Inspection Reports for
Life Care Center of Bridgeton
12145 BRIDGETON SQUARE DR, BRIDGETON, MO, 63044-2616
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
17.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
215% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
76% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Deficiencies: 1
Date: Jul 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements and identify any deficiencies in care or facility operations.
Findings
The report identifies a deficiency related to providing appropriate treatment and care according to orders, resident preferences, and goals. The deficiency is noted as causing minimal harm or potential for actual harm affecting a few residents.
Deficiencies (1)
F 0684: Provide appropriate treatment and care according to orders, resident’s preferences and goals. The deficiency text is not available.
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: May 30, 2025
Visit Reason
The inspection was conducted due to a complaint alleging staff abuse and neglect of Resident #4, as well as concerns about failure to follow physician orders for Resident #13 and fall prevention interventions for Residents #7 and #9.
Complaint Details
The complaint involved allegations of staff abuse toward Resident #4, failure to follow physician orders for Resident #13's blood sugar management, and inadequate fall prevention measures for Residents #7 and #9. The abuse allegation was substantiated with findings of staff failing to report the incident. The blood sugar management and fall prevention issues were also substantiated based on record reviews and observations.
Findings
The facility failed to ensure staff followed abuse and neglect policies, resulting in unreported allegations of abuse by staff. The facility also failed to notify the physician timely when Resident #13's blood sugar exceeded ordered parameters and did not obtain STAT lab orders. Additionally, the facility failed to maintain fall prevention measures such as keeping beds in the lowest position and fall mats in place for Residents #7 and #9.
Deficiencies (3)
F 0607: The facility failed to ensure staff followed abuse and neglect policies by not reporting Resident #4's allegation of arm twisting by a CNA, allowing the alleged perpetrator to continue working until suspension.
F 0684: The facility failed to notify the physician timely when Resident #13's blood sugar levels exceeded ordered parameters and failed to obtain STAT lab orders, resulting in delayed treatment and hospitalization.
F 0689: The facility failed to ensure fall prevention interventions for Residents #7 and #9 by not keeping beds in the lowest position and fall mats on the floor when residents were unattended, and failing to include these interventions in care plans.
Report Facts
Residents sampled: 10
Census: 69
Blood sugar readings exceeding parameters: 7
Fall risk assessment scores: 18
Fall risk assessment scores: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Certified Nursing Assistant | Failed to report Resident #4's allegation of abuse to charge nurse |
| CNA P | Certified Nursing Assistant | Alleged perpetrator accused of twisting Resident #4's arm |
| LPN A | Licensed Practical Nurse | Received but did not act on Resident #4's abuse allegation |
| LPN R | Licensed Practical Nurse | Observed fall mats not in place for Resident #7 and corrected bed position |
| Interim Director of Nursing | Director of Nursing | Expected staff to follow abuse reporting and fall prevention policies |
| Administrator | Facility Administrator | Oversaw investigation and policy enforcement regarding abuse and fall prevention |
Inspection Report
Routine
Census: 86
Deficiencies: 11
Date: Feb 28, 2025
Visit Reason
Routine inspection of Life Care Center of Bridgeton to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and communication, call light accessibility, resident trust fund management, timely physician notification of condition changes, activities of daily living care, medication management, behavioral health services, medication storage, food safety and hygiene, and infection control practices.
Deficiencies (11)
F 0550: Staff failed to treat residents with dignity by removing personal items without permission, speaking unprofessionally, and using cell phones during care.
F 0558: Facility failed to accommodate a resident's mobility needs by not providing a specialized call light within reach.
F 0568: Facility failed to follow up on outstanding resident trust fund checks totaling multiple amounts dating back to 2020.
F 0580: Facility failed to notify physician timely of elevated temperature for Resident #26, delaying hospital transfer and treatment.
F 0677: Facility failed to provide adequate ADL care for Resident #29, including hair care, shaving, foot care, and skin hygiene.
F 0684: Facility failed to obtain labs as ordered, document change in condition, communicate changes to next shift, and provide feeding assistance per physician orders for Resident #14 and Resident #9.
F 0740: Facility failed to provide necessary behavioral health care and services to Resident #68, including addressing anxiety and providing counseling services.
F 0761: Facility failed to discard expired medications, date opened eye drops/ointments, and store insulin pens properly in medication carts.
F 0801: Facility failed to employ a qualified dietary director with current certification.
F 0812: Facility failed to ensure staff performed appropriate hand hygiene and food safety practices during meal service affecting multiple residents.
F 0880: Facility failed to implement Enhanced Barrier Precautions for residents with wounds, feeding tubes, or tracheostomies, including failure to post signage and staff not wearing gowns during care.
Report Facts
Resident census: 86
Outstanding resident trust fund checks: 8
Outstanding trust fund check amounts: 2819.36
Resident call light calls: 10
Resident call light calls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to notify physician of elevated temperature for Resident #26 and incomplete documentation |
| CNA D | Certified Nursing Assistant | Named in resident dignity deficiency and ignoring resident's call light |
| CNA S | Certified Nursing Assistant | Named in removing resident's clothing without permission and failure to follow Enhanced Barrier Precautions |
| LPN B | Licensed Practical Nurse | Named in failure to receive report and follow up on resident condition change |
| NP AA | Nurse Practitioner Psychiatry | Named in behavioral health deficiency and counseling service recommendation |
| Dietary Director | Dietary Director | Named in failure to maintain current certification and food safety deficiencies |
| Executive Director | Executive Director | Named in expectations for food safety, medication storage, and infection control |
| DON | Director of Nursing | Named in multiple deficiencies including infection control, behavioral health, and resident care |
| IP | Infection Preventionist | Named in infection control deficiency and failure to educate family on Enhanced Barrier Precautions |
| SSD | Social Services Director | Named in behavioral health deficiency and resident grievance follow-up |
Inspection Report
Life Safety
Census: 86
Capacity: 91
Deficiencies: 4
Date: Feb 28, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with life safety code requirements, including emergency preparedness, sprinkler system maintenance, smoking regulations, and electrical equipment safety.
