Inspection Reports for
Lewis & Clark Gardens
1221 BOONES LICK RD, SAINT CHARLES, MO, 63301-2328
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
23.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
329% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
60% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: Jan 15, 2026
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of physical and verbal abuse by a staff member towards Resident #1.
Complaint Details
The complaint involved allegations by Resident #1 that a staff member (CNA A) squeezed his/her face and yelled at him/her. The facility initially did not report the allegation to the state agency because the resident denied the abuse when interviewed with the alleged staff present. The investigation was incomplete with no interviews of the alleged perpetrator or witnesses. The Administrator acknowledged the failure to report and incomplete investigation.
Findings
The facility failed to timely report allegations of abuse to the state survey agency and did not conduct a thorough investigation of the abuse allegations involving Resident #1. The resident alleged that a staff member squeezed his/her face and yelled at him/her, but the facility did not report the incident because the resident later denied the allegation during an interview with staff present. The investigation lacked interviews or statements from the alleged perpetrator or other witnesses.
Deficiencies (2)
Failed to timely report suspected abuse to the state survey agency within required timeframes.
Failed to conduct a timely and thorough investigation of an allegation of abuse involving a resident.
Report Facts
Residents Affected: 1
Facility Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Alleged perpetrator identified by Resident #1 as 'Firehead' who squeezed resident's face and yelled at him/her |
| CNA B | Certified Nurse Aide | Reported Resident #1's allegations to Director of Nursing and Assistant Director of Nursing |
| Director of Nursing | Director of Nursing | Interviewed resident and staff; did not report allegation to state agency as resident denied abuse |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in interviews and reporting of abuse allegations |
| Administrator | Administrator | Received abuse report on 1/9/26; did not report to state agency due to resident denial; acknowledged failure to complete investigation |
| Activity Director | Activity Director | Witnessed resident's report of abuse and reported to Administrator |
Inspection Report
Routine
Census: 89
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service standards, specifically ensuring that food and drink are palatable, attractive, and served at safe and appetizing temperatures.
Findings
The facility failed to provide residents with meals served at proper temperatures and palatability. Multiple residents reported food being cold, undercooked, bland, or unappetizing. Observations confirmed food items served at temperatures below required standards and issues with food preparation and serving practices.
Deficiencies (1)
Failure to provide each resident with a palatable meal served at appetizing temperatures and texture that conserved nutritive value and flavor.
Report Facts
Food temperature: 108
Food temperature: 118
Food temperature: 70.7
Food temperature: 58.5
Census: 89
Number of hall trays: 100
Number of hall trays: 200
Number of hall trays: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide A | Dietary Aide | Responsible for recording food temperatures and assisting in food preparation; admitted to missing temperature recordings. |
| Dietary Manager | Dietary Manager | Responsible for overseeing food preparation and menu adherence; added salad dressing and responded to complaints. |
| Administrator | Administrator | Provided statements regarding expectations for food quality and temperature. |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Date: Sep 15, 2025
Visit Reason
The inspection was conducted due to a complaint regarding failure to provide bathing assistance to four residents temporarily relocated to the COVID isolation unit.
Complaint Details
Complaint #2610531 regarding failure to provide bathing assistance to residents on the COVID isolation unit. The complaint was substantiated with findings of missed showers and inadequate bathing care.
Findings
The facility failed to provide bathing for four residents who required assistance during their stay on the COVID isolation unit. Shower schedules were not followed, and documentation of showers was missing for multiple days. Staff cited issues such as a broken shower drain and staffing shortages. Hospice aides were not allowed on the COVID unit, and facility staff did not consistently provide showers or bed baths as required.
Deficiencies (1)
Failure to provide bathing assistance to residents on the COVID isolation unit as scheduled.
Report Facts
Census: 85
Days without shower: 13
Days without shower: 9
Days without shower: 6
Date survey completed: Sep 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Audited shower sheets and provided information about shower schedules and hospice aide responsibilities |
| CNA A | Certified Nurse Assistant | Main shower aide on the COVID isolation unit; provided information about shower availability and work schedule |
| Director of Nursing | Director of Nursing (DON) | Provided information about shower schedules, missing shower documentation, and facility policies |
| Nurse Assistant C | Nurse Assistant | Provided information about shower functionality on the COVID isolation unit |
| Administrator | Administrator | Provided information about shower requirements, bed baths during shower outages, and hospice aide roles |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 4
Date: Jun 23, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to provide housekeeping services, abuse and neglect of residents, failure to report abuse allegations, and inadequate care planning for residents with Huntington's disease.
Complaint Details
The complaint investigation revealed that Resident #1 was subjected to neglect and abuse by staff, including a fall caused by a CNA who pushed the resident and failed to assist or assess him. Resident #2 reported that a staff member threatened to hit him with a closed fist and was fearful of retaliation. The facility failed to report this allegation timely. Both residents have diagnoses affecting mobility and cognition.
Findings
The facility failed to maintain a clean and safe environment for Resident #1, failed to prevent abuse and neglect by staff including a fall caused by a CNA, failed to timely report an allegation of abuse involving Resident #2, and failed to develop a comprehensive care plan addressing the needs of Resident #1 with Huntington's disease. Staff lacked understanding of Huntington's disease and did not communicate properly with the resident.
Deficiencies (4)
Failed to provide housekeeping services to maintain a clean, sanitary, and orderly environment for Resident #1.
Failed to ensure Resident #1 was free from abuse and neglect when CNA pushed the resident causing a fall and did not assist or assess the resident.
Failed to timely report an allegation of abuse involving Resident #2 who was threatened by a staff member.
Failed to develop a comprehensive, person-centered care plan for Resident #1 addressing Huntington's disease and related symptoms.
Report Facts
Facility census: 69
Residents sampled: 7
Date of fall incident: Jun 13, 2025
Date of inspection: Jun 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in abuse and neglect finding for pushing Resident #1 causing a fall and failing to assist or call nurse |
| LPN D | Licensed Practical Nurse | Performed skin assessment of Resident #1 after fall |
| RN C | Registered Nurse | Observed incident, did not perform skin assessment, reported to DON |
| Director of Nursing | Director of Nursing | Informed of abuse incident after family complaint, responsible for care plan development |
| Administrator | Administrator | Suspended CNA A pending investigation, stated abuse is not tolerated |
| Director of Housekeeping Services | Director of Housekeeping Services | Reported prior administrator told staff not to enter Resident #1's room for cleaning |
| Social Services Director | Social Services Director | Reported awareness of abuse allegation involving Resident #2 |
| LPN/Assistant Director of Nursing | Licensed Practical Nurse/Assistant Director of Nursing | Reported delayed reporting of abuse allegation involving Resident #2 |
| Therapy Program Manager | Therapy Program Manager | Received report from Resident #2 about abuse allegation |
| Certified Medication Technician B | Certified Medication Technician | Reported staff fear and lack of knowledge about Resident #1's Huntington's disease |
| Housekeeper E | Housekeeper | Reported fear of Resident #1 and lack of knowledge about Huntington's disease |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: May 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation involving an allegation of staff to resident verbal abuse by Certified Medication Technician (CMT) B towards Resident #1.
Complaint Details
The complaint was substantiated. Resident #1 reported verbal abuse by CMT B, who yelled and used inappropriate language. Witnesses and staff statements confirmed the incident. The facility suspended and terminated CMT B and notified appropriate parties including the police.
