Inspection Reports for
Livingston Manor Care Center
939 E BIRCH DR, CHILLICOTHE, MO, 64601-2189
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
33% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 11
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, safety, and facility management.
Findings
The facility was found deficient in multiple areas including improper management of resident personal funds, inadequate surety bond coverage, failure to complete employee background checks, incomplete discharge summaries, improper respiratory care, insufficient RN staffing coverage, failure to maintain medication refrigerator temperatures, inaccurate menu posting and meal preparation, unsanitary kitchen conditions, and lack of a documented water management program.
Deficiencies (11)
Failed to properly hold, secure, and manage each resident's personal money deposited with the nursing home, including failure to reimburse discharged residents timely.
Failed to maintain a surety bond amount sufficient to cover residents' funds held in the Resident Trust Fund account.
Failed to complete employee background checks, including Certified Nurse Aide Registry checks, prior to staff working with residents.
Failed to complete discharge summaries for two sampled residents.
Failed to provide safe and appropriate respiratory care, including undated oxygen and nebulizer tubing and lack of CPAP orders for a resident.
Failed to ensure a registered nurse was on duty for eight consecutive hours per day, seven days per week.
Failed to ensure medication room refrigerator temperature was checked daily and maintained properly.
Failed to ensure menus were posted in advance, followed, and residents were provided choices consistent with their preferences.
Failed to ensure pureed food was prepared with a smooth, pudding-like consistency without chunks.
Failed to maintain kitchen and food storage areas in a sanitary manner, including food stored uncovered or undated and dirty kitchen surfaces.
Failed to establish and maintain a documented water management program to minimize risk of Legionella outbreaks.
Report Facts
Facility census: 31
Resident trust fund average monthly balance: 36673.99
Required surety bond amount: 56775
Surety bond amount: 60000
Deficiency counts: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in respiratory care deficiency related to oxygen and CPAP management |
| Business Office Manager | Interviewed regarding resident personal funds management | |
| Administrator | Interviewed regarding multiple deficiencies including resident funds, surety bond, respiratory care, and staffing | |
| Dietary Manager | Interviewed regarding menu planning and kitchen sanitation deficiencies | |
| Social Services Director | Interviewed regarding discharge summary deficiencies | |
| Director of Nursing | Interviewed regarding discharge summaries, respiratory care, and staffing | |
| Maintenance Supervisor | Interviewed regarding water management program deficiency |
Inspection Report
Routine
Census: 31
Deficiencies: 2
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with nutritional menu planning and food service sanitation standards at Livingston Manor Care Center.
Findings
The facility failed to ensure menus were posted in advance and followed, affecting three sampled residents. Additionally, the kitchen and food storage areas were found to be unsanitary with multiple sanitation violations observed.
Deficiencies (2)
Menus were not posted in advance and were not followed, affecting residents' nutritional needs and choices.
Food was not stored in a sanitary manner and the kitchen was not maintained in a sanitary condition.
Report Facts
Residents affected: 3
Facility census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding menu choices and kitchen sanitation | |
| Activities Director | Interviewed regarding resident meal choices on memory care unit | |
| Registered Dietitian | Interviewed regarding food storage and kitchen sanitation | |
| Administrator | Interviewed regarding expectations for dietary department and kitchen sanitation |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Jun 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #2 physically abused Resident #1 by hitting him/her in the head.
Complaint Details
The complaint investigation found that Resident #2 hit Resident #1 in the head on 5/23/25. The facility staff did not place Resident #2 on increased supervision until the resident was moved to the secured memory care unit on 5/29/25. Neither resident recalled the incident or was targeting the other. The physician adjusted Resident #2's medication and started antibiotics after a positive urine analysis for infection.
Findings
The facility failed to protect Resident #1 from physical abuse by Resident #2. Staff did not place Resident #2 on increased monitoring until six days after the incident, despite the facility's abuse policy requiring protective measures. Resident #2 was moved to a secured memory care unit only after approval from the responsible party.
Deficiencies (1)
Failure to protect Resident #1 from physical abuse by Resident #2, including delayed increased monitoring of Resident #2 after the incident.
Report Facts
Residents affected: 2
Facility census: 37
Date of incident: May 23, 2025
Date Resident #2 moved to secured unit: May 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Reviewed camera footage and described incident; instructed staff to monitor Resident #2 closely | |
| Charge Nurse | Assessed residents after incident and notified physician, administrator, and responsible parties | |
| Physician | Reviewed and adjusted Resident #2's medication and ordered urine analysis | |
| Dietary Staff | Notified nursing staff of the incident and intervened during the abuse |
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 2
Date: Apr 5, 2025
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control regulations, specifically focusing on hand hygiene and enhanced barrier precautions related to wound care for residents.