Findings
The facility failed to develop and maintain a comprehensive emergency preparedness plan, maintain sprinklers according to NFPA standards, properly dispose of cigarette butts, and ensure electrical wiring compliance with the National Electrical Code. These deficiencies had the potential to affect all residents, staff, and building occupants.
Deficiencies (4)
E004 Emergency Plan. The facility failed to develop an emergency plan including generator fuel contact information and annunciator panel details. This deficiency could affect all residents and staff during an emergency.
K353 Sprinkler System. The facility failed to maintain sprinklers per NFPA standards and did not provide documentation of quarterly inspections over the last 12 months. This could affect all residents in smoke compartments.
K741 Smoking Regulations. The facility failed to maintain smoking areas free of cigarette butts and did not provide a self-closing metal trash can in the smoking area. This deficiency could affect all staff and residents.
K920 Electrical Equipment. The facility failed to maintain electrical wiring in compliance with the National Electrical Code, including use of non-UL rated power strips in patient care areas. This could affect residents and staff in two smoke compartments.
Report Facts
Facility capacity: 91
Resident census: 86
Date of survey completion: Feb 28, 2025
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 1
Date: Dec 31, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Bridgeton following a survey completed on 12/31/2024. It addresses a past noncompliance related to resident safety and elopement risk.
Findings
The facility failed to ensure a kitchen exit door was locked and armed, resulting in a resident eloping from the facility. The facility census was 74 at the time. The deficiency was corrected by adding a second alarm and staff training on door security and elopement risk management.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the kitchen exit door was locked and armed, allowing a resident to elope from the facility for approximately 30 minutes. The deficiency was corrected by adding a second alarm and staff training on elopement risk and door security.
Report Facts
Facility census: 74
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Dec 31, 2024
Visit Reason
The inspection was conducted following a complaint related to a resident elopement incident where a resident exited the facility through an unsecured kitchen door and was found outside the premises.
Complaint Details
The complaint investigation found that Resident #1 eloped through an unsecured kitchen door early morning and was outside the facility for about 30 minutes. The resident was found near the building with no injuries initially but later developed a hematoma requiring hospital transfer. The resident was not previously assessed as an elopement risk. Staff interviews revealed the door alarm may have been disabled or unlocked from the previous day. The facility took corrective actions including additional alarms and staff education.
Findings
The facility failed to ensure the kitchen exit door was locked and armed, allowing a resident to elope for approximately 30 minutes. The resident was found unharmed but later developed a hematoma requiring hospital evaluation. The facility implemented corrective actions including staff in-service and adding a second alarm to the door.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent a resident elopement through an unlocked and unarmed kitchen exit door.
Report Facts
Facility census: 74
Temperature: 35
Elapsed time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Reported resident missing and contacted administrator |
| LPN B | Licensed Practical Nurse | Searched outside premises and found resident |
| Administrator | Oversaw investigation and corrective actions | |
| Director of Nursing | DON | Informed about resident elopement and investigation |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: May 22, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's restriction of visitation rights for a resident's relative.
Complaint Details
The complaint involved restriction of visitation rights for a resident's relative. The facility prohibited the relative from visiting due to allegations of unruly behavior and stalking patterns. The complaint was substantiated as the facility failed to provide alternate visitation methods and did not document justification for restrictions.
Findings
The facility failed to ensure a resident's right to receive visitors of their choosing and did not provide alternate visitation methods. The facility restricted a resident's relative from visiting without documented justification and failed to follow proper procedures for visitation restrictions.
Deficiencies (2)
F563: The facility failed to ensure the resident's right to receive visitors of their choosing and did not provide alternate visitation methods such as private settings or video teleconferencing. The facility restricted a resident's relative from visiting due to allegations without documented justification or court orders.
A8032: The facility failed to ensure residents could communicate and meet privately with persons of their choice, placing unreasonable limitations on solicitations. This deficiency is linked to F563.
Report Facts
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding visitation restrictions and facility policies | |
| Assistant Director of Nurses (ADON) | Interviewed regarding visitation restrictions and facility policies | |
| Corporate Nurse | Interviewed regarding visitation arrangements and electronic access for visits |
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
The visit was conducted to address a deficiency related to the employment of staff with adverse actions on their record, specifically concerning a Certified Nurse Aide (CNA) who was on the Employee Disqualification List (EDL).
Findings
The facility failed to develop and implement policies and procedures to prevent abuse, neglect, and misappropriation of resident property by employing a CNA listed on the EDL. The deficiency was corrected by removing the CNA from the schedule and completing background checks on all employees.
Deficiencies (1)
F 606: The facility failed to prevent employment of staff with adverse actions by hiring a CNA listed on the Employee Disqualification List. The CNA was terminated and background checks were completed for all employees to correct the deficiency.
Report Facts
Census: 74
Deficiency ID: 606
Employee Disqualification List (EDL) length: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Mueller | Executive Director | Signed the plan of correction document |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
The inspection was conducted due to a complaint or concern regarding the facility's failure to prevent employing a staff member listed on the Employee Disqualification List (EDL), which indicated ineligibility to work in a certified long-term care facility.
