Inspection Reports for
Manchester Rehab and Healthcare Center
312 SOLLEY DR, BALLWIN, MO, 63021-5248
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
227% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
54% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 74
Deficiencies: 7
Date: May 23, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, environment, and food service at Manchester Rehab and Healthcare Center.
Findings
The facility was found deficient in multiple areas including lack of clean towels and linens, unrepaired broken window in a resident's room, incomplete temperature logs for residents' personal refrigerators, inadequate hot water temperature, failure to maintain a clean environment in the Memory Care Unit hallway, failure to provide adequate assistance with activities of daily living resulting in residents being left soiled, failure to provide scheduled showers, and failure to serve food at safe and palatable temperatures.
Deficiencies (7)
Failure to ensure residents and staff had access to clean towels and linens.
Failure to repair a broken window in a resident's room, resulting in a non-homelike environment.
Failure to maintain completed temperature logs for residents' personal refrigerators.
Failure to maintain hot water temperature at the minimum required 105 degrees Fahrenheit.
Failure to keep the Memory Care Unit hallway free from trash.
Failure to provide necessary assistance with activities of daily living, leaving residents soiled for extended periods and not providing showers as scheduled.
Failure to ensure food was served at a palatable, safe, and appetizing temperature, with hot food served below 120 degrees Fahrenheit.
Report Facts
Sample size: 19
Census: 74
Food temperature: 99.2
Food temperature: 97.5
Food temperature: 109
Food temperature: 96
Water temperature: 67
Water temperature: 69
Water temperature: 88
Water temperature: 102
Water temperature: 67.1
Water temperature: 93.3
Water temperature: 95
Water temperature: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse MM | Licensed Practical Nurse | Signed shower sheet documenting shower was not completed due to no linen available. |
| Laundry Aide G | Laundry Aide | Reported issues with linen availability and laundry staffing. |
| Nursing Assistant H | Nursing Assistant | Reported inability to shower residents due to lack of linen. |
| Certified Nursing Assistant E | Certified Nursing Assistant | Reported issues with linens not being cleaned on time. |
| Hospice CNA NN | Hospice Certified Nursing Assistant | Reported difficulty finding clean towels. |
| Maintenance Assistant Z | Maintenance Assistant | Responsible for overseeing housekeeping supervisor role and maintaining refrigerator temperature logs. |
| Administrator | Facility Administrator | Acknowledged issues with boarded window, linen shortages, water temperature, and food temperature. |
| Certified Nursing Assistant U | Certified Nursing Assistant | Observed residents left soiled and reported last checks several hours prior. |
| Licensed Practical Nurse P | Licensed Practical Nurse | Observed resident left soiled and promised to get aide to clean resident. |
| Nurse Assistant BB | Nurse Assistant | Assisted resident with changing soiled brief and was unaware resident was soiled earlier. |
| Licensed Practical Nurse X | Licensed Practical Nurse | Discussed expectations for showering, hygiene, and nail care. |
| Certified Nursing Assistant KK | Certified Nursing Assistant | Reported resident required total assistance with hygiene and showering. |
| Director of Nursing | Director of Nursing | Discussed expectations for resident care, showering, and hygiene. |
| Dietary Aide I | Dietary Aide | Reported food should be served at safe and palatable temperature. |
| Dietary Aide J | Dietary Aide | Reported food should be served at safe and palatable temperature. |
Inspection Report
Census: 74
Deficiencies: 11
Date: May 23, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care, and facility operations, including investigation of resident care issues, elopement incidents, medication management, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to provide a safe and homelike environment, inadequate staff screening, inaccurate resident assessments, failure to provide necessary assistance with activities of daily living, failure to perform required neurological assessments post-fall, inadequate supervision of residents at risk for elopement and falls, improper respiratory care, lack of communication with dialysis providers, expired medications and incomplete medication room temperature logs, failure to obtain ordered laboratory specimens, and failure to serve food at safe and palatable temperatures.
Deficiencies (11)
Failure to ensure residents and staff had access to clean towels, repair broken window, maintain refrigerator temperature logs, maintain hot water temperature, and keep hallways free of trash.
Failure to complete criminal background checks and NA Registry checks prior to employee start date for newly hired or transferred employees.
Failure to ensure residents received accurate assessments by incorrectly coding side rails as restraints when not restricting freedom of movement.
Failure to provide necessary assistance with activities of daily living including bathing, dressing, toileting, and hygiene for residents.
Failure to obtain treatment orders for dressing and compression stockings, and failure to perform post-fall neurological assessments.
Failure to provide adequate supervision and interventions to prevent elopement and falls, including failure to use gait belt during assisted transfer and failure to respond appropriately to door alarms on secured memory care unit.
Failure to properly store bipap masks and oxygen concentrators and failure to set oxygen concentrator to proper rate.
Failure to maintain ongoing communication and collaboration with dialysis facility regarding dialysis care and services.
Failure to ensure medications and solutions were not expired and failure to complete medication room refrigerator temperature logs.
Failure to provide or obtain laboratory services as ordered by the physician, including failure to obtain urine specimens for testing.
