Inspection Reports for
Luther Manor Retirement &Amp; Nursing Center
3170 HIGHWAY 61 NORTH, HANNIBAL, MO, 63401-6571
Back to Facility Profile10 Reports
Inspection Report — Oct 18, 2023
Life Safety
Date: Oct 18, 2023
Visit Reason
CMS-2567 Life Safety (federal) survey and accompanying Missouri Department of Health and Senior Services State Form; Life Safety survey (K-tags) and Emergency Preparedness findings (E-tag) were cited.
Findings
Nine federal Life Safety/Emergency Preparedness deficiencies were cited addressing emergency preparedness and multiple fire- and life-safety issues including vertical openings/ceiling penetrations, corridor doors, smoke barriers, fire drills, smoking-area disposal, fire door inspection/testing, electrical power strips/extension cords, and oxygen cylinder storage. Eight Missouri state licensure deficiencies were cited addressing construction and safety requirements including noncombustible floor barriers, oxygen storage, smoke section walls/doors, ashtray/disposal requirements, building maintenance, portable heater prohibition, electrical wiring/equipment, and electrical certification.
Deficiencies (8)
19 CSR 30-85.022(3) Noncombustible Material Between Floors: Refer to K311.
19 CSR 30-85.022(6) Oxygen Storage: Refer to K923.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Refer to K741.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(28) Heating System-No Portable: Based on observation and interview, the facility failed to prohibit portable space heater use and portable space heaters were observed in multiple staff offices.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K920.
19 CSR 30-85.032(31)(B) Electrical System-Certification Every 2 Years: Based on record review and interview, the facility failed to ensure an electrical wiring inspection/certification was conducted every two years.
Report Facts
residents potentially affected: 31
residents potentially affected: 52
residents potentially affected: 52
residents potentially affected: 17
residents potentially affected: 14
full oxygen cylinders: 50
Inspection Report — Apr 26, 2023
Complaint Investigation
Date: Apr 26, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the file cites complaint numbers MO217105 and MO217362 indicating a complaint investigation.
Complaint Details
Complaint numbers MO217105 and MO217362; substantiation not stated in the file.
Findings
The survey cited two deficiencies: one federal health deficiency and one Missouri state licensure deficiency related to transfer/discharge practices. Both items involve failure to readmit a resident and deficiencies in discharge/transfer procedures and physician coverage.
Deficiencies (1)
19 CSR 30-88.010(16) Reasons to Transfer/Discharge: Refer to F622.
Report Facts
residents sampled: 5
Inspection Report — Aug 19, 2022
Routine
Date: Aug 19, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency involving treatment/services to prevent and heal pressure ulcers and one Missouri state licensure deficiency for pressure sore prevention/treatment.
Deficiencies (1)
19 CSR 30-85.042(74) Pressure Sore Prevention/Treatment: Refer to F686.
Report Facts
residents sampled: 6
Inspection Report — Jun 10, 2022
Complaint Investigation
Date: Jun 10, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO #201359).
Complaint Details
MO #201359; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal deficiency for failure to provide required notice before transfer/discharge for a resident, and one Missouri licensure deficiency for discharge appeal/notice requirements referencing the federal finding.
Deficiencies (1)
19 CSR 30-88.010(17) Discharge Appeal Rights: See the deficiency cited at F623.
Report Facts
residents sampled: 3
residents affected: 1
Inspection Report — Feb 7, 2020
Routine
Date: Feb 7, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The CMS-2567 cited 2 federal deficiencies involving abuse/neglect policy compliance and food procurement/food safety and sanitation; the Missouri State Form cited 4 state deficiencies concerning TB infection control/screening, food protection/temperature, frozen food storage temperature, and kitchen ventilation/hood filter cleaning.
Deficiencies (4)
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Based on interview and record review, the facility failed to perform annual TB screenings for seven of 14 sampled residents.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(20) Frozen Food at Zero Degrees F or Below: Refer to F812.
19 CSR 30-87.030(55) Ventilation: Hoods, Clean, Filters Removable: Refer to F812.
Report Facts
residents_sampled: 14
residents_affected: 7
Inspection Report — Feb 7, 2020
Life Safety
Date: Feb 7, 2020
Visit Reason
CMS-2567 Life Safety Code (K-tag) survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 6 federal life safety (K-tag) deficiencies addressing building construction/barrier penetrations, sprinkler system maintenance, fire drills, electrical wiring and essential electrical/generator testing, and gas cylinder storage, and 5 Missouri state deficiencies that reference those federal findings.