Findings
The facility failed to maintain standard infection control precautions, including hand hygiene and use of personal protective equipment during wound care for two residents. Deficiencies included lack of PPE carts, inadequate signage for enhanced barrier precautions, and staff not following proper hand hygiene protocols.
Deficiencies (2)
F880 Infection Prevention and Control: The facility failed to maintain standard infection control precautions, including hand hygiene and use of personal protective equipment during wound care for two residents. Staff did not wear gowns or perform hand hygiene as required, and PPE carts and signage were missing.
A4086 Infection Control/Communicable Disease: The facility did not meet infection control requirements to report communicable diseases within seven days as required by Missouri regulations. This deficiency is related to F880.
Report Facts
Facility census: 33
BIMS score: 15
Mental status score: 10
Date of survey: Apr 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in infection control deficiency related to improper hand hygiene and PPE use during wound care |
| CNA A | Certified Nurse Aide | Named in infection control deficiency related to improper hand hygiene and PPE use during wound care |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff expectations for PPE and hand hygiene during wound care |
Inspection Report
Routine
Census: 33
Deficiencies: 4
Date: Apr 5, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, specifically regarding hand hygiene and use of personal protective equipment during wound care.
Findings
The facility failed to maintain standard infection control precautions, including inadequate hand hygiene during glove changes and failure to wear protective gowns during wound care for residents on Enhanced Barrier Precautions (EBP). The facility lacked PPE carts and signage near resident rooms and did not obtain physician orders for EBP. These deficiencies affected two sampled residents.
Deficiencies (4)
Failure to perform hand hygiene with glove changes during wound care for two residents.
Failure to wear personal protective gowns when assisting with wound care for a resident on Enhanced Barrier Precautions.
Lack of PPE carts and signage near or outside resident rooms indicating EBP precautions.
Failure to obtain physician orders to implement Enhanced Barrier Precautions for residents with wounds.
Report Facts
Facility census: 33
Number of residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings related to failure to perform hand hygiene and improper glove use during wound care |
| CNA A | Certified Nurse Aide | Named in findings related to failure to perform hand hygiene and improper use of protective gowns |
| Director of Nursing | Director of Nursing | Provided interview detailing expected infection control practices and deficiencies |
Inspection Report
Routine
Census: 29
Deficiencies: 24
Date: May 30, 2024
Visit Reason
Routine state inspection of Livingston Manor Care Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide dignified care, inadequate resident council grievance handling, improper management of resident funds, incomplete resident rights education, inaccurate resident assessments and care plans, medication administration errors, environmental maintenance issues, and infection control lapses.
Deficiencies (24)
Staff failed to treat residents with dignity and respect during meal assistance and blood sugar monitoring in the dining room.
Facility failed to act promptly and resolve resident grievances and did not maintain documentation of concerns or follow-up.
Residents lacked access to personal funds after business hours and facility failed to maintain proper accounting of resident funds.
Facility failed to inform residents of their rights periodically during their stay.
Facility failed to clarify and document advance directive status for a resident, with conflicting code status orders.
Facility used incorrect Medicare Advance Beneficiary Notice forms for some residents.
Facility environment was not maintained in a clean, comfortable, and homelike manner with issues including temperature control, broken tiles, dust, odors, and missing blinds.
Facility failed to ensure residents had access to grievance forms, the ability to file anonymous grievances, and knowledge of grievance officers.
Facility failed to complete required background checks, disqualification list checks, and nurse aide registry checks prior to employment for multiple staff.
Facility failed to complete accurate comprehensive assessments and care plans reflecting resident preferences and needs for multiple residents.
Facility failed to employ a qualified activity professional and failed to provide meaningful activities to residents, especially those with dementia.
Facility failed to provide appropriate pressure ulcer care including offloading heels, completing skin assessments, and dressing checks.
Staff failed to lock wheelchairs during mechanical lifts for resident transfers.
Staff failed to provide proper catheter care including cleaning catheter tubing and drainage spout and placing graduate on a barrier.
Staff failed to provide proper respiratory care including ensuring oxygen tubing was dated and changed weekly, humidifier bottle contained sterile water, and tubing was not on the floor.
Facility failed to assess residents for bed rail entrapment risks, obtain physician orders, and measure entrapment zones for installed bed rails.
