18 Reports
Inspection Report — May 15, 2025
Routine
Date: May 15, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two state deficiencies were cited addressing failure to complete a community based assessment when a significant change occurred and failure to review individualized service plans when a significant change occurred.
Deficiencies (2)
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change: Based on interview and record review, the facility failed to complete a community based assessment (CBA) whenever a significant change had occurred in a resident's condition which required a change in services for one of three sampled residents (Resident #1). The facility did not provide a policy regarding updating CBAs.
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: Based on interview and record review, the facility failed to review an individualized service plan (ISP) whenever a significant change had occurred in a resident's condition which required a change in services for one of three sampled residents (Resident #1). The facility did not provide a policy regarding updating ISPs.
Report Facts
residents sampled: 3
Inspection Report — Jan 21, 2025
Routine
Date: Jan 21, 2025
Visit Reason
CMS-2567 federal form present and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
1 state licensure deficiency (Class III) for failure to complete certified nurse aide (CNA) registry checks for employees. No federal health survey deficiencies were cited in this file.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on record review and interview, the facility failed to ensure CNA registry checks were completed for all employees; this affected six of ten sampled staff who did not have nurse aide registry checks completed.
Report Facts
employees affected: 6
employees sampled: 10
Inspection Report — Jun 17, 2024
Routine
Date: Jun 17, 2024
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 state deficiencies: missing annual fire alarm system inspection/certification and non-electric lighting (candles and an oil lamp) observed in resident rooms and hallways. Both deficiencies are cited as Class II.
Deficiencies (2)
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: Records review and interview found no current annual fire alarm testing documentation and the facility failed to conduct the required annual inspection.
19 CSR 30-86.032(14) Lighting-Electric Only: Observations found candles and a glass oil lamp with previously burnt wicks in resident rooms and a hallway, indicating non-electric lighting was present.
Report Facts
residents affected: 30
Inspection Report — May 11, 2023
Routine
Date: May 11, 2023
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One state licensure deficiency (Class II) for hazardous area door requirements. The laundry room door lacked a self-closing device and the deficiency affected all 33 residents.
Deficiencies (1)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: Based on observation and interview on 05/11/23, the facility failed to ensure doors to hazardous areas were self-closing and kept closed; the laundry room door did not have a self-closing device.
Report Facts
residents_affected: 33
Inspection Report — Mar 9, 2023
Routine
Date: Mar 9, 2023
Visit Reason
Federal CMS-2567 (health survey) and Missouri Department of Health and Senior Services State Form (state licensure) are included in this file; the survey type is not stated.
Findings
Four deficiencies were cited: two federal health deficiencies addressing failure to provide required transfer/discharge notice to the State Long-Term Care Ombudsman and high medication administration error rates, and two Missouri state licensure deficiencies referencing the same transfer/ discharge notice and medication system issues.
Deficiencies (2)
19 CSR 30-85.042(46) Safe/Effective Medication System: Refer to F759.
19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: Refer to F623.
Report Facts
residents_sampled: 12
residents_affected_by_transfer_notice_issue: 2
medication_errors: 13
medication_error_opportunities: 25
medication_error_rate_percent: 52
Inspection Report — Mar 9, 2023
Life Safety
Date: Mar 9, 2023
Visit Reason
CMS-2567 Life Safety survey with Emergency Preparedness pages and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Thirty deficiencies were cited: 17 federal deficiencies covering emergency preparedness, means of egress, doors and locking arrangements, emergency lighting, fire alarm notification and testing, sprinkler system maintenance, smoke barriers, generators, electrical systems, power cords and gas cylinder storage; and 13 Missouri state deficiencies referencing many of the same issues (emergency lighting/generator, fire alarm, sprinkler, exits, door locks, smoke barriers, electrical).
Deficiencies (13)
19 CSR 30-85.012(12B) Emergency Lights, Generator for Life Support: Refer to K918.
19 CSR 30-85.022(4) Hazardous Areas: Refer to K211.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: Refer to K343.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Refer to K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(12) Exit Requirements: Refer to K211.