Deficiencies (5)
19 CSR 30-85.022(3) Noncombustible Material Between Floors: Refer to K161.
19 CSR 30-85.022(6) Oxygen Storage: Refer to K923.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K918.
19 CSR 30-85.023(31)(A) Electrical Wiring & Equipment Maintained: Refer to K911.
Report Facts
residents potentially affected: 30
residents potentially affected: 54
residents potentially affected: 39
residents potentially affected: 17
Inspection Report — Sep 25, 2019
Complaint Investigation
Date: Sep 25, 2019
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form; complaint investigation stated on the forms (MO160516).
Complaint Details
MO160516; the complaint investigation noted the violation was determined to be at an imminent danger/Class I level during the investigation.
Findings
Three deficiencies were cited: two federal deficiencies related to failure to meet professional standards (missing ordered lab work) and failure to provide adequate supervision resulting in a resident fall/head injury, and one Missouri state licensure deficiency referencing the federal supervision/fall finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F689.
Report Facts
residents_sampled: 7
Inspection Report — Dec 6, 2018
Routine
Date: Dec 6, 2018
Visit Reason
CMS-2567 federal health survey and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Twelve deficiencies were cited: seven federal health survey deficiencies involving resident transfer/bed-hold notices, ADL/personal care, continence/catheter care, drug regimen review, food preparation/texture, and immunizations; and five Missouri state licensure deficiencies addressing employee TB screening, cleanliness/odor/infection control, and food service/texture requirements.
Deficiencies (5)
19 CSR 30-85.042(27) Communicable Disease-Employees: Based on interview and record review, the facility failed to ensure tuberculosis prevention procedures were implemented and did not complete tuberculin skin tests (TSTs) on three newly hired employees.
19 CSR 30-85.042(68) Clean, Dry, Odor Free: See the deficiency cited at F677 and F690.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F883.
19 CSR 30-85.052(3) Foods-Nutritive Value/Flavor/Appearance: See the deficiency cited at F804.
19 CSR 30-85.052(4) Food Texture-Chewing Difficulty: See the deficiency cited at F804.
Report Facts
residents sampled: 14
residents with urinary catheters reported: 5
residents on a pureed diet: 8
Inspection Report — Dec 6, 2018
Life Safety
Date: Dec 6, 2018
Visit Reason
CMS-2567 federal life safety and emergency preparedness pages and Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
The file contains 8 federal deficiencies (emergency preparedness and life safety issues including testing, hazardous area protection, cooking range suppression, smoke barriers, smoking regulations, generator documentation, power cord usage, and gas cylinder storage) and 9 Missouri state licensure deficiencies addressing fire hazards, hazardous areas, oxygen storage, range hood certification, smoke section walls/doors, ashtrays, fire drill/emergency preparedness plans, building construction/maintenance, and electrical wiring.
Deficiencies (9)
19 CSR 30-85.022(2)(E) No Fire Hazard General Requirements: Based on observation and interview, the facility failed to ensure a furnace room was not used for storage of combustibles and beauty shop items, resulting in combustible materials stored in the furnace room and creating a fire hazard.
19 CSR 30-85.022(4) Hazardous Areas: The facility did not ensure hazardous areas were properly separated and protected by fire-resistive construction or approved fire protection, and therefore hazardous areas were not adequately secured.
19 CSR 30-85.022(6) Oxygen Storage: Oxygen storage was not in accordance with NFPA requirements; tanks were mixed (empty and full), not adequately labeled or secured, and storage practices placed residents at risk.
19 CSR 30-85.022(9) Range Hood Certification: The facility failed to ensure the range hood and extinguishing system were certified and maintained per NFPA requirements and that the hood/nozzle arrangement provided required protection.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Smoke section walls and doors were not continuous and self-closing doors did not reliably close, compromising smoke section integrity.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: The facility failed to ensure designated smoking areas had proper noncombustible ashtrays and safe disposal; cigarette butts and ashes were observed not properly contained.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: The facility failed to document or request annual consultation/review of their emergency evacuation plan from the local fire department as required.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: The facility did not maintain the physical plant in accordance with applicable construction and maintenance standards, as evidenced by deficiencies in essential systems and their documentation.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with the cited standards, with observed use of extension cords and improperly installed cords/equipment.
Report Facts
residents potentially affected: 32
residents potentially affected: 36
residents potentially affected: 17
Inspection Report — Oct 2, 2018
Complaint Investigation
Date: Oct 2, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation. Complaint numbers cited in the file: MO147326, MO147219, MO147330, MO147321, MO146443, MO146447, MO146701.