Complaint Details
The complaint was substantiated. The facility was found to have employed a disqualified staff member on the Employee Disqualification List from 8/13/20 until termination on 1/12/24. The facility was unaware of the need for routine post-hire background checks until discovery on 1/12/24.
Findings
The facility failed to develop and implement adequate policies and procedures to prevent abuse and neglect by employing a Certified Nurse Aide who was on the EDL. The facility took corrective actions by removing the employee from the schedule, auditing all employees' background checks, and planning quarterly background checks for all active staff.
Deficiencies (1)
F 0606: The facility failed to prevent employing a staff member listed on the Employee Disqualification List, who was ineligible to work in a certified long-term care facility. The staff member was hired in 2014, placed on the EDL in 2020, and terminated in 2024 after discovery.
Report Facts
Census: 74
Disqualification length: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Staff member employed while listed on the Employee Disqualification List |
| Administrator | Interviewed regarding background check procedures and corrective actions | |
| AP/Payroll Coordinator | Interviewed regarding background check knowledge and procedures | |
| Corporate Representative | Interviewed regarding corrective actions and background check vendor plans |
Inspection Report
Life Safety
Census: 69
Capacity: 91
Deficiencies: 9
Date: Jan 9, 2024
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code for the facility.
Findings
The facility was found to be noncompliant with multiple Life Safety Code requirements including emergency lighting, cooking facilities hood system maintenance, sprinkler system maintenance, smoke barrier penetrations, fire drills documentation, smoking regulations, electrical system maintenance, gas equipment storage and training, and oxygen cylinder security. These deficiencies had the potential to affect all 69 residents present at the time of the survey.
Deficiencies (9)
K291 Emergency lighting was not provided at the emergency generator transfer switch, affecting all 69 residents.
K324 The kitchen hood system had loose caulk and a four-inch gap above the stove and failed to maintain semi-annual fire suppression inspections, affecting staff and 69 residents.
K353 The facility failed to document weekly inspections of the dry sprinkler system gauges, affecting all 69 residents.
K372 Smoke barriers had multiple unsealed gaps and holes around pipe penetrations in various rooms, affecting all 69 residents.
K712 The facility failed to conduct quarterly fire drills on all shifts and lacked documentation for 2023, affecting all 69 residents.
K741 Smoking regulations were not met; cigarette butts were found outside a non-designated smoking area and noncombustible ashtrays were not provided, potentially affecting one resident.
K918 The facility failed to maintain and test the emergency generator according to NFPA 110 standards, including missing weekly inspections for December 2023, affecting all 69 residents.
K923 Oxygen cylinders in the storage room were unsecured and unprotected from mechanical damage, affecting 19 residents.
K926 Staff were not trained on safe handling of gas equipment and oxygen tanks, and training documentation was missing, affecting all 69 residents.
Report Facts
Occupied beds: 69
Total beds: 91
Residents potentially affected: 69
Residents potentially affected: 19
Inspection Report
Routine
Deficiencies: 12
Date: Jan 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, environment, care, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to post ombudsman contact information, maintain a clean environment, timely notify the ombudsman of resident transfers, complete PASARR screenings, provide adequate personal hygiene care, secure urinary catheters properly, serve palatable food, ensure staff wear proper hair restraints, maintain accurate resident weights, disinfect glucometers properly, perform hand hygiene consistently, maintain clean resident care equipment, and ensure scales were calibrated.
Deficiencies (12)
F 0575: The facility failed to post required contact information for the ombudsman, affecting all residents.
F 0577: The facility failed to ensure nursing home survey results were readily accessible to residents and visitors.
F 0584: The facility failed to maintain a clean and homelike environment, including residue buildup on feeding pumps, stained furniture, and disrepair of resident furniture.
F 0623: The facility failed to notify the Regional State Ombudsman of resident transfer/discharge for one resident.
F 0645: The facility failed to ensure two residents had required Level I PASARR screenings completed prior to admission.
F 0677: The facility failed to provide showers or bed baths twice weekly for two residents dependent on staff for bathing.
F 0690: The facility failed to secure an indwelling urinary catheter to the resident's thigh and allowed the drainage bag to touch the floor, risking infection.
F 0804: The facility failed to serve palatable food; fish served was too hard to eat, affecting five residents.
F 0812: The facility failed to ensure staff wore hair restraints properly during food service; hair was exposed.
F 0842: The facility failed to maintain accurate resident weights due to uncalibrated scales, affecting one resident.
F 0880: The facility failed to disinfect glucometers properly between residents, failed to don appropriate PPE entering a COVID-positive resident's room, failed to perform hand hygiene consistently, and failed to maintain clean resident care equipment and laundry room.
F 0908: The facility failed to ensure scales were in proper working condition, resulting in inaccurate resident weights.
Report Facts
Residents affected: 11
Residents affected: 6
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 8
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Confirmed catheter not secured and improper glucometer cleaning |
| LPN2 | Licensed Practical Nurse | Confirmed glucometer cleaning with alcohol wipes |
| LPN3 | Licensed Practical Nurse | Confirmed glucometer cleaning with alcohol wipes |
| Executive Director | Acknowledged lack of ombudsman postings, environmental concerns, and scale calibration issues | |
| Director of Nursing | Acknowledged responsibility for ombudsman notifications and scale calibration issues | |
| Maintenance Director | Acknowledged lack of awareness of cleaning schedule for resident care equipment | |
| Food Service Director | Observed with improper hair restraint during meal service | |
| Infection Preventionist | Observed with improper hair restraint and discussed hand hygiene expectations | |
| Certified Nursing Assistant 4 | CNA | Failed to perform hand hygiene and wear face shield entering COVID-positive resident's room |
| Certified Nursing Assistant 1 | CNA | Failed to perform hand hygiene after handling soiled linen |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 12
Date: Jan 7, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services. The facility was found to not be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The survey was a Recertification and Complaint survey. The facility was found not in substantial compliance with 42 CFR 483 subpart B. Specific complaints included failure to post ombudsman contact information, failure to provide transfer/discharge notices, inadequate care and environment, and infection control issues.