19 CSR 30-85.022(16) Door Locks: Refer to K222.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372 and K374.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: Based on record review and interview, the facility failed to request an annual fire department consultation review of the fire and evacuation plan.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K226, K372, K914.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K920.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Refer to K920.
Inspection Report — Apr 21, 2022
Routine
Date: Apr 21, 2022
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 state deficiencies were cited addressing building systems: one for sprinkler system maintenance/testing for missing monthly pressure gauge readings, valve position checks and documentation, and one for electrical wiring inspection for lack of documentation of the required two-year inspection.
Deficiencies (2)
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on observations, interviews and record review on 4/21/22 the facility failed to properly perform monthly pressure gauge readings and valve position checks of the sprinkler system and lacked monthly sprinkler inspection documentation.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Based on record review and interview on 4/21/22 the facility failed to show documentation that electrical wiring had been inspected within the last two years by a qualified electrician and no records of an electrical inspection were available.
Report Facts
residents potentially affected: 27
residents potentially affected: 27
Inspection Report — Mar 22, 2022
Complaint Investigation
Date: Mar 22, 2022
Visit Reason
Missouri state licensure survey (State Form); complaint investigation cited (MO197941).
Findings
1 state deficiency concerning medication administration and documentation related to blood glucose monitoring and insulin administration for sampled residents.
Deficiencies (1)
19 CSR 30-86.047(47)(G) Medication Administration, Documented: Based on record review and interview, the facility failed to ensure blood sugar checks and insulin administration were appropriately documented for two of four sampled residents.
Report Facts
residents sampled: 4
residents affected: 2
Inspection Report — Mar 10, 2020
Routine
Date: Mar 10, 2020
Visit Reason
Missouri state licensure survey (State Form); the pages document a fire safety inspection. The survey type is not stated.
Findings
4 state deficiencies citing locked exit doors, incomplete fire alarm/smoke detector interconnection, compromised smoke section partitions/doors, and electrical wiring/GFCI protection.
Deficiencies (4)
19 CSR 30-86.022(7)(E) Locked Exit Doors: The surveyor found an exterior egress door with a keyed cylinder on the inside portion of the door that would require a key to exit, and the maintenance director did not have a key.
19 CSR 30-86.022(9)(A)(1) Smoke Detectors-NFPA 13 Complete Fire Alarm Systems: The surveyor found the facility did not have a complete fire alarm system; a smoke detector in the front foyer was not interconnected to the complete fire alarm system.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds Protection from Hazards: The surveyor found the one-hour fire-rated smoke separation door near room 136 failed to fully close and latch when released from the magnetic holder and a 20 x 24 inch hole in the one-hour fire-rated smoke separation wall in the attic.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The surveyor found electrical outlets were not protected by ground fault interrupter circuits in the entry way of each apartment and in medicine rooms, outlets located within six feet of a water source were not GFCI protected.
Report Facts
residents potentially affected: 34
Inspection Report — Jan 9, 2020
Routine
Date: Jan 9, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Six deficiencies were cited: four federal deficiencies for inadequate ADL/perineal care, unsafe transfers/assistive device use, catheter care/UTI prevention, and infection prevention/control (including TB testing), and two Missouri state citations addressing nursing care per resident condition and infection control/communicable disease.
Deficiencies (2)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F677, F689 and F690.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
Report Facts
residents sampled: 12
residents affected: 3
Inspection Report — Jan 9, 2020
Life Safety
Date: Jan 9, 2020
Visit Reason
CMS-2567 Life Safety survey and Missouri Department of Health and Senior Services State Form were included; the survey is a Life Safety (K-tag) survey.
Findings
Two deficiencies were cited: one federal Life Safety deficiency concerning electrical receptacles/testing and one Missouri State licensure deficiency for electrical wiring and equipment maintenance that references the Life Safety finding.
Deficiencies (1)
19 CSR 30-85.032(3)(A) Electrical Wiring & Equipment Maintained: Refer to K914.
Inspection Report — Mar 19, 2019
Routine
Date: Mar 19, 2019
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Four Missouri state licensure deficiencies were cited related to fire safety: storage of combustible equipment creating a fire hazard, missing semi-annual fire alarm inspection records, a fire separation door that did not close and latch properly, and exposed wiring in an open junction box.