Staff failed to provide adequate personal hygiene care including perineal care, oral care, face and hand washing, and shaving per resident preferences.
Staff failed to provide safe and effective medication administration including crushing enteric coated tablets, improper nasal spray administration, and failure to prime insulin pens.
Facility failed to ensure medications were properly labeled, stored, and not left at bedside; medication carts were unclean.
Facility failed to complete discharge summary for a discharged resident.
Facility failed to employ a registered nurse for eight consecutive hours per day, seven days per week.
Facility failed to ensure food safety including hand hygiene, food temperature monitoring, dishwasher testing, food labeling and storage, and sanitation practices.
Facility failed to maintain an effective infection prevention and control program including incomplete tuberculosis screening and lack of hand sanitizer on memory care unit.
Call light systems were not accessible or functional for multiple residents with call lights out of reach, draped over bed fixtures, or missing cords.
Report Facts
Medication errors: 8
Resident census: 29
Medication administration omissions: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in medication administration errors including insulin pen priming and nasal spray administration |
| CNA H | Certified Nurse Aide | Named in catheter care and perineal care deficiencies |
| CNA I | Certified Nurse Aide | Named in catheter care and call light accessibility |
| Dietary Manager | Dietary Manager | Named in hand hygiene and food safety deficiencies; lacked certification |
| Administrator | Administrator | Named in multiple interviews regarding facility expectations and deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding facility expectations and deficiencies |
| Activity Director | Activity Director | Named in activity program deficiencies and lack of certification |
| Maintenance Supervisor | Maintenance Supervisor | Named in environmental and call light maintenance deficiencies |
| Business Office Manager | Business Office Manager | Named in employee background check and resident funds deficiencies |
Inspection Report
Life Safety
Census: 29
Capacity: 94
Deficiencies: 9
Date: May 30, 2024
Visit Reason
The inspection was conducted as an emergency preparedness survey and life safety code compliance check for the facility.
Findings
The facility was found to be in substantial compliance with emergency preparedness regulations with no deficiencies cited. However, multiple life safety code deficiencies were identified related to means of egress, vertical openings, sprinkler system maintenance, and electrical equipment safety.
Deficiencies (9)
K211 Means of Egress - General: The facility failed to ensure a hard path of safety out all exit doors and failed to ensure residents could move away from the building during an emergency due to a locked courtyard requiring a padlock code.
K311 Vertical Openings - Enclosure: The facility failed to ensure there were no penetrations through the ceiling in seven smoke sections, potentially affecting residents in dining rooms.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure all sprinkler heads were in good condition, with six heads discolored green indicating corrosion.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure safe electrical wiring, allowing six-way adaptors and surge protectors improperly used in patient care areas.
A1065 Drinking Fountains: The facility failed to ensure water fountains worked properly; several fountains were non-functional or covered, affecting residents' access.
A2007 Noncombustible Material Between Floors: The facility failed to fire-stop openings between floors with suitable noncombustible material.
A2034 Sprinkler System-Test/Maintain: The facility failed to maintain and test sprinkler systems in accordance with regulations.
A3001 Substantially Constructed/Maintained: The facility failed to maintain the building in good repair per construction standards.
A3037 Extension Cords/Duplex Receptacles: The facility failed to ensure extension cords and adaptors met safety standards and were not subject to physical damage.
Report Facts
Facility capacity: 94
Resident census: 29
Deficiencies cited: 9
Inspection Report
Abbreviated Survey
Census: 29
Deficiencies: 5
Date: Feb 26, 2024
Visit Reason
The visit was an abbreviated survey conducted to investigate allegations of resident-to-resident sexual abuse and to assess the facility's compliance with abuse and neglect regulations.
Complaint Details
The investigation was complaint-driven based on allegations of resident-to-resident sexual abuse. The immediate jeopardy was removed during the survey, and the deficiency severity was lowered. The complaint was substantiated.
Findings
The facility failed to protect residents from sexual abuse and failed to report allegations of abuse within required timeframes. Immediate jeopardy was identified but later removed, and the severity of the deficiency was lowered to level D at exit.
Deficiencies (5)
F600: The facility failed to protect two residents from resident-to-resident sexual abuse and did not report the incidents to the Administrator or Director of Nursing in a timely manner.
F609: The facility failed to report allegations of resident-to-resident sexual abuse to the Department of Health and Senior Services within the required timeframe for three residents.
F610: The facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse and did not prevent further potential abuse during the investigation.
