The facility failed to keep complete records of all fire drills including simulated resident evacuation times and personnel participation.
A3015: Toilet rooms were not easily accessible, well-lighted, or properly ventilated with required locks as per regulations.
A3030: Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards.
A3037: Extension cords and duplex receptacles were used improperly, not UL-approved, or placed where subject to physical damage.
A4013: The facility failed to develop policies and procedures to ensure resident health and safety including emergency preparedness and infection control.
Report Facts
Facility census: 197
Total licensed capacity: 239
Number of smoke zones: 36
Number of resident rooms affected by HVAC deficiency: 10
Number of residents potentially affected by HVAC deficiency: 14
Number of surge protector locations with deficiencies: 20
Number of fire drills reviewed: 12
Document
Deficiencies: 0
Date: Mar 23, 2018
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
No findings or inspection results are available due to lack of content.
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