Deficiencies (4)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements: Observed a 1-gallon gas can and a gas-powered snow blower stored in the same room as three large gas water heaters, creating a fire hazard; maintenance removed the items.
19 CSR 30-86.022(9)(F) Fire Alarm System Records Complete Fire Alarm Systems: Facility could not provide copies of the semi-annual fire alarm system inspection reports and no current semi-annual reports were available.
19 CSR 30-86.032(2) Substantially Constructed & Maintained: First floor stairway fire separation door did not close and latch properly when released from the open position.
19 CSR 30-88.032(13) Electrical Wiring, Maintained, Inspected: Open electrical junction box in the communications control room with exposed wires lacking wire nuts.
Report Facts
residents potentially affected: 38
Inspection Report — Nov 15, 2018
Life Safety
Date: Nov 15, 2018
Visit Reason
Federal Life Safety (CMS-2567) survey with accompanying Missouri Department of Health and Senior Services State Form; the survey is a Life Safety Code survey.
Findings
Seven deficiencies were cited: five federal Life Safety deficiencies addressing construction type/separations, corridor doors, smoke barriers and fire drill practices, and two Missouri state citations (both Class II) concerning fire alarm testing/maintenance and substantial construction/maintenance.
Deficiencies (2)
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems.: Please refer to K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Please refer to K133, K363, K372 and K374.
Inspection Report — Nov 14, 2018
Routine
Date: Nov 14, 2018
Visit Reason
Missouri Department of Health and Senior Services State Form (state licensure survey); the survey type is not stated.
Findings
Three State Form deficiencies were cited regarding tuberculosis screening, individualized service plan signatures, and self-control of medication including medication orders and labeling. Two were Class II and one was Class II*.
Deficiencies (3)
19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on record review and interview, the facility failed to screen four sampled residents for tuberculosis as required; the facility census was 37.
19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures: Based on record review and interview, the facility failed to ensure that six of seven sampled residents had individualized service plans completed and signed by an authorized representative and the resident upon admission and at least annually; the facility census was 37.
19 CSR 30-86.047(40) Self-Control of Medication Requirements: Based on observation, interview, and record review, the facility failed to ensure two residents had a physician order for self-administration and failed to ensure medications were current with the physician order sheet and properly labeled; the facility census was 37.
Report Facts
residents not screened for TB: 4
sampled residents without signed ISPs: 6
residents lacking physician self-administration orders: 2
Inspection Report — Mar 26, 2018
Complaint Investigation
Date: Mar 26, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO140084).
Complaint Details
Complaint MO140084; substantiation not stated.
Findings
Two deficiencies were cited: one federal health deficiency involving a failure to properly investigate and respond to an allegation of misappropriation of a resident's property, and one Missouri licensure deficiency related to development and implementation of policies prohibiting abuse, neglect and misappropriation.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F610.
Report Facts
amount of alleged improper charges: 769.91
sample size and frequency in plan of correction: 4
Inspection Report — Feb 27, 2018
Routine
Date: Feb 27, 2018
Visit Reason
Missouri Department of Health and Senior Services State Form (facility licensure survey); the survey type is not stated.
Findings
Six Missouri State Form deficiencies were cited addressing community based assessment form use, safe and effective medication system and medication administration practices, Schedule II medication reconciliation, drug regimen review, monthly resident condition/medication summaries, and documentation of disclosure of resident rights.
Deficiencies (6)
19 CSR 30-86.047(28)(F)(3) Community Based Assessment - Other Form: Based on record review and interview the facility failed to use the MO580-2835 Assessment for Admission to Assisted Living Facilities form and did not have department approval to use a different form for three of three sampled residents.
19 CSR 30-86.047(46) Safe & Effective Medication System: Based on observation, record review, and interview the facility failed to implement a safe and effective medication system; staff did not prime a Humalog Kwikpen prior to administration to a resident, failed to administer or offer an ordered medication to another resident, and a Certified Medication Technician signed out controlled substance medications prior to administering them.