Findings
The facility failed to post required contact information for the ombudsman, failed to ensure survey results were readily accessible to residents, and failed to maintain a safe, clean, and homelike environment. Additional deficiencies included failure to provide adequate notice before transfer/discharge, failure to complete PASARR screening, inadequate ADL care, food safety issues, infection prevention and control failures, and failure to maintain safe operating conditions for equipment.
Deficiencies (12)
F575 The facility failed to post required contact information for the ombudsman affecting all residents.
F577 The facility failed to ensure survey results were readily accessible to residents and visitors.
F584 The facility failed to maintain a safe, clean, and homelike environment including peeling veneer on beds, stained mattresses, and unclean furniture.
F623 The facility failed to provide proper notice before transfer or discharge to residents and the Ombudsman.
F645 The facility failed to complete PASARR screening for two residents prior to admission.
F677 The facility failed to provide adequate ADL care for two residents unable to carry out necessary services.
F690 The facility failed to ensure proper care for residents with urinary and bowel incontinence including securing catheters and providing appropriate treatment.
F804 The facility failed to provide adequate food and nutrition services; food was served cold and hard to eat for multiple residents.
F812 The facility failed to ensure food safety including proper hair restraints worn by staff during meal service.
F842 The facility failed to maintain accurate and confidential resident records and failed to weigh residents properly due to uncalibrated scales.
F880 The facility failed to maintain an effective infection prevention and control program including improper cleaning of glucometers and failure to follow hand hygiene protocols.
F908 The facility failed to maintain safe operating condition of patient care equipment including scales not working properly.
Report Facts
Survey Census: 65
Sample Size: 22
Supplemental Residents: 2
Deficiencies cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)1 | Registered Nurse | Observed performing blood glucose monitoring and infection control procedures |
| Licensed Practical Nurse (LPN)2 | Licensed Practical Nurse | Confirmed specialty mattress condition |
| Executive Director | Executive Director | Provided information on ombudsman postings and survey results accessibility |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding survey results, infection control, and equipment cleaning |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental rounds and furniture condition |
| Food Service Director (FSD) | Food Service Director | Observed during meal service and food temperature testing |
| Infection Preventionist (IP) | Infection Preventionist | Observed during meal service and interviewed about infection control |
| Certified Nursing Assistant (CNA)4 | Certified Nursing Assistant | Acknowledged hand hygiene deficiencies |
| Licensed Practical Nurse (LPN)3 | Licensed Practical Nurse | Interviewed about glucometer cleaning |
| Maintenance Assistant/Housekeeping Supervisor (MA) | Maintenance Assistant/Housekeeping Supervisor | Interviewed regarding cleaning schedule and environmental conditions |
| Registered Dietician (RD) | Registered Dietician | Interviewed regarding resident weights and nutrition |
Inspection Report
Plan of Correction
Census: 68
Deficiencies: 2
Date: Oct 17, 2023
Visit Reason
The inspection was conducted to investigate compliance with quality of care regulations following a resident's death and to review the facility's plan of correction for identified deficiencies.
Findings
The facility failed to follow nursing standards for a resident with a gastrostomy feeding tube, resulting in inadequate documentation and failure to notify the physician of a change in condition. The resident was found unresponsive and later pronounced dead. The facility's policies and procedures for monitoring changes in resident status and enteral feeding were reviewed and found deficient.
Deficiencies (2)
F684 Quality of care: Staff failed to follow nursing standards for a resident with a gastrostomy feeding tube, did not document change in condition, and failed to notify the physician. The resident was found unresponsive and later pronounced dead.
A4075 Nursing care per resident condition: Facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice, as evidenced by the deficiency cited at F684.
Report Facts
Resident census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Theile | Executive Director | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Oct 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to follow facility policies and nursing standards for a resident with a gastrostomy feeding tube who experienced a change in condition and was later found unresponsive and deceased.
Complaint Details
The investigation was complaint-driven, focusing on failure to follow policies for a resident with a gastrostomy feeding tube who had a change in condition. The complaint was substantiated as staff failed to document emesis, assessments, and notify the physician. The resident subsequently died.
Findings
Staff failed to document and communicate a resident's change in condition, including emesis and assessments, and failed to notify the physician. The resident was found unresponsive and required CPR, later pronounced dead at the hospital. Facility policies on change in condition and tube feeding were not followed.
Deficiencies (1)
F 0684: Staff failed to provide appropriate treatment and care according to orders and resident preferences for one resident with a gastrostomy feeding tube, including failure to document change in condition, assessments, and physician notification. The resident was later found unresponsive and died despite resuscitation efforts.