A8022: The facility did not meet the requirement to be free from abuse, including verbal abuse, corporal punishment, and involuntary seclusion.
A8025: The facility failed to report allegations of abuse to the Department of Health and Senior Services as required by state regulations.
Report Facts
Facility census: 29
Date of survey: Feb 26, 2024
Date of corrective action completion: Mar 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Witnessed inappropriate resident interaction and failed to report it immediately |
| LPN A | Licensed Practical Nurse | Nurse on duty who was informed of the resident interaction |
| Administrator | Interim Administrator | Notified of immediate jeopardy and involved in corrective action plan |
| Director of Nursing | Director of Nursing | Responsible for reporting and investigating allegations of abuse |
| Certified Medication Technician A | Certified Medication Technician | Observed and reported resident interaction involving sexual behavior |
Inspection Report
Abbreviated Survey
Census: 29
Deficiencies: 3
Date: Feb 26, 2024
Visit Reason
The visit was conducted due to allegations and observations of resident to resident sexual abuse and failure to timely report and investigate these incidents.
Findings
The facility failed to protect residents from sexual abuse by another resident, failed to timely report the abuse to the state authorities, and failed to thoroughly investigate and document the incidents. Immediate jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (3)
Failed to protect residents from resident to resident sexual abuse.
Failed to timely report allegations of resident to resident sexual abuse to the Department of Health and Senior Services.
Failed to follow facility policy and thoroughly investigate allegations of resident to resident sexual abuse.
Report Facts
Facility census: 29
Delay in management: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to report and investigate sexual abuse incidents |
| LPN B | Licensed Practical Nurse | Witnessed sexual abuse incident but failed to report to Administrator |
| Certified Medication Technician A | Certified Medication Technician | Observed and reported sexual abuse incident between residents |
| Administrator | Facility Administrator | Unaware of incidents until reported; expected timely reporting and investigation |
| DON | Director of Nursing | Expected to be notified of abuse incidents and to ensure investigations |
| Transportation aide | Facility Transportation Aide | Observed sexual abuse incident and later reported it to Administrator |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 25, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
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
Annual Inspection
Deficiencies: 0
Date: May 25, 2023
Visit Reason
Annual survey inspection of Livingston Manor Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 4
Date: Oct 5, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to resident trust fund security, treatment and care according to orders, food preparation consistency, and kitchen sanitation.
Findings
The facility failed to maintain an adequate surety bond for resident funds, failed to properly assess and notify physicians regarding a resident's change in condition leading to death, served pureed food with inappropriate consistency, and failed to maintain kitchen sanitation and proper sanitizer levels in the dishwasher.
Deficiencies (4)
Failed to maintain a surety bond in an amount to cover any loss or theft of residents' money held in the Resident Trust Fund account.
Failed to assess and notify physician of a resident's change in condition and seizure-like activity, and improperly managed a dislodged urinary catheter leading to resident death.
Failed to ensure pureed food was prepared with a smooth, pudding-like consistency without lumps or chunks for residents with pureed diet orders.
Failed to ensure kitchen sanitation including proper dishwasher sanitizer levels, storage of toxic materials away from food, and maintenance of kitchen facilities.
Report Facts
Facility census: 39
Surety bond amount: 40000
Required surety bond amount: 45000
Dishwasher sanitizer ppm: 0
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings related to failure to assess and notify physician about resident's seizure and catheter issues |
| CNA G | Certified Nurse's Aide | Witnessed resident seizure and assisted in care |
| Administrator | Involved in resident care decisions and interviews regarding deficiencies | |
| TS A | Transportation Staff | Assisted in transporting resident to hospital |
| CNA C | Certified Nurse's Aide | Assisted in transporting resident and reported condition |
| Dietary Manager | Responsible for food preparation and interviewed regarding pureed food consistency | |
| Dietary Aide A | Responsible for dishwashing and sanitizer testing | |
| Maintenance Director | Responsible for kitchen repairs | |
| Hospital Nurse A | Provided hospital triage and care information | |
| PCP A | Primary Care Physician | Provided expectations for resident care and communication |
Inspection Report
Life Safety
Census: 39
Capacity: 94
Deficiencies: 7
Date: Oct 5, 2022
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements, including fire alarm systems, door locks, corridor requirements, and electrical systems.
Findings
The facility failed to maintain an updated emergency preparedness plan and did not meet several life safety code requirements related to egress doors, exit signage, fire alarm system testing, corridor doors, and electrical receptacle testing. Multiple deficiencies were cited with varying severity levels.