Findings
The facility failed to ensure Resident #1 was free from verbal abuse when CMT B yelled, used vulgar language, and told the resident to shut up during care refusal. The facility investigated, suspended, and terminated the staff member, educated staff on abuse policies, and corrected the deficiency.
Deficiencies (1)
Failure to protect Resident #1 from verbal abuse by CMT B who yelled, used vulgar language, and told the resident to shut up.
Report Facts
Residents Affected: 1
Facility Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medication Technician | Named in verbal abuse finding and terminated for actions |
| LPN C | Licensed Practical Nurse | Provided statement regarding resident's report of abuse |
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Lewis & Clark Gardens following a survey conducted on 04/24/2025. The visit was related to addressing past noncompliance and correcting deficiencies identified during a prior incident involving resident safety.
Findings
The facility failed to ensure adequate supervision and accident hazard prevention for one resident, resulting in the resident eloping through an alarmed exit door without staff knowledge and sustaining serious injuries. The facility has since updated policies, increased alarm volume, and implemented 15-minute checks to correct the issues.
Deficiencies (1)
F 689: The facility failed to ensure one resident received adequate supervision to prevent accidents, resulting in elopement through an alarmed exit door and multiple serious injuries. The facility also failed to complete required 15-minute checks for this resident.
Report Facts
Facility census: 76
Sample size: 8
Resident wandering risk score: 4
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to a resident at risk for elopement, resulting in the resident exiting the facility unsupervised and sustaining serious injuries.
Complaint Details
The complaint investigation found that Resident #1, who was at risk for wandering and elopement, exited the facility through an alarmed fire exit door without staff knowledge. Staff did not hear the alarm promptly, and 15-minute checks were not completed as required. The resident was found outside with severe injuries. The immediate jeopardy was corrected on 4/18/25.
Findings
The facility failed to respond timely to a door alarm when Resident #1, assessed at risk for elopement, exited through an alarmed door unnoticed by staff. The resident was not monitored with required 15-minute checks and subsequently fell outside the facility, sustaining multiple facial fractures and a subdural hemorrhage. The facility implemented corrective actions including staff education, alarm volume adjustment, and ongoing audits.
Deficiencies (1)
Failure to ensure adequate supervision to prevent accidents for a resident at risk for elopement, including delayed response to door alarm and failure to complete required 15-minute checks.
Report Facts
Facility census: 76
Wandering risk score: 4
Distance resident found from exit door: 400
Time resident missing: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Reported resident missing, did not hear alarm until halfway down hall, called 911 |
| NA A | Nursing Assistant | Noted resident call light on but resident not in room, did not hear door alarm |
| LPN F | Licensed Practical Nurse | Tested alarmed fire exit door, reported alarm volume issues |
| Director of Nursing | Director of Nursing | Notified of missing resident, instructed staff to call police |
| Administrator | Administrator | Reported resident exited alarmed door, confirmed resident was on 15-minute checks |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 1
Date: Apr 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's government issued debit card by a Certified Nurse Aide (CNA A).
Complaint Details
The complaint was substantiated. The resident reported unauthorized use of their debit card by CNA A, who withdrew cash and paid bills without permission. Law enforcement was involved, and the resident filed a police report.
Findings
The facility failed to protect one resident from misappropriation of property when CNA A used the resident's debit card without permission to withdraw cash and pay bills totaling $1,369.69. CNA A was suspended, investigated, and terminated. The facility educated staff on misappropriation policies and took corrective actions.
Deficiencies (1)
Failed to ensure one resident remained free from misappropriation of property when CNA A took and used the resident's government issued debit card without permission.
Report Facts
Total fraudulent charges: 1369.69
Facility census: 76
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in misappropriation of resident property finding; suspended and terminated. |
| Officer A | Law enforcement officer who investigated the complaint and interviewed involved parties. | |
| Business Office Manager | Assisted resident in reviewing debit card transactions and reported findings. | |
| Administrator | Administrator | Notified of the violation and oversaw corrective actions. |
| Social Services Director | Social Services Director | Interviewed residents to determine if other money was taken. |
| Director of Nursing | Director of Nursing | Interviewed residents to determine if other money was taken. |
Inspection Report
Routine
Census: 85
Deficiencies: 2
Date: Oct 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in nursing care, including wound care and activities programming, based on observations, interviews, and record reviews.
Findings
The facility failed to ensure staff followed physician's orders for wound care for two residents, resulting in improper wound treatment and lack of order reconciliation after hospital readmission. Additionally, the facility failed to provide an ongoing activities program meeting individual interests, especially lacking activities in the evenings and on weekends for multiple residents.
Deficiencies (2)
Failure to follow physician's orders for wound care for two residents, including not resuming hospital discharge orders and improper wound dressing application.
Failure to implement an ongoing activities program designed to meet individual interests and provide activities in the evenings and on weekends.
Report Facts
Facility census: 85
Residents sampled: 10
Residents reviewed for activities deficiency: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse D | Licensed Practical Nurse | Named in wound care deficiency for not using ordered Iodosorb packing strips and not resuming wound care orders |
| Licensed Practical Nurse B | Licensed Practical Nurse | Described admission order reconciliation process related to wound care orders |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in wound care treatment and order reinstatement |
| Director of Nursing | Director of Nursing | Provided expectations regarding following physician and hospital discharge orders |
| Administrator | Administrator | Provided expectations regarding order resumption and wound care compliance |
| Wound Care Consultant Nurse Practitioner | Nurse Practitioner | Provided expert expectations on wound care treatment and order adherence |
| Residents' Physician | Physician | Provided expectations on following hospital discharge orders and wound treatments |
| Activity Director | Activity Director | Described activities staffing, scheduling, and documentation deficiencies |
| Activity Assistant | Activity Assistant | Described activities provided during evenings and weekends |
| Licensed Practical Nurse E | Licensed Practical Nurse | Reported no weekend activities except occasional Bingo |
Inspection Report
Routine
Census: 82
Deficiencies: 11
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards including resident care, infection control, food service, and safety.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs for oxygen and mobility aids, failure to follow physician orders for wound care, inadequate activities programming, unsecured hazardous materials, improper respiratory care, food safety and preparation issues, infection control lapses, and incomplete pneumococcal vaccination administration.
Deficiencies (11)
Failure to provide reasonable accommodation of needs for one resident including portable oxygen, wheelchair, and cardiac monitor use.
Failure to ensure staff followed physician's orders for wound care for two residents.
Failure to implement an ongoing activities program designed to meet individual interests and provide activities in evenings and weekends.
Failure to ensure hazardous materials were kept secured and inaccessible to residents.
Failure to provide safe and appropriate respiratory care including oxygen therapy, CPAP/BiPAP use, labeling of oxygen tubing, and proper storage of nebulizer masks.
Failure to ensure food was palatable and served at safe and appetizing temperatures.
Failure to prepare pureed food items according to recipe to ensure smooth consistency without chunks.
Failure to provide nourishing evening snacks to residents who wished to have a snack and failure to provide equal opportunity for snacks.
Failure to ensure kitchen cleanliness, proper hand hygiene and glove use by staff, proper dishwashing and sanitizing, and maintenance of freezer temperature at or below 0°F.
Failure to ensure nursing staff performed appropriate hand hygiene and glove changes during care, failure to implement Enhanced Barrier Precautions for one resident, and failure to complete required Tuberculin Skin Testing for three employees.
Failure to provide pneumococcal vaccine as indicated by CDC guidelines for five residents.