Report Facts
Residents sampled: 18
Residents affected: 1
Census: 68
Tube feeding rate: 70
Tube feeding duration: 20
Flush volume: 150
Vital signs: 98.6
Vital signs: 97
Vital signs: 18
Vital signs: 13689
Blood glucose: 158
Vital signs: 97.6
Vital signs: 90
Vital signs: 18
Blood pressure: 14285
Oxygen saturation: 96
Tube feeding residual: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Charge Nurse | Named in failure to document resident's emesis, assessments, and physician notification |
| Nurse F | Evening Shift Nurse | Reported resident had emesis but did not communicate fully to Nurse D |
| Nurse G | Day Shift Nurse | Found resident unresponsive and initiated CPR |
| CNA E | Certified Nursing Assistant | Reported resident's large emesis and bowel movement during night shift |
| ADON | Assistant Director of Nursing | Participated in CPR and interviews |
| Executive Director | Administrator | Interviewed regarding expectations for nurse documentation and physician notification |
| Speech Therapist | Provided assessment of resident's swallowing and mastication |
Inspection Report
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Life Care Center of Bridgeton, related to a regulatory survey completed on 09/26/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
A COVID-19 focused infection control survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
The complaint investigation focused on COVID-19 infection control practices and found no deficiencies.
Findings
The facility was found to be in compliance with relevant COVID-19 emergency preparedness and infection control regulations. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 3
Date: Dec 5, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding medication administration and follow-up care for residents.
Findings
The facility failed to meet professional standards by not ensuring timely medication administration and follow-up appointments for residents. Deficiencies included missed medication doses and lack of proper procedures for medication availability and resident transportation for appointments.
Deficiencies (3)
F658 Comprehensive Care Plans: The facility failed to ensure one resident received medication per physician orders and another resident received timely post-operative follow-up care. The facility's medication policy did not address actions if medication was unavailable.
A4054 Written Orders; Restraints: No medication, treatment, or diet shall be given without a lawful written order. The facility did not meet this requirement as cited at F658.
A4073 Prescription/Emergency Medication Supply: The facility failed to develop policies ensuring emergency drug supply safety and availability, as evidenced by deficiencies cited at F658.
Report Facts
Census: 72
Sample size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Shuele | Executive Director | Signed the statement of deficiencies and plan of correction |
| Registered Nurse A | RN | Interviewed regarding medication administration procedures |
| Licensed Practical Nurse B | LPN | Interviewed regarding medication administration procedures |
| Director of Nursing | DON | Interviewed regarding medication administration and resident follow-up procedures |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 9
Date: Jul 11, 2022
Visit Reason
The inspection was a complaint investigation triggered by allegations of abuse, neglect, and misappropriation of resident funds at Life Care Center of Bridgeton.
Complaint Details
The complaint investigation was substantiated. The facility failed to thoroughly investigate allegations of misappropriation of resident funds and abuse, and failed to protect residents from further harm during the investigation.
Findings
The facility failed to notify residents' representatives and physicians about pressure ulcers, failed to thoroughly investigate allegations of misappropriation, and did not follow professional standards for care and abuse prevention. Multiple residents had pressure ulcers that were not properly assessed or treated, and the facility did not timely investigate or report abuse allegations.
Deficiencies (9)
F580: The facility failed to notify residents' representatives and physicians when residents developed pressure ulcers and did not document notifications. Pressure ulcers were present and untreated for multiple residents.
F610: The facility failed to thoroughly and timely investigate allegations of abuse and misappropriation of resident funds, and did not protect residents from further potential abuse during the investigation.
F658: The facility failed to provide care consistent with professional standards for residents with pressure ulcers, including failure to follow physician orders and monitor blood sugar and weights.
F686: The facility failed to ensure residents received care to prevent and treat pressure ulcers, including failure to assess, document, and treat pressure ulcers and to complete required skin assessments and wound care.
A4075: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4083: The facility failed to keep residents free from avoidable pressure sores by not providing adequate treatment and prevention.
A4087: The facility failed to notify the resident's physician in accordance with emergency treatment policies after significant changes in condition.
A4088: The facility failed to immediately notify the responsible party or resident's record designee of significant changes in condition.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, and failed to report alleged violations as required.
Report Facts
Resident census: 69
Pressure ulcers identified: 3
Employee signatures: 12
Employee signatures: 23
Weight of resident: 357
Weight of resident: 357
Pressure ulcer measurements: 4.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Reported alleged misappropriation of resident funds and was involved in investigation | |
| Director of Nurses | DON | Involved in wound care and investigation of abuse allegations |
| Medical Director | Expected facility to notify physician and resident representative of new pressure ulcers | |
| Payroll Manager | Reported alleged misappropriation of resident funds to Department of Health and Senior Services |
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 1
Date: Apr 8, 2022
Visit Reason
This document is a Plan of Correction related to a previous deficiency regarding abuse and neglect at the Life Care Center of Bridgeton.
Findings
The facility failed to ensure one of four sampled residents remained free from abuse by a staff member who threatened to slap the resident. The staff member was terminated and the deficiency was corrected on 3/21/22.
Deficiencies (1)
F600: The facility failed to ensure one resident remained free from verbal abuse by a staff member who threatened to slap him/her. The staff member was terminated and the deficiency was corrected on 3/21/22.
Report Facts
Resident census: 72
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 4
Date: Oct 1, 2021
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident at the facility.
Complaint Details
The complaint investigation was substantiated as the facility failed to properly investigate allegations of abuse and failed to ensure proper medication management and discharge procedures.
Findings
The facility failed to thoroughly investigate an allegation that an agency staff member was rude to a resident and slapped the resident's hand. The facility also failed to ensure accurate medication administration and proper discharge procedures for sampled residents.