19 CSR 30-86.047(51)(A)(1) Schedule II Meds-Reconcile Each Shift, Record: Based on record review and interview the facility failed to reconcile controlled substance Schedule II medications each shift as required; narcotic shift count forms lacked staff signatures for numerous shifts.
19 CSR 30-86.047(54) Drug Regimen Review: Based on record review and interview the facility failed to have a physician or registered nurse review the medication regimen at least every other month for three of three sampled residents; no medication regimen reviews (MRRs) were found in the residents' records.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on record review and interview the facility failed to complete a monthly summary of the resident's general condition and needs for three of three sampled residents; monthly summaries were missing for multiple months.
19 CSR 30-88.010(6) Disclosure of Res Rights Info Documented: Based on record review and interview the facility failed to document the annual disclosure of resident rights for one of three sampled residents (Resident #4).
Report Facts
residents sampled: 3
Inspection Report — Feb 27, 2018
Routine
Date: Feb 27, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services state licensure survey (State Form); the survey type is routine.
Findings
The file contains 8 federal deficiencies addressing resident rights/dignity, professional standards for services and inhalation/medication administration, ADL/perineal care, accident hazards/gait-belt use, medication error rates, drug labeling/storage, food sanitation, and infection control; and 7 Missouri state deficiencies (19 CSR citations) referencing medication systems/storage, nursing care, infection control/communicable disease, clean clothing/hair restraints, nonfood contact surfaces cleaning, and dignity/privacy.
Deficiencies (7)
19 CSR 30-85.042(47) Safe/Effective Medication System: Refer to F759.
19 CSR 30-85.042(55) Medication Storage: Refer to F761.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F677, F689 and F658.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Refer to F812.
19 CSR 30-87.030(54) Nonfood Contact Surfaces, Cleaning: Refer to F812.
19 CSR 30-88.010(29) Dignity/Privacy: Refer to F550.
Report Facts
residents sampled: 19
medication error rate (percent): 25.93
residents affected by medication errors: 3
Inspection Report — Feb 27, 2018
Life Safety
Date: Feb 27, 2018
Visit Reason
CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Nine deficiencies were cited: four federal Life Safety deficiencies addressing a compromised fire barrier/door assembly, deficient fire alarm testing and monthly activation, missing sprinkler system testing, and inadequate fire drill timing; and five Missouri state deficiencies corresponding to fire alarm testing/activation, sprinkler testing, employee fire safety training, and facility construction/maintenance that reference the federal findings.
Deficiencies (5)
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: See the deficiency cited at K345.
19 CSR 30-85.022(10)(E) Fire Alarm System, Monthly Activation: See the deficiency cited at K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: See the deficiency cited at K351.
19 CSR 30-85.022(34)(A)(1 - 3) Fire Safety Training Requirements-employee: See the deficiency cited at K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: See the deficiency cited at K133.
Report Facts
fire drills conducted: 4
14 CMS Surveys
Inspection Report — Feb 1, 2025
Life Safety
Date: Feb 1, 2025
Visit Reason
CMS-2567 Life Safety Code form (K-tag) for Linden Woods Village; the survey is a life safety survey.
Findings
8 life safety deficiencies were cited addressing kitchen hood fire-extinguishing system maintenance, fire alarm testing and documentation, smoke detector inspection and testing, sprinkler coverage and maintenance, required fire drills, fire door inspection/testing, and essential electrical/generator system requirements. Several deficiencies were noted as having the potential to affect all residents.
Deficiencies (8)
K 324 Cooking Facilities: Based on record review and interview, the facility failed to maintain documentation on the maintenance and testing of the fire-extinguishing system in the kitchen hood every six months; this deficient practice had the potential to affect all residents who resided at the facility.
K 345 Fire Alarm System - Testing and Maintenance: Based on record review and interview, the facility failed to maintain documentation of the annual maintenance and testing of the fire alarm system; this deficient practice had the potential to affect all residents who resided at the facility.