Report Facts
Facility census: 82
Deficiencies cited: 11
Temperature: 100
Temperature: 85
Temperature: 110
Freezer temperature: 15
Freezer temperature: 20
Freezer temperature: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician N | Unaware of resident's need for heart monitor and portable oxygen | |
| Certified Nursing Assistant I | Unaware of resident's need for heart monitor, wheelchair, and portable oxygen | |
| Licensed Practical Nurse O | Agency nurse unaware of resident's need for heart monitor and CPAP | |
| Director of Nursing | Unaware of resident's need for heart monitor and CPAP; responsible for immunization oversight | |
| Director of Therapy Services | Informed staff about wheelchair availability but had not evaluated resident | |
| Licensed Practical Nurse D | Charge nurse on duty during resident readmission; missed resuming wound treatment orders | |
| Licensed Practical Nurse C | Charge nurse responsible for verifying orders on readmission | |
| Licensed Practical Nurse B | Described admission order process and uncertainty about Admissions Champion | |
| Administrator | Expected staff to follow hospital discharge orders and wound care orders | |
| Wound care consultant Nurse Practitioner | Expected staff to follow wound care treatment orders and notify if supplies unavailable | |
| Resident's physician | Expected staff to follow hospital discharge orders and wound care orders | |
| Activity Assistant | Described activities assistance and evening/weekend activity limitations | |
| Activity Director | Described activity program limitations and staffing | |
| Maintenance Supervisor | Unaware of unsecured hazardous materials | |
| Certified Nurse Assistant A | Failed to wash hands and change gloves appropriately during incontinence care | |
| Certified Nurse Assistant B | Failed to wash hands and change gloves appropriately during incontinence care | |
| Certified Nurse Assistant X | Failed to wash hands and change gloves appropriately during incontinence care | |
| Certified Nurse Assistant U | Failed to wash hands and change gloves appropriately during incontinence care | |
| Director of Nursing | Responsible for employee TB testing oversight | |
| Assistant Director of Nursing | Responsible for administering pneumonia vaccinations |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: Jun 26, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to provide necessary care and assistance for activities of daily living and failure to provide appropriate care to maintain or improve range of motion for residents.
Complaint Details
The visit was complaint-related, focusing on allegations that the facility failed to provide adequate personal hygiene care and failed to apply prescribed therapeutic devices for residents.
Findings
The facility failed to ensure staff provided adequate personal hygiene care including nail care and shaving for two residents, and failed to apply hand splints and palm protectors as directed for one resident with hand contractures. The deficiencies were observed in a sample of nine residents.
Deficiencies (2)
Failure to provide necessary care and services to maintain good personal hygiene, including nail care and grooming to include shaving for two residents.
Failure to apply hand splints and palm protectors as directed by Occupational Therapy for one resident with hand contractures.
Report Facts
Residents sampled: 9
Residents affected: 2
Residents affected: 1
Facility census: 82
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 3
Date: May 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to prevent sexual abuse between two residents whose capacity to consent to sexual activity had not been determined.
Complaint Details
The complaint investigation was triggered by an incident where two residents engaged in sexual intercourse without documented capacity to consent. The investigation confirmed the incident and found failures in supervision and care planning. The immediate jeopardy was removed after corrective actions were implemented.
Findings
The facility failed to prevent sexual abuse between two residents with cognitive impairments. The investigation revealed inadequate supervision and failure to assess capacity to consent. The facility also failed to provide adequate personal hygiene care and failed to apply prescribed hand splints and palm protectors for a resident with contractures.
Deficiencies (3)
Failure to prevent sexual abuse between two residents with cognitive impairments.
Failure to provide necessary care and services for activities of daily living including nail care, grooming, and shaving for two residents.
Failure to apply hand splints and palm protectors as directed by therapy for a resident with hand contractures.
Report Facts
Facility census: 85
BIMS score: 2
Shower frequency: 1
Shower refusals: 5
Splint wearing duration: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Aide | Reported observations of residents' interactions and hygiene care deficiencies. |
| CMT D | Certified Medication Technician | Discovered residents engaged in sexual intercourse and reported the incident. |
| RN E | Registered Nurse | Reported on the incident and residents' conditions. |
| DON | Director of Nursing | Provided information on staff expectations and supervision related to the incident and splint application. |
| Rehab Director | Rehabilitation Director | Provided training on splint application and reported on resident's refusal and staff compliance. |
| Administrator | Facility Administrator | Provided expectations for staff regarding supervision, hygiene, and splint application. |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: May 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to prevent sexual abuse between two residents and related abuse and neglect concerns.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent sexual abuse between two residents, including one resident with cognitive impairment who could not consent. The violation was initially at Immediate Jeopardy level but was removed after corrective actions were implemented.
Findings
The facility failed to prevent sexual abuse between two residents, one of whom was cognitively impaired and unable to consent. The investigation found inadequate documentation and interventions regarding the residents' capacity to consent and contact between them. The facility implemented corrective actions to address the immediate jeopardy and subsequent deficiencies.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent sexual abuse between two residents, one with diminished decision-making capacity, and did not document interventions or assess capacity to consent to sexual activity.
A8022 Free From Abuse: The facility was found to have an imminent danger class I level abuse violation related to the sexual abuse incident, which was removed after corrective action.
Report Facts
Facility Census: 85
Number of sampled residents: 13
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 7
Date: Dec 27, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, failure to promptly address resident council grievances, inadequate cleanliness and odor control, failure to follow physician orders for medications and supplements, failure to provide adequate oral care and assistance with meals, and failure to properly assess and document pressure ulcers.
Deficiencies (7)
Failed to honor residents' preferences for bathing, resulting in residents not receiving showers as desired.
Failed to act promptly on grievances and recommendations of the Resident Council and failed to provide documentation of responses.
Failed to maintain carpet in good repair and odor free; failed to ensure resident equipment was clean and in good repair.
Failed to establish and implement a grievance policy and make prompt efforts to resolve grievances.
Failed to follow physician orders for medications and supplements for weight loss, resulting in missed doses and unavailable supplements.
Failed to provide necessary oral hygiene, access to fluids, and assistance with dining for a resident unable to perform ADLs independently.
Failed to follow policy for pressure ulcer prevention and care, including failure to document skin and wound assessments and notify physician of pressure ulcer.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Facility census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in medication administration and bathing preference findings |
| Certified Nurse Aide A | Certified Nurse Aide | Named in bathing preference findings |
| Certified Nurse Aide B | Certified Nurse Aide | Named in bathing preference findings |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in bathing preference, medication administration, and pressure ulcer findings |
| Activities Director | Activities Director | Named in resident council grievance findings |
| Administrator | Administrator | Named in resident council grievance and medication administration findings |
| Social Services Director | Social Services Director | Named in grievance policy findings |
| Certified Medication Technician A | Certified Medication Technician | Named in medication administration findings |
| Dietary Manager | Dietary Manager | Named in medication administration and supplement findings |
| Registered Dietician | Registered Dietician | Named in supplement administration findings |
| Certified Nurse Aide C | Certified Nurse Aide | Named in oral care and pressure ulcer findings |
| Certified Nurse Aide D | Certified Nurse Aide | Named in oral care and pressure ulcer findings |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 7
Date: Dec 27, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for Lewis & Clark Gardens nursing facility.
Findings
The facility was found deficient in multiple areas including resident self-determination, resident/family group participation, safe and homelike environment, grievance procedures, comprehensive care plans, and treatment to prevent pressure ulcers. Several residents' rights and care standards were not met as evidenced by interviews, observations, and record reviews.