Complaint Details
Complaint numbers: MO147326, MO147219, MO147330, MO147321, MO146443, MO146447, MO146701; substantiation not stated in the document.
Findings
2 deficiencies: one federal health deficiency for failure to prevent and monitor resident falls resulting in multiple serious injuries, and one Missouri state licensure deficiency for nursing care per resident condition that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F689.
Report Facts
residents sampled: 5
number of falls for one resident: 15
20 CMS Surveys
Inspection Report — Oct 2, 2025
Routine
Date: Oct 2, 2025
Visit Reason
Routine inspection of Luther Manor Retirement & Nursing Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident fund management, code status documentation, background screening for employees, transfer/discharge notifications, accident prevention, incontinent care, food safety and temperature control, infection control practices, facility-wide assessment updates, quality assurance processes, and legionella water management.
Deficiencies (12)
F 0568: Facility failed to maintain individual resident ledgers for resident funds, send quarterly statements, and distribute accrued interest properly for two residents.
F 0578: Facility failed to document residents' code status for CPR clearly and accessibly, affecting five residents.
F 0607: Facility failed to complete required background screenings including criminal background checks and NA registry checks prior to employment for multiple staff.
F 0628: Facility failed to provide written transfer/discharge notices with required information to residents and representatives for three residents and failed to notify the Ombudsman.
F 0689: Facility failed to provide adequate supervision and prevent injury for two residents, resulting in a laceration and an elopement with injury.
F 0690: Facility failed to provide proper incontinent care and infection control for a resident with an indwelling catheter, risking urinary tract infection.
F 0804: Facility failed to serve meals at safe and appetizing temperatures; multiple residents reported cold food.
F 0812: Facility failed to maintain safe food storage temperatures, practice proper hand hygiene and glove use, wear hair restraints, and maintain a clean ice machine.
F 0838: Facility failed to update and document a comprehensive facility-wide assessment to determine necessary resources for competent resident care.
F 0867: Facility failed to implement an effective quality assessment and assurance committee with documented corrective plans.
F 0880: Facility failed to utilize Enhanced Barrier Precautions properly for residents with multidrug-resistant organisms and failed to handle contaminated linens according to policy. Facility also lacked a comprehensive Legionella water management program.
F 0947: Facility failed to ensure nurse aides received the required 12 hours of annual in-service education including dementia care and abuse prevention.
Report Facts
Resident fund interest amounts: 3.86
Resident fund interest amounts: 2.41
Resident fund interest amounts: 1
Resident fund interest amounts: 1.04
Resident fund interest amounts: 1.3
Resident fund interest amounts: 1.67
Resident fund interest amounts: 1.42
Resident fund interest amounts: 1.47
Facility refrigerator temperature: 49
Facility freezer temperature: 23
Food temperature: 96.1
Food temperature: 100.7
Food temperature: 107.4
Food temperature: 114.1
Food temperature: 104.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN P | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| CNA O | Certified Nurse Assistant | Named in wound care and infection control deficiencies |
| CNA G | Certified Nurse Assistant | Named in Enhanced Barrier Precautions deficiency |
| CNA F | Certified Nurse Assistant | Named in Enhanced Barrier Precautions deficiency |
| Cook BB | Cook | Named in food handling and hygiene deficiencies |
| Dietary Manager | Dietary Manager | Named in food temperature and hygiene deficiencies |
| Housekeeper M | Housekeeper | Named in soiled linen handling deficiency |
| Administrator | Administrator | Named in background screening and facility assessment deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including infection control and education |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in infection control and wound care deficiencies |
Inspection Report — Oct 2, 2025
Annual Inspection
Date: Oct 2, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident safety, facility-wide assessment, and staff training.
Findings
The facility failed to provide adequate supervision and accident prevention, resulting in injuries to residents during transfers and elopement incidents. The facility also failed to update and document a facility-wide assessment and did not ensure nurse aides received required annual in-service education.
Deficiencies (3)
F 0689: The facility failed to prevent injury during resident transfers and failed to provide adequate supervision to prevent elopement and falls, resulting in actual harm to residents.
F 0838: The facility failed to update and document a facility-wide assessment to determine necessary resources for competent resident care during daily operations and emergencies.
F 0947: The facility failed to ensure nurse aides received the required 12 hours of annual in-service education, including dementia care and abuse prevention.
