Deficiencies (last 8 years)
Deficiencies (over 8 years)
14.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
156% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
85% 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
Plan of Correction
Census: 34
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding community based assessments and individualized service plans in an assisted living facility.
Findings
The facility failed to complete community based assessments and individualized service plan reviews when significant changes occurred in residents' conditions. The facility census was 34 at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change: The facility failed to complete a community based assessment when a significant change occurred in a resident's condition and did not provide a policy regarding updating CBAs.
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: The facility failed to review an individualized service plan at least annually or when a significant change occurred and did not provide a policy regarding updating ISPs.
Report Facts
Facility census: 34
Additional monthly charge: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding Resident #1's condition and ISP requirements | |
| Assisted Living Director | Responsible for corrective actions and plan of correction implementation | |
| RN A | Registered Nurse | Completed new path to safety assessment for Resident #2 |
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, specifically focusing on the facility's abuse prevention, identification, investigation, and reporting policies.
Findings
The facility failed to ensure that all employees had completed nurse aide registry checks as required by policy. Six of ten sampled staff did not have nurse aide registry checks completed, indicating noncompliance with abuse prevention policies.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to develop and implement policies ensuring nurse aide registry checks for all employees, as six of ten sampled staff lacked these checks.
Report Facts
Facility census: 36
Sampled staff: 10
Staff without registry checks: 6
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 6
Date: Jan 2, 2025
Visit Reason
The inspection was conducted as a regulatory annual survey of Linden Woods Village nursing home to assess compliance with federal regulations regarding resident care, medication management, food safety, and other facility operations.
Findings
The facility was found deficient in several areas including failure to ensure residents' participation in care planning, failure to notify the Ombudsman of hospital transfers and discharges, inadequate documentation and monitoring of psychotropic medication use, improper labeling and storage of medications and biologicals, failure to accommodate resident dietary preferences, and unsafe food handling and sanitation practices.
Deficiencies (6)
Failed to ensure residents' right to participate in the development and implementation of their person-centered care plans for two residents.
Failed to notify the Ombudsman of hospital transfers or discharges for two residents.
Failed to document indications for increase and attempt gradual dose reduction of antipsychotic medication for one resident.
Failed to ensure one opened vial of Mantoux tuberculin purified protein derivative (PPD) was dated for residents' use.
Failed to accommodate one resident's dietary preferences by serving bacon despite a 'no bacon' order.
Failed to ensure sanitizer used to sanitize food contact surfaces was at effective levels and failed to ensure food stored was labeled and discarded after use-by or expiration dates.
Report Facts
Facility census: 37
BIMS score: 12
BIMS score: 15
BIMS score: 3
Sanitizer ppm: 0
Sanitizer ppm: 400
Medication incidents: 16
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding care plan participation, psychotropic medication indications, and medication increase justification |
| Social Services Director | Social Services Director (SSD) | Confirmed failure to notify Ombudsman of resident transfers and discharges |
| MDS Coordinator | MDS Coordinator (MDSC) | Provided information on missed care plan conferences for residents |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) | Observed undated opened PPD vial and set it aside for discard |
| Culinary Director | Culinary Director (CD) | Verified sanitizer levels and food storage expiration dates |
| Restorative Aide | Restorative Aide (RA) | Admitted to writing incorrect breakfast order for Resident 11 |
| Dietary Aide | Dietary Aide (DA) | Served breakfast tray with bacon despite 'no bacon' order |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 6
Date: Jan 2, 2025
Visit Reason
A recertification survey was conducted to assess compliance with Federal and State laws and regulations at Linden Woods Village.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to residents' rights to participate in care planning, notice requirements before transfer/discharge, psychotropic drug use, labeling and storage of drugs and biologics, resident allergies and food preferences, and food safety requirements.
Deficiencies (6)
F553 Residents' right to participate in planning care was not ensured for two residents, placing them at risk for non-person-centered care.
F623 The facility failed to notify the Ombudsman of two residents' emergent hospital transfers, lacking required transfer/discharge notices.
F758 The facility failed to ensure one resident had documented indications for increasing antipsychotic medication and gradual dose reduction attempts.
F761 The facility failed to ensure one undated opened vial of Mantoux tuberculin purified protein derivative was discarded, risking inaccurate tuberculosis testing.
