Inspection Reports for
Life Care Center of Cape Girardeau

Complaint number 2681501 triggered the investigation. The complaint involved inadequate hydration assistance to residents, which was substantiated by observations and interviews during the survey.

The facility failed to provide residents with fresh, easily accessible water at bedside, assistance with holding a water cup, and cueing/offering hydration for three of the four sampled residents, resulting in minimal harm or potential for actual harm to a few residents.

Complaint #MO00256082. The complaint involved the facility's failure to follow the resident's DNR orders, resulting in inappropriate initiation of CPR and emergency services.

The facility failed to properly document and communicate the resident's code status, leading to staff initiating CPR on a resident with a documented Do Not Resuscitate (DNR) order. The investigation revealed discrepancies between the resident's hospice DNR orders and the facility's records, lack of proper authorization for code status changes, and poor communication among staff. Corrective actions were implemented during the survey to address the immediate jeopardy.

The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, failure to honor resident preferences for shaving and bedtime, failure to refund resident funds timely, failure to provide current Ombudsman information, incomplete care plans, failure to obtain ordered weights, delayed feeding assistance, missed showers, lack of CPR certification for transport staff, incomplete CNA performance reviews, improper medication storage, failure to maintain safe food temperatures, improper food storage and labeling, inadequate infection control practices, and unsafe environmental conditions such as items stored on overbed light fixtures.

Complaint investigations #MO00249530 and #MO00249411 were conducted regarding CPR procedures and medication errors. The CPR complaint was substantiated with findings of noncompliance. The medication error complaint was substantiated with findings of missed medication doses.

The facility failed to provide timely access to residents' medical records, did not follow proper CPR protocols for a resident, and did not adhere to physician medication orders for one resident. The facility census was 94 at the time of inspection.

Complaint #MO00249530 related to medical records access; Complaint #MO00249411 related to code status and medication administration failures.

The facility failed to provide requested medical records to a resident within the required 24 hours, failed to ensure accurate and consistent code status communication leading to inappropriate CPR on a resident, and failed to administer a critical transplant medication for multiple days, increasing risk of transplant rejection.

The facility failed to provide adequate pain management for two residents due to medication shortages and delays in pharmacy orders, resulting in actual harm. Additionally, one resident did not receive required physician visits within the mandated timeframes.

The complaint investigation was substantiated based on findings of inadequate pain management and failure to ensure timely physician visits.

The facility failed to ensure adequate pain management for residents, with documented medication administration issues and residents experiencing untreated pain. The facility also failed to ensure timely physician visits for one resident, with no documented physician or care provider visit within required timeframes.

Complaint #MO245231 regarding unsafe transfer and transportation of Resident #1, substantiated by interviews and record review.

The facility failed to ensure the environment was free from accident hazards by not using a Hoyer lift and appropriate transportation for Resident #1, causing actual harm. Staff used a personal car and manual transfer methods that caused the resident significant pain and distress. Transportation arrangements were inadequate and delayed.

Complaint #MO245231 was investigated regarding the improper transfer and transportation of Resident #1, resulting in pain, injury, and distress. The complaint was substantiated by interviews and record reviews.

The facility failed to ensure a safe environment free of accident hazards by not properly supervising and assisting a resident during transfers using a Hoyer lift, resulting in pain and injury. The facility also lacked a policy for transfers and had issues with transportation arrangements for the resident.

Complaint #MO240798 involved failure to accommodate bariatric needs and pressure ulcer care for Resident #2. Complaint #MO240637 involved failure to provide adequate supervision for Resident #1 during transfer to the emergency room.

The facility failed to provide a bariatric bed for a resident with severe obesity, resulting in discomfort and fear of falling. The facility also failed to identify and treat a facility-acquired pressure ulcer for the same resident. Additionally, the facility failed to provide adequate supervision by sending a cognitively impaired resident unescorted to the emergency room in a cab instead of an ambulance.

Complaint investigation involved complaints MO240798 and MO240637 regarding failure to provide reasonable accommodations for bariatric residents, failure to prevent and treat pressure ulcers, and failure to provide adequate supervision and safe transportation for cognitively impaired residents. The complaints were substantiated as evidenced by the findings.

The facility failed to provide reasonable accommodations for a bariatric resident, failed to identify and treat a facility-acquired pressure ulcer for a resident, and failed to provide adequate supervision and assistance devices to prevent accidents for a cognitively impaired resident.

Complaint #231931 and MO232783 related to failure to provide showers. Complaint #MO232652 and MO233045 related to wound care and pressure ulcer treatment failures.

The facility failed to provide scheduled showers to eight sampled residents, resulting in missed bathing opportunities. Additionally, the facility failed to provide appropriate wound care and pressure ulcer treatment for two residents, leading to hospitalization with sepsis and worsening pressure ulcers.