Report Facts
Resident sample size: 23
Laceration length: 15
Laceration depth: 10
Antibiotic treatment duration: 10
Wound length: 13.5
Fall injury abrasion size: 5
Fall injury abrasion size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN P | Licensed Practical Nurse | Named in transfer injury incident and wound care |
| CNA C | Certified Nurse Assistant | Involved in resident transfer during injury incident |
| CNA S | Certified Nurse Assistant | Involved in resident transfer during injury incident |
| Director of Nursing | Director of Nursing (DON) | Provided interview on transfer procedures and staff education |
| LPN B | Licensed Practical Nurse | Involved in assessment and care after resident fall and elopement |
| ADON | Assistant Director of Nursing | Provided interview and nursing note related to resident fall |
| CNA T | Certified Nurse Assistant | Last staff to see resident before elopement incident |
Inspection Report — Jul 23, 2025
Complaint Investigation
Date: Jul 23, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to document and implement fall interventions to prevent falls for a resident, which resulted in injury.
Complaint Details
The investigation was complaint-related, focusing on a resident who fell on 07/06/25 due to failure to use fall prevention wedge cushions. The fall resulted in a fracture. Staff interviews revealed poor communication and lack of knowledge about interventions. The complaint was substantiated with actual harm.
Findings
The facility failed to implement all fall prevention interventions, including the use of wedge cushions for a high-risk resident, leading to a fall and fracture. Staff communication and documentation of interventions were inadequate, and new staff were unaware of required interventions.
Deficiencies (1)
F 0689: The facility failed to document and implement fall interventions, including wedge cushions, for a resident at high risk for falls, resulting in a fall and tibia fracture. Staff were unaware or did not use the wedge cushions, and care plan updates and interdisciplinary team meetings were lacking.
Report Facts
Fall event dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Completed fall event report on 07/06/25 and provided interview about fall interventions |
| CNA A | Certified Nurse Assistant | Assisted resident on 07/06/25 but did not use wedge cushions due to lack of knowledge |
| CNA B | Certified Nurse Assistant | Assisted resident on 07/06/25 but did not use wedge cushions due to lack of knowledge |
| LPN C | Licensed Practical Nurse | Provided interview about fall interventions and wedge cushion use |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations for fall prevention interventions |
| Care Plan Coordinator | Care Plan Coordinator | Interviewed about care plan documentation and interdisciplinary team meetings |
| Administrator | Administrator | Interviewed about expectations for staff to follow fall prevention interventions |
Inspection Report — Jun 16, 2025
Complaint Investigation
Date: Jun 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify a resident's physician about hip pain following a fall.
Complaint Details
The investigation was complaint-related, focusing on the failure to notify the physician timely about the resident's hip pain after a fall. The complaint was substantiated based on interviews and documentation review.
Findings
The facility failed to notify the physician timely of a resident's hip pain after a fall on 05/21/25, resulting in a delayed diagnosis of a fractured hip. Multiple staff interviews and record reviews confirmed the lack of timely communication despite the resident's complaints and administration of pain medication.
Deficiencies (1)
F 0580: The facility failed to notify the resident's physician timely of hip pain following a fall on 05/21/25, resulting in delayed diagnosis of a left hip fracture.
Report Facts
Pain medication doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented the fall and initial resident complaints; did not notify physician of hip pain |
| LPN B | Licensed Practical Nurse | Administered Tylenol for hip pain; did not recall notifying physician |
| LPN E | Licensed Practical Nurse | Administered Tylenol at 11:45 P.M.; did not notify physician of resident's pain |
| RN C | Registered Nurse | Notified physician via fax on 05/23/25 about the fall and pain complaints |
| Certified Nurse Assistant D | Certified Nurse Assistant | Witnessed the fall and resident's initial complaint of pain |
| Resident's Nurse Practitioner | Nurse Practitioner | Expected timely notification of resident's hip pain and stated he would have ordered an x-ray earlier |
| Director of Nursing | Director of Nursing | Expected staff to notify physician of any complaints of pain |
| Administrator | Administrator | Expected staff to notify physician of any complaints of pain |
Inspection Report — May 23, 2025
Complaint Investigation
Date: May 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an injury of unknown origin involving a resident's fractured humeral shaft.
Complaint Details
The complaint investigation focused on whether the facility properly reported an injury of unknown origin for Resident #1 who had a new fracture of the left humeral shaft. The facility did not report the injury as required. Interviews with nursing staff, the Director of Nursing, Assistant Director of Nursing, and Administrator confirmed the fracture was not reported because it was not considered new or of unknown origin until the state agency investigation.