F806 The facility failed to accommodate one resident's dietary preferences, potentially reducing meal consumption and nutritional status.
F812 The facility failed to ensure proper food safety practices, including sanitizing food contact surfaces and labeling food with use-by dates, risking foodborne illness.
Report Facts
Survey Census: 38
Sample Size: 16
Supplemental Residents: 7
Facility Census: 37
Deficiencies cited: 42
Medication charting incidents: 16
Psychotropic drug PRN order limit: 14
Inspection Report
Life Safety
Census: 37
Deficiencies: 8
Date: Dec 31, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and life safety codes, including testing and maintenance of fire protection systems, fire drills, smoke detection, sprinkler systems, and emergency power systems.
Findings
The facility failed to maintain required documentation and testing for multiple fire safety systems including the kitchen hood fire-extinguishing system, fire alarm system, smoke detectors, sprinkler systems, fire drills, fire doors, and emergency power systems. These deficiencies had the potential to affect all 37 residents and staff at the facility.
Deficiencies (8)
K-324: The facility failed to maintain documentation for the 6-month maintenance and testing of the kitchen hood fire-extinguishing system for the 2024 calendar year.
K-345: The facility failed to maintain documentation of the annual maintenance and testing of the fire alarm system in accordance with NFPA standards.
K-347: The facility failed to document semi-annual visual inspections and annual functional testing of smoke detectors as required by NFPA 72.
K-351: The facility failed to provide complete sprinkler coverage in the Mechanical Storage Low/Voltage room and failed to ensure sprinkler system gauges were inspected weekly.
K-353: The facility did not have documentation of weekly visual inspections of dry sprinkler system gauges during the survey.
K-712: The facility failed to conduct fire drills on the second shift for the fourth quarter of 2024 as required by NFPA Life Safety Code.
K-761: The facility failed to ensure annual testing, inspection, and maintenance of fire doors assemblies were documented for 2024.
K-918: The facility failed to ensure the emergency power system generator had a remote manual stop, lacked documentation for weekly visual inspections for November and December 2024, and failed to have the annual fuel quality test report for 2024.
Report Facts
Residents affected: 37
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and provided records related to fire safety system maintenance and testing |
Inspection Report
Plan of Correction
Census: 30
Deficiencies: 2
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to assess compliance with fire alarm system inspections and lighting restrictions in the facility.
Findings
The facility failed to conduct the required annual fire alarm system inspection and failed to ensure lighting was restricted to electricity only. Both deficiencies affected all 30 residents in the facility.
Deficiencies (2)
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: The facility failed to conduct an annual fire alarm testing inspection as required. No current annual fire alarm testing documentation was found.
19 CSR 30-86.032(14) Lighting-Electric Only: The facility failed to ensure lighting was restricted to electricity only, as evidenced by the presence of candles and oil lamps with previously burnt wicks.
Report Facts
Facility census: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Signed the plan of correction | |
| Administrator | Interviewed regarding fire alarm inspection and lighting issues | |
| Plant Operations Manager | Responsible for ensuring fire alarm inspections and resident room audits |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The document is a plan of correction following a deficiency related to hazardous area requirements in an assisted living facility.
Findings
The facility failed to ensure that doors to hazardous areas were self-closing and kept closed unless equipped with an electromagnetic hold-open device interconnected with the fire alarm system. Specifically, the laundry room door did not have a self-closing device.
Deficiencies (1)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to ensure doors to hazardous areas were self-closing and kept closed unless an electromagnetic hold-open device interconnected with the fire alarm system was used. The laundry room door lacked a self-closing device.
Report Facts
Facility census: 33
Inspection Report
Routine
Census: 35
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding timely notification to residents, representatives, and the State Long-Term Care Ombudsman before transfer or discharge, and to evaluate medication administration practices.
Findings
The facility failed to send timely written transfer or discharge notices to the Ombudsman affecting some residents. Additionally, the facility had a 52% medication error rate, including crushing medications that should not be crushed, incorrect medication administration, and improper application of eye drops.
Deficiencies (2)
Failed to send a written copy of transfer or discharge notice to a representative of the State Long-Term Care Ombudsman.
Failed to administer medications with less than 5% error rate; made 13 medication errors out of 25 opportunities (52% error rate).