K 347 Smoke Detection: Based on record review and interview, the facility failed to document the semi-annual visual inspection and the annual functional testing of the smoke detectors; this deficient practice had the potential to affect all residents who resided at the facility.
K 351 Sprinkler System - Installation: Based on observation and interview, the facility failed to provide complete sprinkler coverage in a mechanical/storage room, leaving that room without required sprinkler coverage; this deficient practice had the potential to affect staff and residents.
K 353 Sprinkler System - Maintenance and Testing: Based on record review and interview, the facility failed to ensure the dry sprinkler system gauges were visually inspected weekly and documented as required; this deficient practice had the potential to affect all residents who resided at the facility.
K 712 Fire Drills: Based on record review and interview, the facility failed to conduct required second-shift fire drills for a required period, resulting in missing required drill documentation; this deficient practice had the potential to affect all residents who resided at the facility.
K 761 Maintenance, Inspection & Testing - Doors: Based on record review and interview, the facility failed to ensure the annual testing, inspection, and maintenance of fire door assemblies was completed and documented as required; this deficient practice had the potential to affect all residents who resided at the facility.
K 918 Electrical Systems - Essential Electric System: Based on observation, record review, and interview, the facility failed to ensure the generator met requirements (including lacking a required remote manual stop and lacking documentation of weekly visual inspections and an annual fuel quality test), which could affect staff and residents.
Inspection Report — Jan 2, 2025
Annual Inspection
Date: Jan 2, 2025
Visit Reason
Federal health survey (CMS-2567); recertification (annual) survey.
Findings
Six federal health deficiencies were cited addressing resident participation in care planning, transfer/discharge notice and Ombudsman notification, psychotropic medication use and PRN orders, medication labeling/storage, resident dietary preferences/allergies, and food procurement/food safety and sanitizing.
Deficiencies (6)
F553 Right to Participate in Planning Care: Based on interview, record review, and policy review, the facility failed to ensure residents' right to participate in the care planning process for two of two sampled residents, placing them at risk for non–person-centered care.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified for residents with hospital transfers and facility policy did not address required Ombudsman notification.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure documentation of indications and attempts at gradual dose reduction for antipsychotic/psychotropic medications for a sampled resident, risking unnecessary or prolonged use.
F761 Label/Store Drugs and Biologicals: The facility had undated/opened Mantoux tuberculin testing vials in medication storage, risking inaccurate tuberculin testing results.
F806 Resident Allergies, Preferences, Substitutes: The facility failed to accommodate a resident's documented dietary preferences (example: 'no bacon') and had menu/tray documentation inconsistent with the resident's preferences, risking reduced meal consumption.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to ensure proper sanitizer concentrations and proper labeling/use-by dating and had expired or improperly labeled foods in refrigerators, risking foodborne illness and cross-contamination.
Report Facts
sampled residents: 16
supplemental residents: 7
Inspection Report — Mar 9, 2023
Routine
Date: Mar 9, 2023
Visit Reason
Federal CMS-2567 (health survey) and Missouri Department of Health and Senior Services State Form (state licensure) are included in this file; the survey type is not stated.
Findings
Four deficiencies were cited: two federal health deficiencies addressing failure to provide required transfer/discharge notice to the State Long-Term Care Ombudsman and high medication administration error rates, and two Missouri state licensure deficiencies referencing the same transfer/ discharge notice and medication system issues.
Deficiencies (2)
F 623 Notice Requirements Before Transfer/Discharge: The facility failed to send a written copy of the transfer/discharge notice to a representative of the Office of the State Long-Term Care Ombudsman, affecting sampled residents and with a facility census of 35.
F 759 Free of Medication Error Rates 5 Percent or More: The facility failed to maintain medication error rates below 5%, with staff making multiple medication administration errors affecting sampled residents.