Findings
The facility failed to report a new fracture of unknown origin for one resident who had surgery for a left humerus fracture. Interviews revealed staff and administration did not consider the new fracture an injury of unknown origin and thus did not report it to the state agency as required.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse, neglect, or injury of unknown origin involving a resident's new fractured humeral shaft to the state survey agency. The resident had no falls or trauma while at the facility, but the new fracture requiring surgery was not reported.
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented resident's follow-up appointment and reported fracture to DON and ADON |
| ADON | Assistant Director of Nurses | Interviewed regarding resident's readmission and fracture reporting |
| DON | Director of Nurses | Interviewed regarding fracture reporting and knowledge of resident's condition |
| Administrator | Administrator | Interviewed regarding knowledge of fracture and reporting to state agency |
Inspection Report — Oct 18, 2023
Routine
Date: Oct 18, 2023
Visit Reason
Routine inspection of Luther Manor Retirement & Nursing Center to assess compliance with health, safety, and regulatory standards.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, staff compliance with hiring and infection control policies, medication administration, food safety, and bed safety. Several residents were affected by issues such as improper infection control, failure to provide written bed hold notices, improper insulin administration, and failure to maintain safe bed rails.
Deficiencies (10)
F 0584: Facility failed to ensure ceiling vents were maintained free of dust and debris, with moderate to heavy buildup observed in multiple areas and resident rooms.
F 0607: Facility failed to check the Nurse Aide Registry prior to hire for five employees and lacked a policy requiring this check.
F 0625: Facility failed to provide written notice of bed hold policy to residents or representatives prior to hospital transfers for three residents.
F 0695: Facility failed to ensure proper infection control for respiratory equipment and oxygen tubing for five residents, including uncovered BiPap masks and outdated nebulizer tubing.
F 0700: Facility failed to conduct ongoing assessments of bed rails per policy for two residents and did not monitor positioning devices as bed rails.
F 0760: Facility failed to ensure proper administration of insulin via insulin pens for three residents, including failure to prime pens and hold injection site for required time.
F 0804: Facility failed to provide food items at safe and appetizing temperatures, with hot foods served below 120°F and cold foods above 41°F.
F 0812: Facility failed to ensure dietary equipment and ice machine were clean and properly maintained, including grease buildup and lack of air gap on ice machine drain.
F 0880: Facility failed to ensure proper infection control, including failure to wash hands after glove removal during incontinent care, failure to post isolation signs and close isolation room doors, and incomplete TB testing for new employees.
F 0909: Facility failed to complete regular inspection of bed frames, mattresses, and bed rails for entrapment hazards for four residents.
Report Facts
Temperature of ham steak: 114
Temperature of apple salad: 58
Temperature of roast beef and Swiss sandwich: 101.5
Temperature of carrot and raisin salad: 64.2
Temperature of milk: 63.1
Temperature of yogurt: 68.4
Blood sugar level: 266
Units of insulin administered: 9
Units of insulin administered: 10
Units of insulin administered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Observed administering insulin without priming pen or holding injection site |
| DON | Director of Nursing | Observed failing to wash hands between glove changes during incontinent care |
| CNA Q | Certified Nurse Assistant | Observed failing to wash hands between glove changes during incontinent care |
| CNA K | Certified Nurse Assistant | Observed failing to wash hands between glove changes during incontinent care |
| Dietary Aide C | Employee file missing documentation of second step TB test reading | |
| CNA G | Certified Nurse Assistant | Employee file missing documentation of TB test results and facility TB testing |
| CNA I | Certified Nurse Assistant | Employee file missing documentation of TB testing |
| Caregiver J | Employee file missing documentation of second step TB test | |
| Dietary Aide H | Employee file with incomplete TB test documentation | |
| CNA K | Certified Nurse Assistant | Employee file with incomplete TB test documentation |
| Infection Preventionist/ADON | Assistant Director of Nursing | Responsible for TB testing and infection control oversight |
Inspection Report — Oct 18, 2023
Life Safety
Date: Oct 18, 2023
Visit Reason
CMS-2567 Life Safety (federal) survey and accompanying Missouri Department of Health and Senior Services State Form; Life Safety survey (K-tags) and Emergency Preparedness findings (E-tag) were cited.