Report Facts
Medication errors: 13
Medication error rate: 52
Residents affected: 2
Residents affected: 6
Facility census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Observed crushing medications incorrectly and improper medication administration. |
| RN B | Registered Nurse | Observed improperly administering eye drops, including touching eye with dropper and insufficient lacrimal pressure. |
| Director of Nursing | Director of Nursing (DON) | Provided information on medication crushing policies and proper eye drop administration. |
| Social Service Director | Social Service Director | Interviewed regarding failure to send transfer/discharge notifications to Ombudsman. |
| Administrator | Administrator | Interviewed about monthly discharge and transfer reports to Ombudsman. |
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident transfer/discharge notifications and medication error rates, and to review the facility's plan of correction for cited deficiencies.
Findings
The facility failed to notify the State Long-Term Care Ombudsman of resident transfers or discharges as required, affecting two sampled residents. Additionally, the facility had a medication error rate exceeding 5%, with 13 errors out of 25 opportunities, affecting six sampled residents.
Deficiencies (2)
F623 - The facility failed to send a written copy of transfer or discharge notice to the State Long-Term Care Ombudsman, affecting two of 12 sampled residents. The facility census was 35.
F759 - The facility failed to ensure medication error rates were below 5%, with 13 errors out of 25 opportunities resulting in a 52% error rate. Errors included incorrect medication administration and failure to follow policies affecting six sampled residents.
Report Facts
Facility census: 35
Medication error rate: 52
Sampled residents affected: 6
Sampled residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Discussed transfer/discharge notification procedures and medication administration during interviews |
| Administrator | Administrator | Provided information about monthly discharge and transfer reports to Ombudsman |
| Executive Director | Executive Director | Signed the plan of correction |
Inspection Report
Life Safety
Census: 35
Capacity: 40
Deficiencies: 28
Date: Mar 9, 2023
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with emergency preparedness, fire safety, and building safety regulations at Linden Woods Village.
Findings
The facility was found deficient in emergency preparedness policies, fire alarm systems, sprinkler system maintenance, means of egress, emergency lighting, and smoke barrier integrity. Several deficiencies were cited related to fire safety equipment, emergency lighting, door locking mechanisms, and storage of oxygen cylinders.
Deficiencies (28)
E015 - The facility failed to ensure policies and procedures addressed subsistence needs for staff and patients during emergencies, including alternate power sources for emergency lighting and fire alarm systems.
A1135 - The facility lacked adequate emergency lighting and generator testing per NFPA 101 standards.
A2008 - Hazardous areas were not properly separated by fire-resistant construction or automatic sprinkler systems.
A2018 - The fire alarm system was incomplete and lacked required visual and audible alarms throughout the building.
A2034 - The sprinkler system was not properly maintained or tested as required by regulations.
A2037 - Exit requirements were not met, including insufficient unobstructed exits and improper door locking arrangements.
A2041 - Door locks did not comply with NFPA 101 requirements for emergency egress and delayed egress locking systems.
A2050 - Emergency lighting was insufficient and lacked proper testing and documentation.
A2054 - Smoke section walls and doors were not properly constructed or maintained to provide required fire resistance.
A2058 - The facility failed to request annual fire department consultation and maintain an up-to-date fire evacuation plan.
A3001 - The building was not substantially constructed or maintained in good repair according to fire safety standards.
A3030 - Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards.
A3037 - Extension cords and duplex receptacles were improperly used and not UL-approved.
K000 - The facility did not meet the Life Safety Code requirements for means of egress, including proper locking arrangements and signage.
K211 - Means of egress were obstructed or improperly maintained, including locked gates and delayed egress doors without proper signage.
K222 - Egress doors were not properly equipped with approved locking devices and lacked appropriate signage for delayed egress.
K223 - Doors with self-closing devices were propped open or restricted, impeding proper fire safety function.
K226 - Horizontal exits lacked proper fire barriers and monitoring to ensure safety and compliance.
K372 - Smoke barriers were not continuous and had unsealed penetrations compromising fire resistance.
K374 - Doors in smoke barriers were not self-closing or automatic-closing as required.
K711 - The facility lacked a complete evacuation and relocation plan with staff training and communication protocols.
K901 - Building systems were not assigned a risk assessment category and lacked documented risk management procedures.