Deficiencies (7)
F561 Self-determination: The facility failed to create an environment respectful of residents' rights to make choices about significant aspects of their lives, including bathing preferences for two residents.
F565 Resident/Family Group and Response: The facility failed to act promptly on grievances and recommendations from the Resident Council and failed to provide rationale and responses to concerns.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain carpet in good repair and odor free, and failed to ensure resident equipment was clean and in good repair.
F585 Grievances: The facility failed to develop a grievance policy and procedure that included all required components and failed to resolve grievances in a timely manner for three residents.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders for medications and supplements for two residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary services to maintain good nutrition, grooming, and oral hygiene for one resident.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to follow its policy for pressure ulcer prevention and care plan interventions for one resident with a Stage II pressure ulcer.
Report Facts
Facility census: 79
Residents sampled: 5
Residents referenced: 3
Plan of correction completion date: Feb 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice Conover | Administrator | Signed the statement of deficiencies and plan of correction |
| Certified Nurse Aide (CNA) A | Interviewed regarding shower aide duties and resident care | |
| Certified Nurse Aide (CNA) B | Interviewed regarding shower aide duties and resident care | |
| Assistant Director of Nursing | Interviewed regarding shower schedules and resident care | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding resident complaints about showers | |
| Administrator | Interviewed regarding resident council concerns and grievance follow-up | |
| Activities Director | Interviewed regarding resident council meetings and grievance follow-up | |
| Social Service Director | Responsible for grievance program and interviewed regarding grievance procedures | |
| Family Member A | Interviewed regarding resident #2's shower care complaints | |
| Family Member B | Interviewed regarding resident #4's grievances and staff disrespect | |
| Certified Medication Technician (CMT) | Interviewed regarding medication administration and Boost supplement | |
| Dietary Manager | Interviewed regarding resident meal supplements and dietary orders | |
| Assistant Director of Nursing (ADON) | Interviewed regarding wound care and medication delivery | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding wound care and resident observations | |
| Certified Nurse Aide (CNA) C | Interviewed regarding resident oral care and feeding assistance | |
| Certified Nurse Aide (CNA) D | Interviewed regarding resident oral care and feeding assistance | |
| Social Service Director | Interviewed regarding resident missing teeth and dental care |
Inspection Report
Life Safety
Census: 73
Capacity: 142
Deficiencies: 7
Date: Dec 6, 2022
Visit Reason
The inspection was a life safety code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to meet several life safety code requirements including egress door locking arrangements, cooking facilities, sprinkler system maintenance, smoke barriers, HVAC ventilation, smoking regulations, and electrical equipment safety. Deficient practices had the potential to affect multiple residents across various smoke compartments.
Deficiencies (7)
K222 Egress Doors: The facility failed to ensure doors within the means of egress opened freely and did not obstruct exit paths, affecting 28 residents.
K324 Cooking Facilities: The facility failed to ensure no gaps between range hood baffles and no cooking equipment in resident rooms, affecting six residents.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinklers free of dust and debris, affecting 73 residents.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers, affecting 15 residents.
K521 HVAC: The facility failed to maintain ventilation units free of dust and debris, affecting 73 residents.
K741 Smoking Regulations: The facility failed to maintain smoking areas properly, affecting multiple occupants.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure electrical wiring and equipment met NFPA 70 standards, affecting 73 residents.
Report Facts
Facility capacity: 142
Resident census: 73
Residents potentially affected: 28
Residents potentially affected: 6
Residents potentially affected: 73
Residents potentially affected: 15
Residents potentially affected: 73
Residents potentially affected: 73
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 1
Date: Dec 6, 2022
Visit Reason
The inspection was conducted to evaluate compliance with communicable disease policies, specifically Tuberculosis Skin Tests (TST) for employees, as part of regulatory oversight.
Findings
The facility failed to ensure that Tuberculin Skin Tests were completed for all new employees according to state requirements. Documentation and follow-up testing were incomplete or missing for several employees.
Deficiencies (1)
19 CSR 30-85.042(27) Communicable Disease-Employees: The facility failed to ensure Tuberculin Skin Tests were completed for three of six new employees as required by Missouri Department of Health regulations.
Report Facts
Facility census: 73
Inspection Report
Recertification Survey Complaint Investigation
Deficiencies: 5
Date: Dec 2, 2022
Visit Reason
A Recertification Survey and Complaint Survey was conducted from 11/28/2022 to 12/02/2022 to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The complaint investigation was substantiated regarding failure to honor advance directives and abuse allegations. The facility was found deficient in these areas.
Findings
The facility was found not in substantial compliance with federal requirements. Deficiencies were cited related to honoring advance directives, abuse investigations, PASARR screening, notification of Medicare non-coverage, and assistance with activities of daily living.
Deficiencies (5)
F578 The facility failed to honor an advance directive for one resident, resulting in cardiopulmonary resuscitation being administered against the resident's wishes.
F582 The facility failed to provide timely notification of Medicare non-coverage and skilled nursing facility advanced beneficiary notices for one resident discharged from therapy services.
F610 The facility failed to thoroughly investigate an allegation of abuse for one resident, lacking sufficient evidence and documentation.
F645 The facility failed to complete Level 1 Preadmission Screening and Resident Review (PASARR) for one resident with intellectual disability.
F677 The facility failed to provide assistance with bathing for one resident, resulting in inadequate personal care.
Report Facts
Residents reviewed for code status: 13
Nurses educated on advance directive protocol: 11
Residents reviewed for PASARR: 3
Residents reviewed for Medicare notification: 3
Residents reviewed for bathing assistance: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Failed to honor Resident #174's advance directive by administering CPR. |
| Director of Nursing | Director of Nursing | Interviewed regarding code status and PASARR processes. |
| Social Services Director | Social Services Director | Interviewed regarding PASARR and Medicare notification policies. |
| Administrator | Administrator | Interviewed regarding advance directives and abuse investigations. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 2, 2022
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to honor advance directives, failure to provide Medicare Part A non-coverage notifications, inadequate abuse investigations, failure to complete PASARR screenings, and failure to provide adequate bathing assistance to residents.
Complaint Details
The complaint investigation revealed failure to honor a resident's DNR advance directive resulting in immediate jeopardy, failure to provide Medicare Part A non-coverage notices, inadequate abuse investigation procedures, failure to complete PASARR screening, and failure to provide scheduled bathing assistance.
Findings
The facility failed to honor a resident's advance directive resulting in immediate jeopardy, failed to provide required Medicare Part A non-coverage notifications, inadequately investigated an abuse allegation, failed to complete a PASARR Level 1 screening for a resident, and failed to provide adequate bathing assistance to a resident.
Deficiencies (5)
Failed to honor an advance directive for one resident by initiating CPR despite a DNR order.
Failed to provide Notice of Medicare Non-Coverage (NOMNC) or Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for one resident discharged from therapy services.
Failed to thoroughly investigate an allegation of abuse for one resident, including lack of interviews with other residents.
Failed to ensure a Level 1 PASARR screening was completed for one resident.
Failed to provide assistance with bathing as scheduled for one resident, resulting in inadequate hygiene.