Findings
Nine federal Life Safety/Emergency Preparedness deficiencies were cited addressing emergency preparedness and multiple fire- and life-safety issues including vertical openings/ceiling penetrations, corridor doors, smoke barriers, fire drills, smoking-area disposal, fire door inspection/testing, electrical power strips/extension cords, and oxygen cylinder storage. Eight Missouri state licensure deficiencies were cited addressing construction and safety requirements including noncombustible floor barriers, oxygen storage, smoke section walls/doors, ashtray/disposal requirements, building maintenance, portable heater prohibition, electrical wiring/equipment, and electrical certification.
Deficiencies (9)
E004 Develop EP Plan, Review and Update Annually: Based on record review and interview, the facility failed to review and update the emergency preparedness plan annually.
K311 Vertical Openings - Enclosure: The facility failed to maintain fire-resistance barriers in vertical openings and ceilings, with multiple unsealed ceiling penetrations and missing tiles observed.
K363 Corridor - Doors: The facility failed to maintain corridor doors to resist passage of smoke, with gaps, holes, and other door deficiencies observed in multiple resident room and corridor doors.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain smoke barriers, with numerous unsealed penetrations and gaps through smoke barrier walls.
K712 Fire Drills: The facility failed to conduct fire drills at unpredictable times and had drills scheduled in a manner that made them predictable.
K741 Smoking Regulations: The facility failed to maintain smoking areas to ensure cigarette butts and ashes were disposed of in appropriate noncombustible ashtrays and not mixed with combustible trash.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to ensure required annual inspection/testing of one-fire rated door assembly and failed to maintain required fire resistance of the door assembly.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure proper use of power strips, extension cords and multi-plug adapters, with multiple noncompliant plugs, extension cords, and devices observed.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure oxygen cylinders were stored separate from combustibles and not within five feet of combustibles, with combustibles and supplies stored near cylinders and storage rooms containing approximately 50 full cylinders.
Report Facts
residents potentially affected: 31
residents potentially affected: 52
residents potentially affected: 52
residents potentially affected: 17
residents potentially affected: 14
full oxygen cylinders: 50
Inspection Report — Apr 26, 2023
Complaint Investigation
Date: Apr 26, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the file cites complaint numbers MO217105 and MO217362 indicating a complaint investigation.
Complaint Details
Complaint numbers MO217105 and MO217362; substantiation not stated in the file.
Findings
The survey cited two deficiencies: one federal health deficiency and one Missouri state licensure deficiency related to transfer/discharge practices. Both items involve failure to readmit a resident and deficiencies in discharge/transfer procedures and physician coverage.
Deficiencies (1)
F 622 Transfer and Discharge Requirements: Based on interview and record review, the facility failed to readmit one resident who required emergent care and was sent to the hospital, and denied re-admission due to inability to find an accepting physician to oversee the resident's care.
Report Facts
residents sampled: 5
Inspection Report — Nov 12, 2022
Complaint Investigation
Date: Nov 12, 2022
Visit Reason
Federal CMS-2567 health survey (COVID-19 Focused Emergency Preparedness and COVID-19 Focused Infection Control); the file states this was associated with a complaint investigation.
Findings
No health survey deficiencies were cited; the survey found the facility in compliance with the applicable COVID-19 emergency preparedness and infection control requirements.
Inspection Report — Aug 19, 2022
Routine
Date: Aug 19, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health deficiency involving treatment/services to prevent and heal pressure ulcers and one Missouri state licensure deficiency for pressure sore prevention/treatment.
Deficiencies (1)
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on observation, interview and record review the facility failed to ensure a resident received necessary treatment and services to promote healing and prevent infection of a pressure ulcer, with missing skin assessments and wound measurements for the resident's coccyx pressure ulcer.
Report Facts
residents sampled: 6
Inspection Report — Jun 10, 2022
Complaint Investigation
Date: Jun 10, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO #201359).
Complaint Details
MO #201359; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal deficiency for failure to provide required notice before transfer/discharge for a resident, and one Missouri licensure deficiency for discharge appeal/notice requirements referencing the federal finding.
Deficiencies (1)
F623 Notice Requirements Before Transfer/Discharge: Based on interview and record review, the facility failed to provide a written notice of discharge with the required information to the resident and/or resident representative for one resident when the facility initiated a transfer to the hospital and denied the resident re-admission.
Report Facts
residents sampled: 3
residents affected: 1
Inspection Report — Dec 9, 2020
Routine
Date: Dec 9, 2020
Visit Reason
Federal CMS-2567 (health and emergency preparedness): COVID-19 Focused Emergency Preparedness and Infection Control survey as stated on the form.
Findings
No health or emergency preparedness deficiencies were cited; the facility was found in compliance with the COVID-19 emergency preparedness and infection control requirements.