Report Facts
residents_sampled: 12
residents_affected_by_transfer_notice_issue: 2
medication_errors: 13
medication_error_opportunities: 25
medication_error_rate_percent: 52
Inspection Report — Mar 9, 2023
Life Safety
Date: Mar 9, 2023
Visit Reason
CMS-2567 Life Safety survey with Emergency Preparedness pages and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Thirty deficiencies were cited: 17 federal deficiencies covering emergency preparedness, means of egress, doors and locking arrangements, emergency lighting, fire alarm notification and testing, sprinkler system maintenance, smoke barriers, generators, electrical systems, power cords and gas cylinder storage; and 13 Missouri state deficiencies referencing many of the same issues (emergency lighting/generator, fire alarm, sprinkler, exits, door locks, smoke barriers, electrical).
Deficiencies (17)
E015 Subsistence Needs for Staff and Patients: Based on record review and interview, the facility failed to ensure policies and procedures to address subsistence needs (alternate energy, emergency lighting, fire detection/extinguishing and sewage/waste disposal) for staff and patients in the event of an emergency.
K211 Means of Egress - General: The facility failed to ensure proper locking arrangements on a gate located within the means of egress and lacked appropriate signage and controls for delayed/controlled egress.
K222 Egress Doors: Doors in required means of egress did not have required signage or proper delayed‑egress/release arrangements and some doors were observed locked or without required unlocking/signage.
K223 Doors with Self-Closing Devices: The facility had multiple doors that were not self-closing or were being propped open (wedges, putty, kick-down stops), impeding required smoke-compartment closures.
K226 Horizontal Exits: The facility failed to ensure fire barrier walls were continuous and free of unsealed penetrations or gaps that could allow smoke/heat to migrate between compartments.
K291 Emergency Lighting: Emergency lighting was not consistently provided or controlled as required (lighting controlled by a switch that could be turned to the off position and other issues noted with emergency lighting locations).
K343 Fire Alarm System - Notification: The facility failed to provide adequate audible/visual notification in the therapy gym; testing showed the therapy gym alarm level was considerably quieter than the rest of the facility.
K345 Fire Alarm System - Testing and Maintenance: Records and inspection/testing were incomplete or performed by personnel without required credentials and certifications for required semi-annual/sensitive testing.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain required sprinkler system inspection/testing records and had penetration gaps in sprinklered areas; required trip/air leakage tests and internal obstruction investigations were not documented.
K372 Subdivision of Building Spaces - Smoke Barrier: Smoke barrier walls had unsealed penetrations and gaps that compromised required smoke barrier continuity.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: Smoke barrier doors were not maintained as self-closing/automatic-closing; doors to private dining and other locations were observed propped open creating gaps between smoke compartments.
K711 Evacuation and Relocation Plan: Staff lacked required training/knowledge on evacuation/relocation procedures and on use/activation of hood suppression systems in the kitchen; required placards/notifications were not in place or known to staff.
K901 Fundamentals - Building System Categories: The facility did not have a documented NFPA 99 risk assessment/building-system category assessment on record.
K914 Electrical Systems - Maintenance and Testing: The facility failed to complete and properly document annual testing of non-hospital grade receptacles in patient areas (testing forms lacked required measured readings/columns and evidence of conduit-to-ground verification).
K918 Electrical Systems - Essential Electric System: Generator testing and exercising were not performed per required durations/frequencies and required maintenance/testing records (including load and transfer switch testing) were incomplete.
K920 Electrical Equipment - Power Cords and Extension Cords: Power strips and extension cords were used in resident care areas and at staff/nurse stations in ways that are not permitted (multi-outlet adapters, inappropriate use of power strips), creating potential hazards.
K923 Gas Equipment - Cylinder and Container Storage: Combustible materials were stored within the oxygen storage room (within five feet of oxygen tanks) and the storage arrangement did not comply with required separation and protection requirements.
Inspection Report — Aug 31, 2021
Routine
Date: Aug 31, 2021
Visit Reason
Federal CMS-2567 forms for a COVID-19 focused Infection Control and Emergency Preparedness survey (federal health and emergency preparedness forms). The documents state a COVID-19 focused infection control and emergency preparedness survey was conducted.
Findings
No deficiencies were cited; the surveyor found the facility in compliance with the applicable COVID-19 infection control and emergency preparedness requirements.
Inspection Report — Sep 30, 2020
Routine
Date: Sep 30, 2020
Visit Reason
Federal CMS-2567 health survey; the form states this was a COVID-19 Focused Infection Control and Emergency Preparedness survey.