Report Facts
Residents reviewed for code status: 13
Residents reviewed for Medicare notification: 3
Residents reviewed for abuse: 3
Residents reviewed for PASARR: 3
Residents reviewed for bathing: 3
Duration of CPR: 17
Residents' medical records reviewed for code status verification: 70
Residents with DNR status reviewed: 25
Nurses educated on advance directive protocol: 11
Bathing frequency expected: 8
Baths documented: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in the finding related to failure to honor Resident #174's advance directive and initiation of CPR. |
| Director of Nursing | DON | Interviewed regarding code status procedures, PASARR screening, and Medicare notification process. |
| Social Services Director | SSD | Interviewed regarding advance directives, Medicare notification, abuse investigation, and PASARR screening. |
| Administrator | Administrator | Interviewed regarding advance directives, abuse investigation, Medicare notification, PASARR screening, and bathing procedures. |
| Assistant Director of Nursing | ADON | Interviewed regarding code status documentation. |
| Certified Medication Technician #3 | CMT | Interviewed regarding bathing assistance for Resident #19. |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding bathing documentation for Resident #19. |
| Restorative Aide #4 | Restorative Aide | Interviewed regarding bathing assistance for Resident #19. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 3
Date: Aug 18, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving Resident #12 and Resident #2, including a report that Resident #12 was trying to kill Resident #2.
Complaint Details
The complaint involved allegations that Resident #12 was trying to kill Resident #2. The facility census was 71. The complaint was substantiated as the facility failed to report the abuse allegation timely and did not complete a proper investigation.
Findings
The facility failed to report an allegation of abuse immediately as required and did not complete a thorough investigation into the alleged abuse. Additionally, the facility failed to follow professional standards of practice during medication administration for several residents.
Deficiencies (3)
F609: The facility failed to report an allegation of abuse involving Resident #12 and Resident #2 within the required timeframes and did not thoroughly investigate the allegations.
F610: The facility failed to complete a timely and thorough investigation of alleged abuse by Resident #12 toward Resident #2 as required by policy.
F658: The facility failed to follow professional standards of practice during medication administration for Residents #13, #14, #15, and #16, including leaving medications unattended and inaccurate documentation.
Report Facts
Facility census: 71
Sampled residents: 16
Residents with medication deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented resident statements and reported threats |
| Certified Nurse Aide (CNA) F | Certified Nurse Aide | Reported threats by Resident #12 |
| Dietary Manager | Reported allegations to administration | |
| LPN B | Licensed Practical Nurse | Observed medication pass and communicated with administration |
| LPN C | Licensed Practical Nurse | Charge nurse aware of threats and police involvement |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding reporting of allegations |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding investigation and reporting |
| Certified Medication Technician (CMT) E | Certified Medication Technician | Prepared medications but failed to administer or destroy them properly |
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 3
Date: Jul 25, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Lewis & Clark Gardens, related to regulatory oversight and compliance with healthcare facility standards.
Findings
The facility failed to provide adequate assistance with activities of daily living, prevent accidents, and maintain sufficient nursing staff. Multiple residents did not receive necessary care such as showers, grooming, and safe transfers, resulting in deficiencies.
Deficiencies (3)
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure three residents received necessary care for grooming and personal hygiene, including showers and nail care.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to implement interventions to prevent falls and properly transfer a resident using a gait belt.
F725 Sufficient Nursing Staff: The facility failed to provide sufficient nursing staff to meet the needs of six residents, resulting in inadequate assistance with grooming and routine showers.
Report Facts
Facility census: 73
Sampled residents: 12
Residents with deficiencies: 3
Residents with insufficient nursing staff: 6
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Date: Mar 25, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged mistreatment and failure to respect resident rights at Lewis & Clark Gardens.
Complaint Details
The complaint involved allegations of rude interaction and emotional abuse by Nursing Assistant A towards Resident #1, including unplugging the call light and refusing assistance. The complaint was substantiated based on interviews, record reviews, and staff statements.
Findings
The facility failed to treat Resident #1 with dignity and respect, as evidenced by a Nursing Assistant's refusal to assist the resident and unplugging the resident's call light, causing distress. The investigation included interviews, record reviews, and staff statements confirming the incident and the facility's failure to ensure proper care and respect.
Deficiencies (2)
F550 Resident Rights/Exercise of Rights. The facility failed to treat Resident #1 with dignity and respect when a Nursing Assistant argued with the resident and turned off the resident's call light upon request, causing distress.
A8030 Dignity/Privacy. Each resident must be treated with consideration, respect, and full recognition of dignity and individuality. This regulation was not met as referenced in F550.
Report Facts
Facility census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant A | Nursing Assistant | Named in the finding for mistreatment of Resident #1 |
| Licensed Practical Nurse B | Licensed Practical Nurse | Responsible nurse during the night shift and involved in interviews |
| Certified Nursing Assistant C | Certified Nursing Assistant | Responsible for residents in rooms 119-128 and involved in interviews |
| Nursing Assistant D | Certified Nursing Assistant | Responsible for residents in rooms 129-226 and involved in interviews |
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 1
Date: Oct 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted to assess the facility's infection prevention and control program during the COVID-19 pandemic.
Findings
The facility failed to maintain an infection control program during the COVID-19 pandemic, including failure to ensure staff utilized appropriate PPE, store PPE properly, and perform hand hygiene after resident contact. Observations and record reviews showed multiple lapses in infection control practices.
Deficiencies (1)
19 CSR 30-85.042(78) Infection Control/Communicable Disease: The facility failed to meet infection control requirements by not using acceptable procedures to prevent infection spread and not reporting communicable diseases as required.
Report Facts
Facility census: 77
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 6
Date: Sep 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted to assess compliance with infection control and resident care requirements during the pandemic.
Findings
The facility was found not in compliance with requirements for maintaining personal hygiene for dependent residents and infection prevention and control practices. Deficiencies were identified related to resident hygiene, infection control program implementation, and call system functionality.
Deficiencies (6)
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary personal hygiene services for three residents on the isolation hall who tested positive for COVID-19.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program that included surveillance, reporting, and hand hygiene compliance.
F919 Resident Call System: The facility failed to maintain an effective resident call system on the isolation hall, resulting in delayed or missed staff responses.
A3026 Call System Requirements: The facility was not equipped with an audible call system in the attendant's work area as required by state regulations.
A4075 Clean, Dry, Odor Free: Residents were not consistently clean, dry, and free of offensive odors as evidenced by personal hygiene deficiencies.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection, including timely reporting and staff hand hygiene.
Report Facts
Facility census: 86
Sampled residents: 11
Residents with hygiene deficiencies: 3
Residents reviewed for medication administration: 3
Residents on isolation hall: 9
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's 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
Complaint Investigation
Census: 98
Deficiencies: 3
Date: Feb 24, 2020
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or misappropriation of resident property involving a missing iPad belonging to Resident #2.
Complaint Details
Complaint MO167125 involved allegations of misappropriation of Resident #2's property (an iPad). The complaint was substantiated as the facility failed to report the allegation timely and maintain proper inventory records.
Findings
The facility failed to report an allegation of misappropriation of property involving Resident #2's missing iPad to the state agency as required. The facility also failed to maintain accurate personal inventory records for residents' belongings.
Deficiencies (3)
F609: The facility failed to report an allegation of misappropriation of property involving Resident #2's missing iPad to the state agency within required timeframes.
A8025: The facility failed to immediately report or cause a report to be made to the department when there was reasonable cause to suspect abuse or neglect of a resident.
A8037: The facility failed to maintain accurate personal inventory records for residents' belongings for four sampled residents, including missing documentation and unaccounted items.