K914 - Electrical systems, including hospital-grade receptacles, were not properly maintained or tested annually.
K918 - Essential electrical systems, including emergency generators, were not properly maintained or tested monthly.
K920 - Power strips and extension cords were improperly used in resident care areas and not regularly audited.
K923 - Oxygen storage areas were improperly maintained with combustible materials stored too close to oxygen tanks.
K353 - Sprinkler system maintenance and testing were incomplete, and the facility failed to maintain sprinkler heads free from obstructions.
K343 - Fire alarm system testing and maintenance were inadequate, and staff failed to maintain the system according to NFPA standards.
Report Facts
Facility capacity: 40
Census: 35
Deficiencies cited: 32
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 2
Date: Apr 21, 2022
Visit Reason
This document is a plan of correction related to deficiencies found during a facility inspection on 04/21/2022.
Findings
The facility failed to properly perform monthly pressure gauge readings and valve position checks on the sprinkler system and did not have documentation of electrical wiring inspections within the last two years. These deficiencies potentially affected all 27 residents present at the time of inspection.
Deficiencies (2)
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to perform monthly pressure gauge readings and valve position checks on the sprinkler system as required. No monthly sprinkler valve check sheets or inspection documentation were available.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to show documentation of electrical wiring inspections within the last two years by a qualified electrician. No records were available for an electrical inspection.
Report Facts
Facility census: 27
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 1
Date: Mar 22, 2022
Visit Reason
The inspection was conducted to investigate medication administration documentation compliance related to blood sugar checks and insulin administration for residents.
Findings
The facility failed to ensure blood sugar checks and insulin administration were appropriately documented for sampled residents. Interviews revealed gaps in documentation and staff communication regarding medication administration.
Deficiencies (1)
19 CSR 30-86.047(47)(G) Medication Administration, Documented: The facility failed to document blood sugar checks and insulin administration for two sampled residents as required. Documentation gaps included missing records of medication administration and reasons for missed doses.
Report Facts
Facility census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication administration and staff certification | |
| Administrator | Interviewed regarding staff documentation practices |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 31, 2021
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC regulations and recommendations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from September 24 to September 30, 2020, to assess compliance with relevant CMS and CDC requirements.
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 9, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted on June 9, 2020 to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness. No deficiencies were cited.
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 4
Date: Mar 10, 2020
Visit Reason
The document is a statement of deficiencies from a fire safety inspection conducted on March 10, 2020, identifying regulatory noncompliance issues at the facility.
Findings
The facility failed to meet fire safety regulations related to locked exit doors, complete fire alarm systems, smoke section partitions, and electrical wiring maintenance. These deficiencies potentially affect all 34 residents present during the inspection.
Deficiencies (4)
19 CSR 30-86.022(7)(E) Locked Exit Doors: The facility failed to ensure egress door locks did not require a key, tool, or special knowledge to unlock from inside. A keyed cylinder was found on an exit door, requiring a key to exit.
19 CSR 30-86.022(9)(A)(1) Smoke Detectors-NFPA 13: The facility lacked a complete fire alarm system; a smoke detector was missing in the front foyer, compromising alarm coverage.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to maintain a one-hour rated smoke partition door that did not fully close and latch, and had a hole cut in the fire-rated wall.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Electrical outlets were not protected by ground fault interrupter circuits and were located within six feet of water sources, posing a safety hazard.
Report Facts
Facility census: 34
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| maintenance director | Interviewed regarding locked exit doors, smoke detector absence, smoke partition door, and electrical outlet issues |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 4
Date: Jan 9, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, and infection control at Linden Woods Village nursing home.
Findings
The facility was found deficient in providing adequate personal hygiene care, safe resident transfers, catheter care to prevent urinary tract infections, and proper administration and documentation of tuberculosis testing. Several residents were affected by incomplete perineal care, improper use of mechanical lifts and gait belts, and failure to clean catheter tubing and drainage equipment properly.
Deficiencies (4)
Failed to ensure dependent residents received complete perineal care, affecting two of 12 sampled residents.
Failed to ensure staff used proper techniques to reduce accidents or injuries during resident transfers using mechanical lifts and gait belts, affecting three of 12 sampled residents.
Failed to provide catheter care in a manner to prevent urinary tract infection, including improper cleaning of catheter tubing and placing drainage equipment on the floor, affecting one of 12 sampled residents.