Deficiencies (4)
F610: The facility failed to thoroughly investigate an allegation of abuse involving an agency staff member being rude and slapping a resident's hand, and failed to obtain statements or notify responsible parties.
F684: The facility failed to ensure accurate physician orders and medication administration for two sampled residents, and failed to investigate and address medication issues.
A4074: The facility failed to provide personal attention and nursing care consistent with residents' conditions and current nursing practice.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, and failed to require reports of abuse or neglect.
Report Facts
Resident census: 68
Sample size: 10
Doses missed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Nurse | Interviewed regarding medication orders and pharmacy communication |
| Nurse E | Nurse | Interviewed regarding medication delivery and resident medication administration |
| Nurse F | Nurse | Interviewed regarding medication expiration date checking |
| Nurse D | Nurse | Interviewed regarding medication list review and resident medication verification |
| Nurse C | Agency Nurse | Interviewed regarding discharge paperwork and medication preparation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding facility policies, investigation, and medication management |
| Regional Vice President | Acting Administrator | Interviewed and agreed with DON's statements |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 16
Date: Jun 16, 2021
Visit Reason
Complaint investigation triggered by resident grievances and concerns regarding quality of life, activities, smoking restrictions, nutrition, medication administration, wound care, and abuse allegations.
Complaint Details
Complaint investigation included allegations of resident rights violations, inadequate activities, medication errors, abuse, neglect, improper wound care, nutrition concerns, and poor facility maintenance. Some allegations substantiated.
Findings
The facility failed to ensure residents' rights to self-determination including smoking and outdoor activities, failed to provide adequate activities and follow-up on resident council concerns, failed to maintain accurate and complete medical records including code status and transfer notices, failed to provide adequate wound care and nutrition monitoring, failed to ensure proper medication administration and storage, and failed to maintain a clean and sanitary kitchen environment. The facility also failed to report abuse allegations timely and investigate thoroughly.
Deficiencies (16)
F 0561: Facility failed to honor residents' rights to make choices about smoking and outdoor activities, restricting residents during COVID-19 without proper notification or accommodations.
F 0565: Facility failed to promptly respond to resident council grievances regarding activities and outdoor access, with no documented follow-up or resolution.
F 0567: Facility failed to ensure residents were aware of availability of their personal funds and access hours, limiting resident access to money on weekends.
F 0578: Facility failed to obtain and update signed code status forms for several residents, including missing signatures and annual reviews.
F 0584: Facility failed to complete and maintain accurate inventories of residents' personal belongings, resulting in missing items and unresolved complaints.
F 0600: Facility failed to prevent neglect when a resident was transferred with a sit to stand lift without assistance, resulting in a fall and head injury; incident was not reported timely to authorities.
F 0609: Facility failed to timely report alleged abuse to the state agency within 2 hours and failed to thoroughly investigate allegations of staff abuse.
F 0620: Facility failed to disclose smoking restrictions to residents admitted during COVID-19 and failed to ensure cognitively impaired residents had appropriate admission agreements signed by representatives.
F 0645: Facility failed to provide care consistent with professional standards including timely neurological checks after falls, proper wound care, oxygen administration, and application of ordered braces and splints.
F 0661: Facility failed to maintain kitchen equipment, walls, ceilings, and floors in a clean and sanitary manner, and failed to prevent cross contamination by leaving meat slicer uncovered and medication spills uncleaned.
F 0677: Facility failed to provide sufficient activity staff and qualified activity director, failed to provide scheduled activities, failed to provide outdoor activities, and failed to address resident council concerns about activities and smoking.
F 0680: Facility failed to maintain complete, accurate, and accessible medical records for multiple residents, including missing documentation of significant events, assessments, and care plans.
F 0690: Facility failed to maintain proper placement of indwelling urinary catheters, leaving tubing and drainage bags on the floor, increasing risk of infection.
F 0692: Facility failed to monitor and provide adequate nutritional care including timely dietitian assessments, response to weight loss, physician notification, provision of ordered supplements, and meal assistance.
F 0693: Facility failed to follow proper medication administration procedures including not administering available medications and signing medications as given before administration.
F 0759: Facility failed to maintain medication error rate below 5%, with two errors observed during medication administration.
Report Facts
Medication error rate: 6.45
Resident weight loss: 14.8
Resident weight loss: 15.16
Resident weight loss: 11.4
Resident weight loss: 13.8
Resident weight loss: 9.6
Resident weight loss: 15.16
Resident weight loss: 14.8
Resident weight loss: 5.6
Resident weight loss: 11.4
Resident weight loss: 16.8
Resident weight loss: 20.1
Resident weight loss: 5.1
Resident weight loss: 16.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in medication administration error and failure to provide ordered medications |
| Administrator | Named in multiple interviews regarding facility policies, QAPI, and resident concerns | |
| DON | Director of Nursing | Named in multiple interviews regarding wound care, medication administration, abuse investigation, and facility operations |
| LPN S | Licensed Practical Nurse | Named in medication administration and documentation error |
| LPN M | Licensed Practical Nurse | Named in medication administration and g-tube medication administration |
| Activity Director | Named in interviews regarding activities staffing and qualifications | |
| Social Worker | Named in grievance and resident council follow-up interviews | |
| IP | Infection Preventionist | Named in abuse investigation and documentation |
Inspection Report
Life Safety
Census: 82
Capacity: 91
Deficiencies: 10
Date: Jun 16, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations, focusing on emergency preparedness, means of egress, cooking facilities, sprinkler system maintenance, electrical systems, fire drills, smoking regulations, and gas and vacuum piped systems.