Report Facts
Facility census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Mentioned in relation to notification of missing tablet and investigation | |
| Administrator | Responsible for reporting allegations to the state agency | |
| Licensed Practical Nurse (LPN) | Reported CNAs were responsible for completing personal inventory lists | |
| Certified Nursing Assistants (CNAs) | Responsible for completing inventory of resident's personal items upon admission |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Date: Dec 23, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's cell phone at Lewis & Clark Gardens.
Complaint Details
The complaint investigation was substantiated. The resident's family reported the missing cell phone and the facility's investigation concluded that CNA A took the phone. The police report and facility investigation supported this finding.
Findings
The facility failed to ensure one resident was free from misappropriation of property when the resident's cell phone was stolen. The investigation found that a Certified Nurse Assistant (CNA A) took the resident's cell phone, supported by phone records and interviews.
Deficiencies (2)
F602 Free from Misappropriation/Exploitation: The facility failed to ensure one resident was free from misappropriation of property when the resident's cell phone was stolen by a staff member.
A8023 Develop/Implement A/N Policies: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse including misappropriation of resident property.
Report Facts
Facility census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Named as the staff member who took the resident's cell phone |
| Director of Nursing | Director of Nursing (DON) | Investigated the incident and connected CNA A with the missing cell phone |
| Administrator | Facility Administrator | Led the investigation and reported findings to police |
Inspection Report
Plan of Correction
Census: 101
Deficiencies: 2
Date: Nov 8, 2019
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding medication administration and nursing care per resident.
Findings
The facility failed to follow physician's orders for medication administration for two residents, resulting in missed or undocumented medication doses. The nursing care provided did not meet current acceptable nursing practice standards.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to follow physician's orders for two residents when staff did not administer medications as ordered, including missed doses and lack of documentation.
A4074 19 CSR 30-85.042(67) Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the findings in F658.
Report Facts
Facility census: 101
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dean Murphy | Administrator | Signed the inspection report and plan of correction |
| Director of Nurses (DON) | Interviewed regarding medication administration issues | |
| Licensed Practical Nurse (LPN) D | Interviewed regarding medication administration |
Inspection Report
Plan of Correction
Census: 94
Deficiencies: 2
Date: Aug 23, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to the facility's failure to follow physician orders and obtain required x-rays for residents using CPAP machines.
Findings
The facility failed to follow physician orders for respiratory treatments for two residents, including failure to obtain an x-ray as ordered. Documentation and orders for CPAP use were incomplete or missing, and staff failed to transcribe and complete orders properly.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders or obtain pressure settings for respiratory treatments for two residents using CPAP machines. Resident #1's x-ray was not obtained as ordered.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with their condition. This regulation was not met as evidenced by the deficiencies cited in F658.
Report Facts
Facility census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daphne Bollinger | Director of Nursing | Named in relation to findings and plan of correction |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 18
Date: Jun 18, 2019
Visit Reason
The inspection was conducted to investigate complaints related to resident dignity, privacy, personal funds management, and allegations of abuse and neglect at Lewis & Clark Gardens nursing facility.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, and deficient practices affecting multiple residents. The facility failed to protect residents from harm and failed to investigate and prevent abuse allegations effectively.
Findings
The facility was found to have multiple deficiencies including failure to respect resident dignity and privacy, inadequate management of resident personal funds, failure to maintain a safe and clean environment, improper medication administration, and insufficient investigation and prevention of abuse allegations.
Deficiencies (18)
F 557: The facility failed to treat residents with dignity and respect, exposing residents during care and failing to provide privacy during personal care.
F 567: The facility failed to protect resident personal funds, including lack of documentation of banking hours and improper handling of resident money.
F 580: The facility failed to notify residents and representatives of significant changes and failed to complete comprehensive assessments for residents.
F 584: The facility failed to maintain a safe, clean, and comfortable environment, with dust and debris on vents and unclean ceilings.
F 610: The facility failed to thoroughly investigate allegations of abuse and failed to protect residents from abuse.
F 637: The facility failed to complete comprehensive assessments and revise care plans for residents with significant changes in condition.
F 658: The facility failed to provide care consistent with professional standards, including inadequate catheter care and failure to meet professional standards.
F 677: The facility failed to provide adequate personal hygiene and grooming, including failure to clean residents and maintain oral care.
F 689: The facility failed to prevent accidents and ensure safe transfers, resulting in risk of injury to residents.
F 690: The facility failed to provide appropriate care for urinary incontinence and catheter care, including failure to prevent urinary tract infections.
F 691: The facility failed to provide adequate care for residents with ostomies, including failure to maintain clean and dry skin.
F 693: The facility failed to provide adequate enteral nutrition and feeding tube care, including failure to prevent complications.
F 697: The facility failed to manage pain effectively for residents, including failure to assess and administer pain medication properly.
F 758: The facility failed to properly manage psychotropic medications, including failure to monitor side effects and maintain documentation.
F 761: The facility failed to properly store and secure medications, including narcotics, and failed to maintain accurate medication records.
F 803: The facility failed to provide adequate nutrition and food service, including failure to serve food at proper temperatures and provide adequate portions.
F 804: The facility failed to maintain infection prevention and control practices, including failure to clean and disinfect equipment and environment.
F 880: The facility failed to establish and maintain an effective infection control program, including failure to prevent transmission of infections and maintain hand hygiene.
Report Facts
Facility census: 101
Plan of Correction completion date: 2019
Inspection Report
Life Safety
Census: 101
Capacity: 142
Deficiencies: 26
Date: Jun 18, 2019
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code survey to assess compliance with federal, state, and local emergency preparedness and fire safety regulations.
Findings
The facility failed to develop a comprehensive emergency preparedness plan and training program, did not conduct required emergency exercises, and failed to maintain the emergency power system plan. Life safety deficiencies included failure to maintain fire barriers, sprinkler system maintenance issues, and failure to post evacuation plans and smoking regulations properly.
Deficiencies (26)
E004: Facility failed to develop a comprehensive emergency preparedness plan based on identified hazard risks and did not have policies for tornado, snow storm, ice storm, or severe thunderstorm.
E036: Facility failed to develop and maintain an emergency preparedness training and testing program and did not document annual staff training on emergency preparedness.
E039: Facility failed to participate in a full-scale emergency exercise and conduct an additional exercise to assess functional capabilities during an emergency.
E041: Facility failed to develop a plan for emergency power systems including backup fuel supply and reliable operation during emergencies.
K161: Facility failed to maintain fire resistance barriers between floors and did not repair multiple unsealed openings in ceilings that could affect 92 residents and staff.
K324: Facility failed to ensure no gaps existed between range hood baffle filters and drip pans, potentially affecting residents and staff.
K353: Facility failed to maintain sprinkler system free of dust and debris in eight smoke compartments, affecting 142 building capacity and 101 census.
K372: Facility failed to maintain smoke barriers and dampers properly, affecting 92 residents in six smoke compartments.
K711: Facility failed to post correct evacuation plans in smoke compartments affecting seven of eight smoke compartments.
K712: Facility failed to conduct fire drills at expected and unexpected times on multiple shifts, potentially affecting occupants in eight smoke compartments.
K741: Facility failed to provide proper smoking receptacles and maintain smoking areas, potentially affecting residents and staff.
K920: Facility failed to ensure electrical equipment power cords and extension cords were used and maintained properly, creating fire hazards affecting 98 residents.
K932: Facility failed to maintain fire protection features including lint buildup in laundry dryers, affecting residents in eight smoke compartments.