Findings
No health or emergency preparedness deficiencies were cited. Initial comments state the facility was found to be in compliance with applicable COVID-19 infection control and emergency preparedness requirements.
Inspection Report — Jun 9, 2020
Routine
Date: Jun 9, 2020
Visit Reason
The file contains CMS-2567 federal health (F tags) and CMS-2567 Emergency Preparedness (E tags) pages; the survey was a COVID-19 Focused Infection Control and Emergency Preparedness survey.
Findings
No health survey deficiencies were cited on the CMS-2567 pages and no Emergency Preparedness deficiencies were cited.
Inspection Report — Jan 9, 2020
Routine
Date: Jan 9, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Six deficiencies were cited: four federal deficiencies for inadequate ADL/perineal care, unsafe transfers/assistive device use, catheter care/UTI prevention, and infection prevention/control (including TB testing), and two Missouri state citations addressing nursing care per resident condition and infection control/communicable disease.
Deficiencies (4)
F677 ADL Care Provided for Dependent Residents: Facility staff failed to provide adequate ADL and perineal care for dependent residents; staff were observed using the same wipe and not separating/cleaning skin folds during incontinence care, affecting sampled residents.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure safe use of assistive devices and safe transfer techniques; observations showed improper gait belt placement and failure to follow lift/caster procedures during transfers.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to provide catheter care to prevent urinary tract infection; staff failed to clean catheter tubing and drainage spout and placed collection equipment improperly, affecting a sampled resident.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention program; observations and record review showed failures in infection control practices including improper TB testing administration/reading and other IPC processes.
Report Facts
residents sampled: 12
residents affected: 3
Inspection Report — Jan 9, 2020
Life Safety
Date: Jan 9, 2020
Visit Reason
CMS-2567 Life Safety survey and Missouri Department of Health and Senior Services State Form were included; the survey is a Life Safety (K-tag) survey.
Findings
Two deficiencies were cited: one federal Life Safety deficiency concerning electrical receptacles/testing and one Missouri State licensure deficiency for electrical wiring and equipment maintenance that references the Life Safety finding.
Deficiencies (1)
K 914 Electrical Systems - Maintenance and Testing: The facility failed to perform the annual inspection and testing of resident room electrical receptacles that were not listed as hospital grade; standard receptacles with unmarked faces were observed and maintenance staff reported the testing had not been performed.
Inspection Report — Nov 15, 2018
Routine
Date: Nov 15, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
No federal health survey deficiencies were cited and no state licensure deficiencies were cited.
Inspection Report — Nov 15, 2018
Life Safety
Date: Nov 15, 2018
Visit Reason
Federal Life Safety (CMS-2567) survey with accompanying Missouri Department of Health and Senior Services State Form; the survey is a Life Safety Code survey.
Findings
Seven deficiencies were cited: five federal Life Safety deficiencies addressing construction type/separations, corridor doors, smoke barriers and fire drill practices, and two Missouri state citations (both Class II) concerning fire alarm testing/maintenance and substantial construction/maintenance.
Deficiencies (5)
K133 Multiple Occupancies - Construction Type: Based on observation, interview and record review, the facility failed to maintain the two hour separation between the skilled unit and the common area free of penetrations; holes around pipes and wires and other penetrations were found and were not filled.
K363 Corridor - Doors: Based on observation and interview, the facility failed to maintain corridor doors so they would close in one action in accordance with NFPA 101; wedges and other impediments and air drafts were observed preventing doors from self-closing.
K372 Subdivision of Building Spaces - Smoke Barrier: Based on record review, observation and interview, the facility failed to maintain and construct required smoke barrier walls; smoke barrier walls were missing in attic areas and multiple gaps/holes and penetrations were observed.
K374 Subdivision of Building Spaces - Smoke Barrier Doors 2012: Based on observation and interview, the facility failed to ensure smoke barrier doors closed upon activation of the fire alarm; sets of smoke barrier doors did not close when the alarm activated.