Failed to provide care to prevent infection by not administering, reading, and documenting Two-Step Tuberculin tests in a timely manner for three of 12 sampled residents.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 3
Census: 35
Fluid volume: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in perineal care deficiency for improper hygiene technique |
| CNA B | Certified Nurse Aide | Named in perineal care deficiency and transfer technique deficiency |
| CNA F | Certified Nurse Aide | Named in perineal care deficiency and catheter care deficiency |
| CNA E | Certified Nurse Aide | Named in transfer technique deficiency and catheter care deficiency |
| Director of Nursing | Director of Nursing | Provided interview statements regarding proper care and transfer techniques |
| Administrator | Administrator | Provided interview regarding TB documentation system limitations |
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 4
Date: Jan 9, 2020
Visit Reason
The document is a Plan of Correction submitted by Linden Woods Village following a facility inspection conducted on 01/09/2020. It addresses deficiencies cited during the inspection related to resident care and safety.
Findings
The facility was found deficient in providing adequate ADL care for dependent residents, ensuring a safe resident environment free of accident hazards, and providing proper catheter care to prevent urinary tract infections. Deficiencies were documented in resident care plans, staff procedures, and infection control.
Deficiencies (4)
F 677: The facility failed to provide necessary ADL care to dependent residents, including proper perineal care and hygiene, affecting 12 sampled residents. Staff did not follow procedures to prevent skin irritation and maintain personal hygiene.
F 689: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents during transfers and ambulation for 3 sampled residents.
F 690: The facility failed to provide catheter care in a manner to prevent urinary tract infections or the possibility of UTI for one sampled resident. Staff failed to clean catheter tubing and drainage spout properly.
F 880: The facility failed to establish and maintain an infection prevention and control program, including proper TB testing and staff education, affecting residents with potential communicable disease risks.
Report Facts
Facility census: 35
Sampled residents affected: 12
Sampled residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Xantry Hyles | Executive Director | Signed the Plan of Correction document |
| Unnamed Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff procedures and care plans |
Inspection Report
Life Safety
Census: 35
Capacity: 40
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association, specifically focusing on electrical systems maintenance and testing.
Findings
The facility failed to perform the required annual inspection and testing of non-hospital grade electrical receptacles in resident rooms. No residents were negatively impacted, but all residents may be at risk due to this deficiency.
Deficiencies (1)
K914 Electrical Systems (receptacles) were not tested annually as required by NFPA 101. The maintenance supervisor was unfamiliar with the inspection process and it had not been performed.
Report Facts
Facility capacity: 40
Resident census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lanytta Hyles | Executive Director | Signed the Plan of Correction and statement of deficiencies |
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 4
Date: Mar 19, 2019
Visit Reason
The inspection was conducted to assess compliance with fire safety and construction regulations at Linden Woods Village, including inspection rights, fire alarm system records, building construction, and electrical wiring maintenance.
Findings
The facility failed to prevent a fire hazard related to storage of gas-powered equipment, did not maintain proper fire alarm system records, failed to properly maintain fire separation doors, and did not maintain the electrical system as required. Deficiencies had the potential to affect all 38 residents.
Deficiencies (4)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard. The facility failed to prevent a fire hazard by storing a gas-powered snow blower and gas can in the same room as large gas water heaters. The maintenance supervisor removed the hazard during the inspection.
19 CSR 30-86.022(9)(F) Fire Alarm System Records. The facility failed to provide copies of the semi-annual fire alarm system inspection report. The annual fire alarm inspection was completed on March 18, 2019.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to properly maintain fire separation doors; the first floor stairway door did not close and latch properly when released from the open position.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to maintain the electrical system; exposed wires in an open electrical junction box lacked wire nuts. The maintenance supervisor planned to correct this deficiency.
Report Facts
Facility census: 38
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 15, 2018
Visit Reason
Annual licensure inspection of Linden Woods Village to assess compliance with state and federal health facility regulations.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 39
Capacity: 40
Deficiencies: 7
Date: Nov 15, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain required two-hour fire barrier separations, corridor doors, smoke barriers, and fire drills as per NFPA 101 standards. Several deficiencies were identified related to fire safety construction, door closures, smoke barrier integrity, and fire drill scheduling.