E004: Facility failed to maintain an emergency preparedness training and testing program based on emergency risk assessment and policies.
K161: Facility will maintain fire resistance barriers between floors and seal openings with fire caulk.
K324: Facility will ensure no gaps exist between range hood baffle filters and drip pans to prevent grease accumulation.
K353: Facility will clean sprinkler heads to prevent buildup of dust and debris and educate staff on maintenance.
K372: Facility will maintain smoke barriers and dampers and educate staff on requirements.
K741: Facility will provide proper smoking receptacles and educate staff and residents on smoking regulations.
K920: Facility will secure power strips and remove improper extension cords to prevent fire hazards.
E036: Facility will develop and maintain emergency preparedness training and testing program meeting requirements.
E039: Facility will participate in full-scale and tabletop emergency exercises to assess preparedness.
E041: Facility emergency generator will be powered by propane with a 1000 gallon tank to ensure operation during disasters.
K711: Facility will post correct evacuation plans in smoke compartments and educate staff on evacuation procedures.
K712: Facility will conduct fire drills at expected and unexpected times and educate staff on fire safety.
K932: Facility will clean lint from dryers and educate staff on proper dryer maintenance.
Report Facts
Facility census: 101
Total capacity: 142
Deficiencies cited: 13
Deficiencies cited: 13
Inspection Report
Annual Inspection
Census: 101
Deficiencies: 19
Date: Jun 18, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, financial access, notification of condition changes, environmental cleanliness, abuse investigation, significant change assessments, care planning, medication administration, personal hygiene, resident transfers, catheter care, feeding tube care, pain management, medication storage and control, food service, and infection control.
Deficiencies (19)
Failed to provide care in a manner that enhanced resident dignity for residents left exposed during personal cares.
Failed to ensure residents had reasonable access to their personal funds; banking hours limited to weekdays 11:00 A.M. to 1:00 P.M.
Failed to notify physician and responsible parties of change in condition for two residents.
Failed to provide a clean and comfortable environment; ceiling vents throughout the facility were covered with thick dust.
Failed to thoroughly investigate an incident of staff to resident abuse; incomplete resident and staff interviews.
Failed to complete significant change in status assessments for two residents within required timeframe.
Failed to develop and update care plans consistent with residents' specific conditions and needs for two residents.
Failed to follow physician orders for pain medication; administered incorrect narcotic medication and missed scheduled doses.
Failed to administer eye drop medication with proper technique and in prescribed amount for one resident.
Failed to provide necessary personal hygiene services including oral care, shaving, incontinence care, and grooming for four residents.
Failed to use proper transfer technique; resident lifted under arms and by pulling pants instead of mechanical lift as directed.
Failed to provide appropriate catheter care and prevent urinary tract infections for residents with indwelling urinary catheters; improper leg bag use and lack of physician orders.
Failed to provide appropriate ostomy care; failed to change leaking ostomy appliance and keep peri-stomal skin clean and dry.
Failed to maintain head of bed elevation during enteral feeding and failed to use proper infection control during feeding tube care.
Failed to maintain a system for gradual dose reductions and monitoring of psychotropic medications; failed to limit PRN psychotropic medication orders to 14 days without physician documentation.
Failed to store all drugs in locked compartments; failed to reconcile controlled drugs; failed to destroy expired narcotics; failed to ensure proper labeling and administration of narcotics.
Failed to serve correct portion sizes and prepare food items according to dietary menu for residents on regular, mechanical soft, and pureed diets.
Failed to ensure food served was at a safe and appetizing temperature; food served cold.
Failed to ensure nursing staff washed hands and changed soiled gloves when indicated; improper handling of dirty linen and trash; improper medication administration infection control; incomplete TB testing; and failed to implement water management program for Legionella.
Report Facts
Residents on regular diet: 76
Residents on mechanical soft diet: 13
Residents on pureed diet: 6
Medication count: 14
Medication count: 16
Expired morphine sulfate vial: 1
Expired lorazepam tablets card: 1
Norco tablets signed out: 2
Temperature of American fried potatoes: 110.3
Weight loss percentage: 14.9
Weight loss percentage: 11.5
Urine volume: 320
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN S | Licensed Practical Nurse | Signed out narcotic medications and administered incorrect narcotic to Resident #90 |
| LPN O | Licensed Practical Nurse | Administered incorrect narcotic medication to Resident #90 |
| CNA V | Certified Nursing Assistant | Provided incontinence care and ostomy care with poor hygiene and infection control |
| CMT R | Certified Medication Technician | Administered narcotic medication removed by LPN S |
| LPN G | Licensed Practical Nurse | Performed feeding tube care without proper infection control |
| CNA U | Certified Nursing Assistant | Provided incontinence care with poor hand hygiene and improper glove use |
| LPN T | Licensed Practical Nurse | Administered medications with bare hands and failed to follow infection control |
| CMT B | Certified Medication Technician | Provided pericare with poor hand hygiene and glove use |
| Dietary Staff W | Dietary Staff | Served incorrect food portions and missed menu items |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
| Administrator | Administrator | Provided multiple interviews regarding facility policies and deficiencies |
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 4
Date: Nov 19, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing homes, including resident assessments, care plans, and provision of care.
Findings
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments timely for one resident and quarterly MDS assessments for two residents. Deficiencies were also found in following physician orders for tracheostomy care, providing scheduled showers to dependent residents, and documentation of treatments and care.
Deficiencies (4)
F636: The facility failed to ensure a comprehensive admission MDS assessment was completed timely for one resident. The admission assessment was not completed within the required 14-day timeframe.
F638: The facility failed to complete quarterly MDS assessments for two residents within the required 92-day timeframe. One assessment was 34 days late and another was 64 days late.
F658: The facility failed to follow professional standards of practice for tracheostomy care for one resident. Documentation showed multiple shifts with no recorded tracheostomy care as ordered by the physician.
F677: The facility failed to provide scheduled showers to three dependent residents. Documentation and observation showed residents did not receive showers or baths as required, with some going weeks without bathing.
Report Facts
Facility census: 100
Days late for quarterly MDS assessment: 34
Days late for quarterly MDS assessment: 64
Number of residents reviewed for deficiencies: 5
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Date: Aug 1, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow physician orders for three residents, focusing on medication administration and care plan compliance.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to follow physician orders and medication administration errors for residents #1, #2, and #6.
Findings
The facility failed to meet professional standards of quality by not following physician orders for residents #1, #2, and #6. Documentation was missing for medication administration, and multiple doses of medications and supplements were not given or recorded properly.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to follow physician orders for three residents, with missing documentation for medication administration and missed doses of medications and supplements.
A4074 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with their condition and current nursing practice. This regulation was not met as evidenced by the deficiencies cited in F658.
Report Facts
Facility census: 101
Missed supplemental feedings: 13
Missed doses of oxycodone: 8
Missed doses of fentanyl patch: 2
Missed doses of dofetilide: 3
Missed doses of droxidopa: 7
Missed doses of Morphine Sulfate ER: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unknown Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration procedures and emergency medication protocols |
| Unknown Director of Nursing | Director of Nursing | Interviewed regarding medication notification and pharmacy procedures |
| Unknown Interim Administrator | Interim Administrator | Interviewed regarding expectations for medication administration |
| Unknown Resident #2's Physician | Physician | Interviewed regarding expectations for following physician orders |
| Unknown Resident #6's Physician | Physician | Interviewed regarding expectations for following physician orders |
Inspection Report
Follow-Up
Census: 110
Deficiencies: 1
Date: May 30, 2018
Visit Reason
The visit was conducted to follow up on a previously cited deficiency regarding the failure to develop and update a comprehensive care plan for a resident.