K712 Fire Drills - Fire Drills are not at varied times: Based on interview and record review, the facility failed to conduct fire drills at varied times on required shifts to assure proficiency of staff response; drill records showed drills were not performed at varied times.
Inspection Report — Mar 26, 2018
Complaint Investigation
Date: Mar 26, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO140084).
Complaint Details
Complaint MO140084; substantiation not stated.
Findings
Two deficiencies were cited: one federal health deficiency involving a failure to properly investigate and respond to an allegation of misappropriation of a resident's property, and one Missouri licensure deficiency related to development and implementation of policies prohibiting abuse, neglect and misappropriation.
Deficiencies (1)
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate and report an allegation of misappropriation of a resident's credit card and did not take appropriate actions such as suspending the alleged perpetrator or promptly notifying appropriate authorities.
Report Facts
amount of alleged improper charges: 769.91
sample size and frequency in plan of correction: 4
Inspection Report — Feb 27, 2018
Routine
Date: Feb 27, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services state licensure survey (State Form); the survey type is routine.
Findings
The file contains 8 federal deficiencies addressing resident rights/dignity, professional standards for services and inhalation/medication administration, ADL/perineal care, accident hazards/gait-belt use, medication error rates, drug labeling/storage, food sanitation, and infection control; and 7 Missouri state deficiencies (19 CSR citations) referencing medication systems/storage, nursing care, infection control/communicable disease, clean clothing/hair restraints, nonfood contact surfaces cleaning, and dignity/privacy.
Deficiencies (8)
F550 Resident Rights/Exercise of Rights: The facility failed to ensure residents were cared for in a dignified manner, with observations and resident reports of rushed, rough handling, inadequate privacy, and lack of timely assistance.
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff followed professional standards for medication and inhalation/respiratory treatments, including improper use and handling of a Humalog Kwikpen and Ventolin HFA inhaler for a resident.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure dependent residents received appropriate perineal and urinary catheter care and showers, with staff not properly cleansing perineal areas, using wipes incorrectly, and not completing required care.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff used proper techniques and gait belts during transfers, placing residents at risk during ambulation and transfer activities.
F759 Free of Medication Error Rts 5 Prcnt or More: The facility's medication administration had an unacceptably high error rate, with multiple observed medication administration errors affecting several residents.
F761 Label/Store Drugs and Biologicals: The facility failed to properly label, date, and store drugs and biologics, including undated multi-dose vials and improperly stored supplements and refrigerated items.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary food-handling practices, with staff not using appropriate hair restraints and dining/service areas observed with dried food residue and unsanitary table conditions.
F880 Infection Prevention and Control: The facility failed to implement infection control practices during wound care, personal care, and linen handling, including lack of hand hygiene, failure to disinfect instruments, and returning soiled items to treatment carts.
Report Facts
residents sampled: 19
medication error rate (percent): 25.93
residents affected by medication errors: 3
Inspection Report — Feb 27, 2018
Life Safety
Date: Feb 27, 2018
Visit Reason
CMS-2567 Life Safety (K-tag) survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Nine deficiencies were cited: four federal Life Safety deficiencies addressing a compromised fire barrier/door assembly, deficient fire alarm testing and monthly activation, missing sprinkler system testing, and inadequate fire drill timing; and five Missouri state deficiencies corresponding to fire alarm testing/activation, sprinkler testing, employee fire safety training, and facility construction/maintenance that reference the federal findings.
Deficiencies (4)
K133 Multiple Occupancies - Construction Type: The facility failed to maintain the required two-hour separation and had unsealed penetrations (around sprinkler pipe and conduits) and lacked assurance the fire door assembly had been inspected.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain the fire alarm system by not conducting required semi-annual inspections and not assuring monthly activation of the system.
K351 Sprinkler System - Installation: The facility failed to maintain the sprinkler system, missing required quarterly testing and inspections and lacking documentation for the August quarter.
K712 Fire Drills: The facility failed to conduct fire drills on the third shift at varied times to ensure staff proficiency; drills were repeatedly conducted at early-morning times rather than varied times.
Report Facts
fire drills conducted: 4
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