Inspection Report — Aug 6, 2020
Routine
Date: Aug 6, 2020
Visit Reason
Federal CMS-2567 health (infection control) and emergency preparedness forms; the document states a COVID-19 Focused Infection Control and Emergency Preparedness survey.
Findings
No deficiencies were cited. The survey found the facility in compliance with COVID-19 infection control and emergency preparedness requirements.
Inspection Report — Jun 3, 2020
Routine
Date: Jun 3, 2020
Visit Reason
Federal health and emergency preparedness (CMS-2567); COVID-19 Focused Infection Control and Emergency Preparedness survey (stated in the Initial Comments).
Findings
No health (F) or emergency preparedness (E) deficiencies were cited; the facility was found in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report — Feb 7, 2020
Routine
Date: Feb 7, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The CMS-2567 cited 2 federal deficiencies involving abuse/neglect policy compliance and food procurement/food safety and sanitation; the Missouri State Form cited 4 state deficiencies concerning TB infection control/screening, food protection/temperature, frozen food storage temperature, and kitchen ventilation/hood filter cleaning.
Deficiencies (2)
F607 Develop/Implement Abuse/Neglect Policies: Based on interview and record review, the facility failed to obtain Nurse Aide (NA) registry/background screenings for multiple employees and did not perform NA registry checks for several non-nursing new hires prior to employment.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observation, interview and record review, the facility failed to ensure food items were labeled, dated or discarded as appropriate, had accumulation of grease and debris on the range hood/filters, and failed to maintain freezer temperatures at 0 degrees Fahrenheit.
Report Facts
residents_sampled: 14
residents_affected: 7
Inspection Report — Feb 7, 2020
Life Safety
Date: Feb 7, 2020
Visit Reason
CMS-2567 Life Safety Code (K-tag) survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 6 federal life safety (K-tag) deficiencies addressing building construction/barrier penetrations, sprinkler system maintenance, fire drills, electrical wiring and essential electrical/generator testing, and gas cylinder storage, and 5 Missouri state deficiencies that reference those federal findings.
Deficiencies (6)
K161 Building Construction Type and Height: The facility failed to maintain the barrier between the first floor and attic by not repairing holes in the ceiling; this deficient practice had the potential to affect 30 residents in four of seven smoke compartments.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinklers free of buildup and debris, with moderate buildup observed on multiple sprinkler heads throughout the building; this deficient practice had the potential to affect 54 residents in four of seven smoke compartments.
K712 Fire Drills: The facility failed to ensure fire drills were conducted under varied and unpredictable conditions, with several drills held within 30 minutes of each other and drills not planned to simulate actual conditions; this had the potential to affect all occupants in seven of seven smoke compartments.
K911 Electrical Systems - Other: The facility failed to maintain electrical wiring in a safe manner, with uncovered junction boxes and spliced wiring observed in attic spaces without covers; this deficient practice had the potential to affect 39 residents in two of seven smoke compartments.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain complete and verifiable monthly generator testing documentation, including start/stop times and evidence the generator was tested under load for 30 minutes; this deficient practice could affect occupant safety across the facility's smoke compartments.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to adequately secure oxygen cylinders, with two oxygen cylinders found free-standing on a nightstand in a resident room; this practice had the potential to affect 17 residents on the 100 Hall.
Report Facts
residents potentially affected: 30
residents potentially affected: 54
residents potentially affected: 39
residents potentially affected: 17
Inspection Report — Sep 25, 2019
Complaint Investigation
Date: Sep 25, 2019
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form; complaint investigation stated on the forms (MO160516).
Complaint Details
MO160516; the complaint investigation noted the violation was determined to be at an imminent danger/Class I level during the investigation.
Findings
Three deficiencies were cited: two federal deficiencies related to failure to meet professional standards (missing ordered lab work) and failure to provide adequate supervision resulting in a resident fall/head injury, and one Missouri state licensure deficiency referencing the federal supervision/fall finding.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: Based on interview and record review, the facility failed to obtain ordered laboratory blood work for one resident (Resident #1) of seven sampled residents.
F689 Free of Accident Hazards/Supervision/Devices: Based on interview and record review, the facility failed to provide adequate supervision while providing care to one dependent resident, resulting in a fall with head injury and subsequent serious outcomes.