The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, specifically the main oxygen storage room had multiple holes in the sheetrock. This deficiency potentially affected all residents and staff.

The visit was complaint-related, triggered by multiple complaints (#231931, MO232783, MO232652, MO233045) alleging deficiencies in resident care, wound management, medication labeling, food safety, and staff training. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to obtain timely signed Medicare coverage notices, maintain a safe and clean environment, notify the Ombudsman of resident transfers, follow physician orders for wound and catheter care, provide showers as scheduled, ensure proper medication labeling and storage, maintain food safety standards, and conduct adequate nurse aide in-service training. Several residents had untreated or poorly managed wounds, missed showers, and incomplete documentation. The facility also failed to implement an effective antibiotic stewardship program.

Complaint MO229416 & MO229431 triggered the investigation. The complaints were substantiated based on observations, interviews, and record reviews showing missed showers and poor hygiene.

The facility failed to provide showers for three out of four sampled residents as scheduled, missing multiple shower opportunities in November and December 2023. Observations and interviews confirmed residents were not receiving showers as planned, resulting in poor hygiene conditions.

The investigation was triggered by complaints MO229416 and MO229431. The complaints were substantiated as the facility failed to provide showers as scheduled, leading to hygiene and odor problems for residents.

The facility failed to provide showers to three sampled dependent residents as required by regulation. Observations and interviews confirmed multiple missed shower opportunities, resulting in residents experiencing poor hygiene and odor issues.

Complaint #MO227683 regarding failure to obtain and record weights as ordered for Residents #7, #8, and #9.

The facility failed to obtain and record weights as ordered by physicians for Residents #7, #8, and #9, missing multiple opportunities to weigh residents in October and November 2023. The failure was attributed to inadequate monitoring by the Director of Nursing despite a new weight monitoring system being implemented less than three months prior.

Complaint #MO227683 was the basis for the inspection.

The facility failed to follow physician orders to obtain daily or weekly weights for three residents, resulting in incomplete weight records. The deficiency was related to staff not recording or obtaining weights as ordered, and failure of nursing management to monitor compliance.

Complaint #MO222548 regarding failure to obtain daily weights as ordered for three residents.

The facility failed to record daily weights as ordered for three residents with congestive heart failure, missing multiple weight recordings in July and August 2023. Interviews with residents and staff confirmed inconsistent weight monitoring practices.

Complaint #MO222548 was investigated regarding failure to obtain daily weights as ordered for residents. The complaint was substantiated based on record reviews and resident interviews.

The facility failed to obtain daily weights as ordered by physicians for three sampled residents, with staff failing to record weights on multiple occasions. Interviews confirmed residents were not weighed daily as required.

The facility failed to implement comprehensive care plans addressing specific resident needs for four sampled residents. Food safety deficiencies were noted including improper food storage, unsanitary kitchen conditions, and uncovered waste containers.

The facility failed to maintain illuminated exit signage, maintain hazardous areas with proper fire barriers, maintain required fire alarm systems, maintain sprinkler heads free of dust and debris, and maintain electrical equipment wiring and power strips properly. These deficiencies potentially affected all residents and staff.

The facility failed to implement individualized care plans addressing bed rails for several residents, had multiple food safety violations including improper food storage and thawing practices, and failed to ensure garbage dumpsters and trash receptacles were properly covered. These deficiencies posed minimal harm or potential for actual harm to residents.

The facility was found to have multiple deficiencies including failure to notify residents and representatives of transfers, inadequate baseline care plans, respiratory care issues, and infection control lapses. Several residents were affected by these deficiencies, and plans of correction were submitted.

The facility failed to meet several Life Safety Code requirements including exit signage illumination and testing, hazardous area enclosures, electrical equipment usage, and oxygen storage compliance. These deficiencies affected all residents, staff, and occupants in the event of an emergency.

Complaint #MO 159067 & 159071 triggered the investigation. The complaints were substantiated as the facility failed to follow physician orders and maintain proper documentation for oxygen and ear drop administration.

The facility failed to follow physician orders for oxygen administration and ear drop treatments for two residents. Nursing staff did not document or clarify medication administration properly, indicating noncompliance with professional standards.

The facility failed to ensure that Physician Order Sheets matched residents' advance directives and that residents were informed of the bed hold policy upon transfer to hospital or therapeutic leave. These deficiencies affected multiple residents and had the potential to impact all residents in the facility.

The facility failed to maintain the kitchen range hood free from grease buildup, maintain smoke barriers and walls, and properly manage smoking disposal cans. These deficiencies potentially affected all residents and staff.

Complaint # MO146523 triggered the investigation. The complaint was substantiated based on findings of missed medications and falsified documentation.

The facility failed to follow physician orders for one resident regarding medication administration, including missed doses of eye drops and respiratory treatments. Licensed staff falsified medication administration records and did not administer prescribed treatments as ordered.