Findings
The facility failed to meet several Life Safety Code requirements including obstructed emergency exit corridors, grease buildup in kitchen hood filters, sprinkler heads obstructed by debris and storage, inadequate electrical wiring and receptacle maintenance, incomplete fire drill documentation, smoking regulation violations, and deficiencies in gas and vacuum piped systems maintenance. These deficiencies had the potential to affect all residents and staff.
Deficiencies (10)
K211 Means of Egress - General: The facility failed to ensure emergency exit corridors were maintained free of obstructions, including equipment stored in exit hallways, blocking a 3-foot wide pathway.
K324 Cooking Facilities: The kitchen range hood filters were covered with built-up grease, and the suppression system above fryer nozzles was coated in grease, indicating failure to maintain cooking facilities per NFPA standards.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of debris and obstructions, with multiple sprinkler heads covered in dust and storage placed less than 18 inches below sprinkler heads.
K511 Utilities - Gas and Electric: Electrical wiring was not maintained in compliance with National Electrical Code, with power strips improperly used and electrical panels obstructed by supplies and trash.
K712 Fire Drills: The facility failed to thoroughly document fire drills, missing dates, times, and drill summaries for multiple drills over the past year.
K741 Smoking Regulations: The facility failed to maintain designated smoking areas, with cigarette butts found outside and staff smoking in non-designated areas.
K907 Gas and Vacuum Piped Systems - Maintenance Program: The facility lacked a documented maintenance program for the piped-in medical gas system, with leaks found and repairs made without prior preventive maintenance documentation.
K914 Electrical Systems - Maintenance and Testing: The facility failed to ensure annual testing and documentation of non-hospital grade electrical receptacles in resident sleeping areas.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain the emergency generator with required fuel supply and testing, and lacked documentation of maintenance and testing.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage in accordance with NFPA code, with unsecured tanks and improper segregation of empty and full cylinders.
Report Facts
Facility capacity: 91
Resident census: 82
Number of smoke compartments: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted as a complaint investigation.
Complaint Details
This complaint investigation involved a COVID-19 focused infection control survey and emergency preparedness survey. No deficiencies were cited.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 2, 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: Jun 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 06/23/2020 through 06/26/2020 to assess the facility's compliance with CMS and CDC recommended practices for 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
Plan of Correction
Census: 86
Deficiencies: 1
Date: Feb 19, 2020
Visit Reason
The inspection was conducted to assess compliance with regulations related to pressure ulcer prevention and treatment at Life Care Center of Bridgeton.
Findings
The facility failed to ensure residents with pressure ulcers received appropriate treatment and care consistent with professional standards. Documentation and monitoring of pressure ulcers were inadequate, and staff did not consistently follow treatment orders or perform required skin assessments.
Deficiencies (1)
F686: The facility failed to provide care to prevent and heal pressure ulcers, including inadequate monitoring, documentation, and treatment for residents with pressure ulcers.
Report Facts
Resident census: 86
Residents identified with pressure ulcers: 14
Sample size: 3
Treatment administration opportunities: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle L. Gutmann-Hines | Director | Signed plan of correction and statement of deficiencies |
| Nurse D | Administered treatment to resident's pressure ulcer and described wound | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Observed cleansing and dressing of resident's pressure ulcer |
| Nurses G, CNA E, and CNA G | Observed at resident's bedside during wound care | |
| DON | Director of Nursing | Provided statements regarding wound care expectations and staff responsibilities |
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 2
Date: Nov 7, 2019
Visit Reason
The inspection was conducted due to a deficiency related to free of accident hazards and supervision/devices, specifically concerning a resident elopement incident.
Findings
The facility failed to provide adequate supervision for a resident who eloped from the building and was found outside. The resident had multiple risk factors including cognitive impairment and history of falls. The facility implemented interventions including 1:1 monitoring and updated care plans to prevent recurrence.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision for a resident who eloped from the building and was found outside in his/her wheelchair. The resident had cognitive impairments and a history of falls.
A4073 Protective Oversight, Voluntary Leave: The facility did not meet requirements for protective oversight and supervision for residents on voluntary leave, as evidenced by the deficiency cited at F689.
Report Facts
Census: 73
Deficiency completion date: F689 corrective action completion date 12/4/19
Deficiency completion date: A4073 corrective action completion date 12/4/19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janelle A. Giermann-Hines | Administrator | Signed deficiency statements and plan of correction |
Inspection Report
Life Safety
Census: 83
Capacity: 91
Deficiencies: 2
Date: Oct 9, 2019
Visit Reason
The inspection was conducted to evaluate the facility's compliance with fire safety regulations, specifically focusing on fire drills and fire safety training for employees.
Findings
The facility failed to ensure staff were familiar with fire procedures during a fire drill, which posed a risk to all occupants. The fire drill was poorly executed, with delays in activating the fire alarm and improper staff response.
Deficiencies (2)
K712 Fire Drills: The facility failed to ensure staff were familiar with fire procedures during a fire drill, resulting in delayed activation of the fire alarm and inadequate staff response. This deficiency affected all occupants and demonstrated a lack of proper fire safety training.
A2064 Fire Safety Training Requirements-employee: The facility did not meet fire safety training requirements for employees, including orientation and periodic training, as evidenced by the deficiencies cited at K712.
Report Facts
Facility capacity: 91
Resident census: 83
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 10
Date: Jul 23, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, and failure to follow infection control procedures related to residents diagnosed with Clostridium difficile and other care concerns.