Deficiencies (7)
K-133: The facility failed to maintain the two-hour fire barrier separation between the skilled unit and common area, with holes around pipes and wires not filled with fire-rated material.
K-363: Corridor doors failed to close in one action as required by NFPA 101, with wedges holding doors open and air drafts preventing closure.
K-372: The facility failed to maintain and construct smoke barrier walls as required by NFPA 101, with missing smoke barriers in the attic and holes/gaps in smoke barrier walls.
K-374: Smoke barrier doors failed to close upon fire alarm activation, affecting three of five smoke compartments.
K-712: Fire drills were not conducted at varied times to ensure staff proficiency in emergency response.
A2019: The facility failed to maintain the complete fire alarm system in accordance with NFPA 72 standards.
A3001: The building was not substantially constructed and maintained in good repair per 19 CSR 30-85.032(2) requirements.
Report Facts
Facility bed capacity: 40
Resident census: 39
Deficiency counts: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Larry Wilson | Executive Director | Signed the plan of correction and report |
| Maintenance Supervisor | Interviewed regarding fire barrier and door issues | |
| Regional Plant Operations Director | Interviewed regarding smoke barrier walls |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 3
Date: Nov 14, 2018
Visit Reason
The inspection was conducted to assess compliance with regulations related to tuberculosis screening, individualized service plans, and self-control of medication in an assisted living facility.
Findings
The facility failed to screen four sampled residents for tuberculosis as required, failed to ensure individualized service plans were completed and signed for six of seven sampled residents, and failed to ensure proper physician orders and labeling for self-administered medications for two residents. The facility census was 37 at the time of inspection.
Deficiencies (3)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to screen four sampled residents for tuberculosis as required by regulations. The TB test results were not properly documented including dates given and read.
19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures: The facility failed to ensure six of seven sampled residents had individualized service plans completed and signed by an authorized representative and the resident or legal representative upon admission and annually.
19 CSR 30-86.047(40) Self-Control of Medication Requirements: The facility failed to ensure two residents had physician orders for self-administered medications and that medications were current, properly labeled, and stored correctly.
Report Facts
Facility census: 37
Sampled residents for ISP: 7
Sampled residents for TB screening: 4
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Mar 26, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment related to misappropriation of resident property at Linden Woods Village.
Complaint Details
The complaint involved an allegation of misappropriation of resident property by a staff member. The investigation found the facility failed to follow policy, did not separate the alleged perpetrator, and failed to notify appropriate parties. The allegation was substantiated based on the investigation and evidence.
Findings
The facility failed to follow its policy in response to an allegation of theft for one resident, did not investigate properly, and did not separate the alleged perpetrator from residents pending investigation. The administrator and Director of Nursing failed to notify appropriate parties and take timely corrective actions. The alleged perpetrator was a Certified Nurse Aide who was terminated after the investigation.
Deficiencies (2)
F610 The facility failed to thoroughly investigate an allegation of misappropriation of resident property and did not prevent further potential abuse during the investigation. The facility did not notify appropriate agencies or take timely corrective actions as required by policy.
A8023 The facility did not develop and implement written policies prohibiting mistreatment, neglect, and misappropriation of resident property, and failed to report such incidents to the appropriate authorities.
Report Facts
Resident census: 37
Amount of credit card purchases: 769.91
Amount of merchandise purchased: 770
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in failure to investigate and notify regarding theft allegation |
| Administrator | Administrator | Named in failure to investigate and notify regarding theft allegation |
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 8
Date: Feb 27, 2018
Visit Reason
The document is a Plan of Correction submitted by Linden Woods Village following a survey conducted on 02/27/2018. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including resident rights, medication administration, infection control, nursing care, and food safety. Specific issues included failure to ensure dignified care, medication errors, inadequate infection control practices, and improper food handling.
Deficiencies (8)
F-550 Resident Rights. The facility failed to ensure residents were cared for in a dignified manner, affecting seven of 19 sampled residents. Staff were observed rushing residents and not adequately assisting with personal care.
F-658 Services Provided Meet Professional Standards. The facility failed to follow professional standards of care for medication administration, including improper use of insulin pens and inhalers for Resident #15.
F-677 ADL Care for Dependent Residents. The facility failed to provide adequate assistance with activities of daily living, including perineal care and urinary catheter care, for several residents.