Findings
The facility failed to develop and update a person-centered comprehensive care plan for one resident, despite evidence of new pressure ulcers and required interventions. Interviews with staff confirmed that care plans were not updated as required.
Deficiencies (1)
F 656: The facility failed to develop and update a comprehensive care plan consistent with resident-specific conditions and needs for one resident. The care plan lacked interventions for pressure ulcer prevention and management despite the resident having new pressure ulcers.
Report Facts
Facility census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in observation and interview regarding pressure ulcer care and care plan updates |
| Director of Nurses | Director of Nurses | Interviewed regarding expectations for updating care plans for residents with pressure ulcers |
| Administrator | Administrator | Interviewed regarding expectations for staff to update resident care plans |
Inspection Report
Plan of Correction
Census: 107
Deficiencies: 11
Date: Mar 21, 2018
Visit Reason
This document is a Plan of Correction submitted by Lewis & Clark Gardens following a survey conducted on 03/21/2018 to address cited deficiencies.
Findings
The facility was found deficient in multiple areas including reasonable accommodations for call light access, return of personal funds, comprehensive care plans, perineal and oral care, medication storage and destruction, infection control, dietary services, and others. The facility census was 107 at the time of survey.
Deficiencies (11)
F558 Reasonable accommodations needs/preferences: The facility failed to ensure residents had reasonable access to call lights and failed to maintain functioning call lights in residents' rooms.
F569 Notice and conveyance of personal funds: The facility failed to return resident funds to discharged residents within five days and failed to convey remaining balances to the state or probate jurisdiction within 30 days of death.
F657 Care plan timing and revision: The facility failed to develop and update comprehensive care plans consistent with residents' specific conditions, needs, and risks for four residents.
F677 ADL care provided for dependent residents: The facility failed to provide complete perineal and oral care for residents requiring assistance.
F688 Increase/prevent decrease in ROM/mobility: The facility failed to assess, evaluate, and provide services to address limited range of motion for two residents.
F690 Bowel/bladder incontinence, catheter, UTI: The facility failed to provide appropriate care and maintenance of indwelling urinary catheters and incontinence care for multiple residents.
F761 Label/store drugs and biologicals: The facility failed to return expired medications and ensure proper storage and destruction of medications.
F800 Provided diet meets needs of each resident: The facility failed to prepare and serve nourishing, palatable, well-balanced diets meeting residents' dietary needs and preferences.
F803 Menus meet resident needs/prep in advance/followed: The facility failed to ensure menus and food preparation met nutritional adequacy and followed physician orders.
F812 Food procurement, store, prepare, serve sanitary: The facility failed to maintain proper food handling, storage, and sanitation practices including freezer temperatures and hand hygiene.
F880 Infection prevention and control: The facility failed to establish and maintain an infection prevention program including hand hygiene, use of PPE, and isolation precautions.
Report Facts
Facility census: 107
Resident funds balances: 1807.89
Resident funds balances: 372.46
Resident funds balances: 150
Resident funds balances: 536.25
Resident funds balances: 101.33
Resident funds balances: 38
Resident funds balances: 507.07
Resident funds balances: 25
Resident funds balances: 27.23
Resident funds balances: 14.08
Resident funds balances: 2
Resident funds balances: 180
Resident funds balances: 100.95
Resident funds balances: 38
Inspection Report
Plan of Correction
Census: 107
Capacity: 142
Deficiencies: 19
Date: Mar 21, 2018
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and related codes at Lewis & Clark Gardens.
Findings
The facility failed to meet several Life Safety Code requirements including delayed egress locking mechanisms, combustible storage room protections, sprinkler system maintenance, smoke barrier door integrity, HVAC ventilation, fire drill procedures, smoking area maintenance, electrical system safety, and night-light functionality in resident rooms.
Deficiencies (19)
K222: The facility failed to ensure emergency exit doors with delayed egress locking mechanisms opened freely and consistently under pressure, affecting 63 occupants in two smoke compartments.
K321: The facility failed to protect combustible storage rooms greater than 50 square feet with self-closing doors, potentially affecting residents, visitors, and staff in multiple smoke compartments.
K353: The facility failed to ensure sprinkler heads were free from debris and uncovered, affecting residents in five smoke compartments.
K374: The facility failed to maintain smoke barrier doors to resist smoke passage, affecting all residents in six smoke compartments.
K521: The facility failed to maintain bathroom ventilation exhaust vents in multiple rooms, affecting residents in three smoke compartments.
K712: The facility failed to conduct fire drills under varied and unexpected conditions on all shifts, potentially affecting all occupants in eight smoke compartments.
K741: The facility failed to maintain smoking areas properly, allowing cigarette butts and trash to intermingle and not maintaining non-smoking areas free of cigarette butts.
K911: The facility failed to maintain electrical wiring in compliance with the National Electrical Code, risking harm to residents in three smoke compartments.
K920: The facility failed to ensure power strips and extension cords were used safely in patient care areas, affecting residents in four smoke compartments.
K932: The facility failed to maintain dryer drums free of lint and debris to prevent fire hazards, affecting residents in one smoke compartment.
A1132: The facility failed to ensure resident rooms had functioning night-lights, affecting the census of 107 residents.
A2008: Hazardous areas were not properly separated by fire-resistant construction and self-closing doors, violating fire safety regulations.
A2034: The facility failed to maintain and test sprinkler systems in accordance with regulatory requirements.
A2037: The facility failed to ensure each floor had at least two unobstructed exits remote from each other, violating exit requirements.
A2054: The facility failed to maintain smoke section walls and doors to prevent smoke passage, violating fire safety standards.
A2056: The facility failed to properly designate and supervise smoking areas, including ashtray maintenance and safe disposal of noncombustible materials.
A2057: The facility failed to maintain smoking areas free of cigarette butts and trash, risking fire hazards.
A3001: The facility failed to maintain the building in good repair according to construction standards for licensed health care occupancies.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 and NFPA 99 standards.
Report Facts
Facility capacity: 142
Census: 107
Residents potentially affected: 63
Residents potentially affected: 88
Residents potentially affected: 103
Residents potentially affected: 77
Residents potentially affected: 33
Residents potentially affected: 26
Inspection Report
Plan of Correction
Census: 105
Deficiencies: 1
Date: Jan 19, 2018
Visit Reason
The visit was conducted as a follow-up plan of correction related to a previous noncompliance regarding failure to provide basic life support including CPR to a resident requiring emergency care.
Findings
The facility failed to provide basic life support including CPR to one resident requiring emergency care. Staff did not initiate CPR despite the resident being a full code and no documentation of a Do Not Resuscitate (DNR) order was found at the time of the incident.
Deficiencies (1)
F 678 Cardio-Pulmonary Resuscitation (CPR) requirement was not met as facility personnel failed to provide basic life support including CPR to a resident requiring emergency care. Staff did not initiate CPR when the resident was found with no respirations and no heart rate despite the resident being a full code.
Report Facts
Facility census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in failure to initiate CPR on resident |
| CNA B | Certified Nurse Assistant | Witnessed resident condition and CPR failure |
| ADON | Assistant Director of Nurses | Involved in staff inservice and post-incident actions |
| DON | Director of Nurses | Instructed staff on CPR policy and resident code status |
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