Deficiencies (7)
E004 Emergency Preparedness Plan: The facility failed to review and update their emergency preparedness plan annually as required. The plan was last documented as reviewed on 4/8/21, but the administrator was unsure of the last review date.
K222 Egress Doors: The facility failed to ensure accepted locking arrangements for controlled egress locks, including magnetic locks on doors that were not properly assessed or secured. Doors were found magnetically locked without proper safety measures.
K293 Exit Signage: The facility failed to maintain illuminated exit signs with annual 90-minute testing on battery backup. Records showed no annual testing was completed as required.
K345 Fire Alarm System Testing: The facility failed to maintain the fire alarm system in accordance with NFPA 72. Records lacked credentials and evidence of proper inspections and testing.
K363 Corridor Doors: The facility failed to maintain corridor doors to resist passage of smoke, with gaps and improper hardware observed. Doors were not checked monthly during fire drills as required.
K901 Building System Categories: The facility failed to assign and document risk assessment categories for building systems as required by NFPA 99. Records lacked categorical risk assessments for building systems.
K914 Electrical Systems Testing: The facility failed to complete and document annual testing of non-hospital grade electrical receptacles in patient sleeping areas. Several rooms lacked documentation of receptacle testing.
Report Facts
Facility capacity: 94
Resident census: 39
Inspection date: Oct 5, 2022
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 10
Date: Oct 5, 2022
Visit Reason
The abbreviated survey was conducted to investigate deficiencies related to financial security, quality of care, food service, and safety compliance at Livingston Manor Care Center.
Findings
The facility failed to maintain a surety bond for resident funds and did not properly assess and notify physicians regarding a resident's change in condition leading to death. Food service deficiencies included failure to prepare foods to meet individual needs and maintain sanitary conditions. The severity of the deficiencies was lowered to Class II and Class III levels after corrective actions were implemented.
Deficiencies (10)
F570 Surety Bond-Security of Personal Funds. The facility failed to maintain a surety bond in an amount sufficient to cover residents' funds in the Resident Trust Fund account.
F684 Quality of Care. The facility failed to assess and notify the physician of a resident's change in condition and seizure-like activity, resulting in inadequate emergency response and the resident's death.
F805 Food in Form to Meet Individual Needs. The facility failed to ensure staff prepared pureed foods with appropriate texture and consistency for residents with chewing difficulties.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to maintain sanitary food storage and preparation areas, including broken tiles, unclean surfaces, and improper sanitizer levels.
A4075 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A5004 Food Texture-Chewing Difficulty. The facility failed to provide appropriate food texture for residents with chewing difficulties.
A6005 Toxic Material Storage. The facility failed to store toxic materials in locked or physically separate areas away from residents.
A7043 Food Service-Dispensing Utensils Use/Storage. The facility failed to prevent contamination by improper storage and use of food service utensils.
A7076 Chemical Sanitization, PPM Measured. The facility failed to properly monitor and maintain sanitizer levels in the dishwasher and kitchen.
A9023 Resident Fund Bond Requirements. The facility failed to maintain a bond amount equal to at least 1.5 times the average monthly balance of residents' personal funds.
Report Facts
Facility census: 39
Surety bond amount: 40000
Required surety bond amount: 45000
Resident #140 admission date: Sep 15, 2022
Resident #140 discharge date: Sep 26, 2022
Resident #140 death date: Sep 26, 2022
Number of residents affected by pureed diet issue: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted 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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 16, 2021
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
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: Jun 4, 2021
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted to assess compliance with CDC and CMS guidelines.
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.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Jan 26, 2021
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to investigate infection control practices and compliance with PPE usage following complaints or concerns about staff mask usage.
Complaint Details
The investigation was complaint-related focusing on COVID-19 infection control and mask usage. The facility was found noncompliant with infection control standards based on observations and interviews.
Findings
The facility failed to maintain an infection control program to prevent the spread of COVID-19 as staff were observed not wearing masks properly or at all. Multiple observations and interviews confirmed noncompliance with mask policies, increasing risk of infection transmission.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain an infection control program to prevent the spread of COVID-19 as staff did not consistently wear face masks properly, increasing risk of transmission.
A4085 Infection Control/Communicable Disease: The facility did not meet the requirement to report communicable diseases within seven days as required by Missouri state regulations.
Report Facts
Facility census: 34
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 4
Date: Dec 21, 2020
Visit Reason
The inspection was conducted as a COVID-19 focused emergency preparedness survey and complaint investigation related to a resident injury during transport and failure to notify the resident's representative.