Report Facts
residents_sampled: 7
Inspection Report — Dec 6, 2018
Routine
Date: Dec 6, 2018
Visit Reason
CMS-2567 federal health survey and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Twelve deficiencies were cited: seven federal health survey deficiencies involving resident transfer/bed-hold notices, ADL/personal care, continence/catheter care, drug regimen review, food preparation/texture, and immunizations; and five Missouri state licensure deficiencies addressing employee TB screening, cleanliness/odor/infection control, and food service/texture requirements.
Deficiencies (7)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notice of transfer/discharge to residents or their representative for two residents transferred to the hospital and did not provide required notice to the ombudsman.
F625 Notice of Bed Hold Policy Before/Upon Transfr: The facility failed to provide written notice of the bed-hold policy to the resident or resident representative upon transfer for two residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure dependent residents received necessary personal hygiene and oral care, with observations and record review showing staff omissions for multiple residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide appropriate catheter and incontinence care for residents with urinary catheters, including improper tubing/bag positioning and lack of dignity bag use, contributing to infection risk.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to develop and implement timely drug regimen review procedures and failed to ensure pharmacist-identified irregularities and GDRs were acted on for identified residents.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to follow recipes and proper procedures for pureed and mechanical soft diets, resulting in unpalatable, watery or overly chewy purees during observed meal service.
F883 Influenza and Pneumococcal Immunizations: The facility failed to ensure pneumococcal vaccination policy and documentation met current guidelines and did not provide required education/documentation for eligible residents.
Report Facts
residents sampled: 14
residents with urinary catheters reported: 5
residents on a pureed diet: 8
Inspection Report — Dec 6, 2018
Life Safety
Date: Dec 6, 2018
Visit Reason
CMS-2567 federal life safety and emergency preparedness pages and Missouri Department of Health and Senior Services State Form pages; the survey type is not stated.
Findings
The file contains 8 federal deficiencies (emergency preparedness and life safety issues including testing, hazardous area protection, cooking range suppression, smoke barriers, smoking regulations, generator documentation, power cord usage, and gas cylinder storage) and 9 Missouri state licensure deficiencies addressing fire hazards, hazardous areas, oxygen storage, range hood certification, smoke section walls/doors, ashtrays, fire drill/emergency preparedness plans, building construction/maintenance, and electrical wiring.
Deficiencies (8)
E039 EP Testing Requirements: Based on interview and record review, the facility failed to conduct the required exercises to test the emergency plan at least annually and had no documentation of participation in a second full-scale exercise or an annual tabletop meeting.
K321 Hazardous Areas - Enclosure: The facility failed to ensure doors protecting hazardous/combustible storage areas were self-closing and were found propped open and combustible storage was located in a room divided by an unsealed vertical wall.
K324 Cooking Facilities: The facility failed to ensure range hood fire suppression nozzles were aimed to adequately provide fire suppression coverage for the range and griddle, with several nozzles not directed toward cooking surfaces.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Smoke barrier walls were not complete or sealed from floor to roof deck, with unsealed penetrations and open areas at the top of drywall and ductwork/pipe penetrations compromising the smoke barrier.
K741 Smoking Regulations: The facility failed to ensure designated smoking areas were equipped with safe-design ashtrays and that smoking materials and ashes were properly contained, with ashes and burned cigarettes observed in the smoking area.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain complete and verifiable documentation of monthly generator testing, lacking records of start/stop times, duration under load, and transfer times.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility used extension cords and power strips beyond temporary use, with multiple appliances and equipment plugged into power strips and extension cords creating a fire hazard.
K923 Gas Equipment - Cylinder and Container Storage: Oxygen tanks in the storage room were not adequately separated, labeled or secured; empty and full tanks were mixed and several tanks were not secured on racks or shelves.
Report Facts
residents potentially affected: 32
residents potentially affected: 36
residents potentially affected: 17
Inspection Report — Oct 2, 2018
Complaint Investigation
Date: Oct 2, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation. Complaint numbers cited in the file: MO147326, MO147219, MO147330, MO147321, MO146443, MO146447, MO146701.
Complaint Details
Complaint numbers: MO147326, MO147219, MO147330, MO147321, MO146443, MO146447, MO146701; substantiation not stated in the document.
Findings
2 deficiencies: one federal health deficiency for failure to prevent and monitor resident falls resulting in multiple serious injuries, and one Missouri state licensure deficiency for nursing care per resident condition that references the federal finding.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate monitoring and to evaluate the effectiveness of fall interventions for a resident who sustained multiple falls and serious injuries including a nasal fracture, hemorrhagic contusion, and a nondisplaced distal femur fracture.
Report Facts
residents sampled: 5
number of falls for one resident: 15
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