Complaint Details
The complaint investigation was substantiated. The facility failed to provide dignity and proper infection control for a resident with C. diff, failed to report and investigate abuse allegations timely, and did not provide adequate care for residents including skin integrity and medication management.
Findings
The facility failed to provide dignity and proper infection control for a resident isolated for C. diff, failed to report and investigate alleged abuse promptly, and did not ensure adequate care for residents including skin integrity, showering, and medication management.
Deficiencies (10)
F550 Resident Rights: The facility failed to provide dignity and proper infection control for a resident isolated for Clostridium difficile, including improper use of gowns and gloves and isolation procedures.
F609 Reporting of Alleged Violations: The facility failed to report an allegation of physical abuse immediately and did not conduct a timely investigation for a resident.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to complete a prompt and thorough investigation of an alleged abuse incident involving a resident.
F645 PASARR Screening: The facility failed to ensure residents with mental disorders had required PASARR level II screening completed for two sampled residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide scheduled showers for four residents requiring assistance and did not document showers for multiple months.
F684 Quality of Care: The facility failed to adequately assess, monitor, and treat a rash and surgical wound for two residents, resulting in untreated skin issues.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to assess, document, and treat pressure ulcers properly for eight residents, including failure to follow physician orders and provide weekly skin assessments.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure proper placement and care of indwelling urinary catheters for six residents, including failure to maintain catheter care and prevent infections.
F756 Drug Regimen Review: The facility failed to ensure timely pharmacist review and follow-up on medication irregularities for multiple residents.
F8030 Dignity/Privacy: The facility failed to treat residents with full recognition of dignity and privacy, including failure to protect residents from abuse and neglect.
Report Facts
Resident census: 81
Sampled residents: 18
Residents with pressure ulcers: 8
Residents with indwelling catheters: 6
Residents reviewed for PASARR screening: 2
Residents reviewed for showering: 4
Residents reviewed for medication issues: 11
Inspection Report
Life Safety
Census: 81
Capacity: 91
Deficiencies: 6
Date: Jul 23, 2019
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code investigation to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to provide adequate emergency preparedness training to staff and maintain proper life safety measures including means of egress, sprinkler system maintenance, smoking regulations, and electrical equipment clearance. Deficiencies had the potential to affect all residents and occupants.
Deficiencies (6)
E037 Emergency Preparedness Training. The facility failed to provide emergency preparedness training to staff on an annual basis and maintain documentation of such training.
K211 Means of Egress - General. The facility failed to ensure emergency exits were maintained free of obstructions and the front exit door did not open automatically as required.
K321 Hazardous Areas - Enclosure. The facility failed to have self-closing devices on doors to storage rooms containing combustibles, risking fire safety.
K353 Sprinkler System - Maintenance and Testing. The facility failed to maintain sprinkler heads free of debris and ensure proper operation and inspection of the sprinkler system.
K741 Smoking Regulations. The facility failed to provide metal containers with self-closing covers for ashtray disposal in designated smoking areas.
K919 Electrical Equipment - Other. The facility failed to maintain adequate 3 feet clearance around electrical panels, risking fire hazards.
Report Facts
Facility capacity: 91
Resident census: 81
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 9
Date: Sep 6, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and evaluate resident care and facility operations.
Findings
The facility was found to have multiple deficiencies related to resident rights, care planning, medication administration, wound care, and staff responsiveness. Several residents exhibited unmet needs and inadequate care practices were observed.
Deficiencies (9)
F550 Resident Rights: The facility failed to ensure residents' rights to dignity, self-determination, and communication were fully respected, including timely assistance and appropriate staff response.
F582 Medicaid/Medicare Coverage/Facility Notice: The facility did not provide required notices to residents regarding Medicare non-coverage and transfer/discharge rights.
F623 Transfer/Discharge Notice: The facility failed to provide timely and complete written notice of transfer or discharge to residents and their representatives.
F637 Comprehensive Person-Centered Care Planning: The facility did not complete comprehensive care plans reflecting residents' needs, preferences, and changes in condition.
F655 Baseline Care Plans: The facility failed to develop effective baseline care plans within 48 hours of admission for residents.
F656 Develop/Implement Comprehensive Care Plans: The facility did not provide care consistent with residents' comprehensive care plans, including timely assessments and interventions.
F661 Discharge Summary: The facility failed to provide discharge summaries for residents discharged from the facility.
F686 Skin Integrity: The facility failed to prevent and treat pressure ulcers and wounds, including inadequate assessments, documentation, and treatment.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision and accident prevention measures to prevent resident falls and injuries.
Report Facts
Facility census: 80
Inspection Report
Life Safety
Census: 80
Deficiencies: 4
Date: Sep 6, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain fire suppression equipment properly, including portable fire extinguishers mounted too high, lack of self-closing metal containers for ashtrays in smoking areas, improper use and maintenance of electrical power strips, and inadequate storage of oxygen tanks. These deficiencies potentially affected all residents, staff, and visitors.
Deficiencies (4)
K355 Portable fire extinguishers were mounted more than 5 feet above the floor, violating NFPA 10 standards. The facility census was 80 at the time of the survey.
K741 The facility failed to provide self-closing metal containers for ashtrays and did not ensure containers were free of combustible materials in designated smoking areas. The facility census was 80 at the time of the survey.
K920 The facility failed to ensure electrical wiring and power strips met NFPA 70 standards, with medical equipment improperly plugged into power strips. The facility census was 80 during the survey.
K923 The facility failed to properly store oxygen tanks, including unsecured tanks and lack of segregation between full and empty cylinders. The facility census was 80.
Report Facts
Facility census: 80
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