Complaint Details
The complaint investigation substantiated that the facility failed to notify the resident's representative of an injury sustained during transport and failed to protect the resident from accident hazards, resulting in injury and hospitalization.
Findings
The facility was found in compliance with COVID-19 emergency preparedness requirements. However, deficiencies were cited for failure to notify the resident's representative of an injury sustained during transport and failure to protect the resident from accident hazards during transport, resulting in a compression fracture and rib fracture.
Deficiencies (4)
F580 Notification of Changes: The facility failed to notify the resident's representative when the resident suffered an injury during transport and was admitted to the hospital.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to protect a resident from injury when staff allowed the resident to sit on a large pillow in a wheelchair during transport, resulting in a fall and fractures.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave as evidenced by the injury incident.
A4087 Notify Responsible Party-Change in Condition: The facility failed to immediately notify the resident's representative of a significant change in condition following the injury incident.
Report Facts
Facility census: 37
Deficiency completion date: Jan 31, 2021
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 11/17/20 to 11/24/20 to assess the facility's compliance with relevant CMS and CDC COVID-19 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: Oct 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from October 20 to October 22, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted from May 27 through June 1, 2020 to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Jan 30, 2020
Visit Reason
The inspection was conducted due to allegations of abuse involving residents at Livingston Manor Care Center.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and observations of staff behavior towards residents. The alleged abuse involved physical and verbal mistreatment by Certified Nurse Aides.
Findings
The facility failed to follow its Abuse Prevention Policy when a staff member allegedly grabbed a resident's arm and failed to report verbal abuse allegations in a timely manner. Multiple staff interviews and record reviews confirmed the incidents and inappropriate staff behavior.
Deficiencies (2)
F607: The facility failed to develop and implement written policies and procedures to prevent abuse, neglect, and exploitation. Staff did not timely report alleged abuse incidents involving residents.
A8023: The facility did not develop and implement policies prohibiting mistreatment, neglect, and abuse of residents. Reporting procedures to the department were inadequate.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelly Allred | Administrator | Named in the Plan of Correction as responsible for education and monitoring compliance |
| CNA C | Certified Nurse Aide | Involved in alleged abuse and verbal mistreatment of residents |
| CNA B | Certified Nurse Aide | Witness and reporter of abuse allegations |
| LPN A | Licensed Practical Nurse | Interviewed regarding incident reports and staff education |
| CMT A | Certified Medication Technician | Interviewed regarding staff behavior and resident care |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 4
Date: May 23, 2019
Visit Reason
The inspection was conducted as an annual survey of Livingston Manor Care Center to assess compliance with regulatory requirements related to resident rights, advance directives, and transfer/discharge notices.
Findings
The facility failed to ensure the physician signed the Out of Hospital Do Not Resuscitate (OHDNR) form for one resident. The facility also failed to provide written notices of transfer or discharge to residents or their responsible parties in a manner they understood, affecting two residents.
Deficiencies (4)
F578: The facility failed to ensure the physician signed the Out of Hospital Do Not Resuscitate form for one resident, affecting resident #29. The facility census was 40.
F623: The facility failed to provide written notices of transfer or discharge to residents or their responsible parties in a language and manner they understood, affecting residents #8 and #36. The facility census was 40.
A8010: The facility failed to inform residents or their legally authorized representatives annually about policies regarding emergency and life-sustaining care and advance directives, as required by state law.
A8018: The facility failed to provide a written notice of discharge to residents or their legally authorized representatives as soon as practicable, including the right to request an expedited hearing.
Report Facts
Facility census: 40
Sampled residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Allen | Administrator | Signed the inspection report and plan of correction |
| Cora Greene | Registered Nurse, Director of Nursing | Added the Notice of Transfer/Discharge form to the nurse station discharge packet |
Inspection Report
Life Safety
Deficiencies: 0
Date: May 23, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and Emergency Preparedness requirements.
Findings
No deficiencies were cited related to Emergency Preparedness or Life Safety Code compliance. The facility met applicable provisions of the 2012 edition of the Life Safety Code.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 4, 2018
Visit Reason
Annual licensure inspection of Livingston Manor Care Center to assess compliance with state and federal regulations.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 4, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and licensure requirements at Livingston Manor Care Center.
Findings
The Emergency Preparation portion of the survey did not result in deficiencies. The facility met the applicable provisions of the 2012 edition of the Life Safety Code. No state licensure deficiencies were cited as a result of this inspection.
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