F-689 Free of Accident Hazards. The facility failed to ensure proper use of gait belts and adequate supervision to prevent accidents for residents requiring assistance.
F-759 Free of Medication Error Rates 5 Percent or More. The facility had a medication error rate of 25.93%, failing to ensure staff administered medications correctly for 19 sampled residents.
F-761 Label/Store Drugs and Biologicals. The facility failed to properly label and store medications, including multidose vials and injectable medications, and did not discard medications timely.
F-812 Food Procurement, Storage, Preparation, Service, Sanitary Conditions. The facility failed to maintain sanitary conditions in food service, including failure to clean tables and restrain hair of dietary staff.
F-880 Infection Prevention and Control. The facility failed to maintain an effective infection control program, including improper hand hygiene, wound care, and cleaning practices, affecting multiple residents.
Report Facts
Resident census: 36
Medication error rate: 25.93
Medication errors: 7
Inspection Report
Life Safety
Census: 36
Capacity: 40
Deficiencies: 9
Date: Feb 27, 2018
Visit Reason
The inspection was conducted to evaluate compliance with fire safety and life safety codes, including fire alarm systems, sprinkler systems, fire drills, and fire door assemblies.
Findings
The facility failed to maintain the two-hour separation between the skilled unit and common area fire barrier, did not conduct required semi-annual fire alarm inspections and testing, failed to maintain the sprinkler system with quarterly inspections, and did not conduct fire drills on the third shift at varied times. Fire door assemblies were not inspected according to NFPA 80 standards.
Deficiencies (9)
K133 Multiple Occupancies - Construction Type: The facility failed to maintain the two-hour separation between the skilled unit and common area fire barrier, with gaps around pipes and conduits not filled with fire rated material.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to conduct required semi-annual fire alarm inspections and testing, and staff did not activate the fire alarm monthly as required.
K351 Sprinkler System - Installation: The facility failed to maintain the sprinkler system with quarterly testing and inspections, missing the quarterly inspection for August 2017.
K712 Fire Drills: The facility failed to conduct fire drills on the third shift at varied times to assure staff proficiency in response.
A2019 Fire Alarm System-Test/Maintain: The facility did not maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition.
A2022 Fire Alarm System, Monthly Activation: The facility did not test the complete fire alarm system at least once a month as required.
A2034 Sprinkler System-Test/Maintain: The facility did not inspect, maintain, and test the sprinkler system as required by regulations.
A2064 Fire Safety Training Requirements-employee: The facility failed to provide fire safety training to all employees during orientation, at least every six months, and when training needs were identified.
A3001 Substantially Constructed/Maintained: The building was not maintained in good repair according to construction standards effective January 1, 1999.
Report Facts
Bed capacity: 40
Resident census: 36
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kaytlyn Lyles | Executive Director | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 6
Date: Feb 27, 2018
Visit Reason
The inspection was conducted to identify deficiencies in compliance with regulations for an assisted living facility and to review the facility's plan of correction.
Findings
The facility failed to use the required community based assessment form for admission, did not implement a safe and effective medication system, failed to reconcile controlled substance medications each shift, did not complete medication regimen reviews at least every other month, and failed to document disclosure of resident rights. Multiple deficiencies were noted related to medication administration, record keeping, and resident rights documentation.
Deficiencies (6)
19 CSR 30-86.047(28)(F)(3) Community Based Assessment - Other Form: The facility failed to use the MO 580-2835 form for community based assessments for three sampled residents. The facility census was 33.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to implement a safe medication system when staff did not prime insulin pens and did not administer ordered medications to residents. The facility census was 33.
19 CSR 30-86.047(51)(A)(1) Schedule II Meds-Reconcile Each Shift, Record: The facility failed to reconcile controlled substance medications each shift as required. The facility census was 33.
19 CSR 30-86.047(54) Drug Regimen Review: The facility failed to have a physician, pharmacist, or registered nurse review the medication regimen at least every other month for three sampled residents. The facility census was 33.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to complete monthly summaries of resident condition and needs for three sampled residents. The facility census was 33.
19 CSR 30-88.010(6) Disclosure of Res Rights Info Documented: The facility failed to document the disclosure of annual resident rights for one of three sampled residents. The facility census was 33.
Report Facts
Facility census: 33
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