Failure to serve food at a palatable, safe and appetizing temperature during tray service.
Report Facts
Sample size: 19
Census: 74
Distance: 1.6
Number of staff in in-service: 23
Number of staff signed in-service: 12
Number of staff signed in-service: 11
Number of staff signed in-service: 10
Number of staff signed in-service: 11
Number of staff signed in-service: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Documented hospital specialist communication and involved in resident elopement incident response |
| LPN HH | Licensed Practical Nurse | Documented resident behavior and elopement incident on 4/24/25 |
| CNA A | Certified Nursing Assistant | Reported resident missing on 4/24/25 and involved in search |
| CNA B | Certified Nursing Assistant | Reported resident missing on 4/24/25 and involved in search |
| LPN V | Licensed Practical Nurse | Provided information on neurological checks policy |
| DON | Director of Nursing | Provided multiple interviews on policies, resident care, and investigations |
| Administrator | Facility Administrator | Provided multiple interviews on policies, resident care, and investigations |
| Regional Nurse CC | Regional Nurse | Provided information on elopement classification and staff in-service |
| LPN X | Licensed Practical Nurse | Provided information on oxygen administration and dialysis communication |
| CMT O | Certified Medication Technician | Provided information on medication cart audits and expired medications |
| LPN P | Licensed Practical Nurse | Provided information on medication cart audits and expired medications |
| CNA W | Certified Nursing Assistant | Provided information on urine specimen collection and resident care |
| LPN Q | Licensed Practical Nurse | Provided information on urine specimen collection and dialysis communication |
| Dietary Aide I | Dietary Aide | Provided information on food temperature expectations |
| Dietary Aide J | Dietary Aide | Provided information on food temperature expectations |
| Housekeeper L | Housekeeper | Provided information on missing resident protocol knowledge |
| NA K | Nurse Aide | Provided information on resident monitoring on memory care unit |
| NA JJ | Nurse Aide | Provided information on resident monitoring on memory care unit |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted following a complaint related to a resident falling backward and sustaining a head injury during transportation in a facility van.
Complaint Details
The complaint investigation was substantiated. The resident fell backward in the wheelchair during transport, sustaining a small gash to the back of the head requiring first aid and ambulance transport due to anticoagulant medication. Staff interviews revealed inadequate training and inconsistent securement practices.
Findings
The facility failed to ensure the resident's wheelchair was properly secured during transport, resulting in the wheelchair flipping backward and the resident sustaining a minor head injury. The investigation found no malfunction with the van or equipment, but identified gaps in staff training and securement practices.
Deficiencies (1)
Failure to properly secure the resident's wheelchair to all locking mechanisms during transport, resulting in a fall and injury.
Report Facts
Census: 53
Time of incident: 1115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Worker A | Driver involved in the incident and subject of investigation and training review | |
| Activity Director | Accompanied driver during transport, provided first aid, and involved in investigation | |
| Administrator | Administrator | Notified of incident, conducted follow-up and interviews |
| Regional Director of Plant Operations | Provided video education and remote guidance on securement procedures | |
| Maintenance Supervisor | Provided information on vehicle maintenance and staff training |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Sep 20, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure professional standards of practice, specifically admitting a resident without physician's orders and failing to provide prescribed medications that evening.
Complaint Details
The complaint involved a resident admitted without physician's orders and not receiving prescribed medications, resulting in the resident being sent to the hospital without orders. The complaint was substantiated with findings of minimal harm and affecting a few residents.
Findings
The facility admitted a resident without physician's orders and did not provide prescribed medications on the evening of admission. The resident experienced falls and was sent to the hospital without physician's orders. The facility lacked an admissions policy to ensure proper physician orders were obtained at admission.
Deficiencies (2)
Facility admitted a resident without physician's orders and failed to provide prescribed medications that evening.
Facility did not have a policy for obtaining physician orders at the time of admission.
Report Facts
Residents affected: 3
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Authored licensed nurse admission assessment; did not document admission orders or medication orders. |
| LPN B | Licensed Practical Nurse | Documented resident found on floor, sent resident to hospital without physician's orders. |
| RN C | Facility Wound Nurse | Documented resident's skin assessment on admission day. |
| LPN D | Licensed Practical Nurse | Documented resident's harmful behavior upon return from hospital. |
| CMT E | Certified Medication Technician | Reported no way of knowing resident had no evening medications as resident's name did not appear in electronic record. |
| CNA F | Certified Nurse Aide | Thought resident was brought a dinner hall tray on admission day. |
| CNA G | Certified Nurse Aide | Reported resident's dinner tray was empty on admission day. |
| Administrator | Reported hospital did not send discharge papers or orders; stated DON responsible for checking admissions. | |
| DON | Director of Nursing | Did not check resident's chart to ensure admission process completed; unaware resident admitted without orders until survey. |
| Regional Corporate Nurse | Stated admission nurse's priority is to obtain and transcribe physician's orders immediately. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Date: Jul 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident safety during transfers, staff access to electronic medical records, and prevention of elopement of a cognitively impaired resident.
Complaint Details
The complaint investigation found actual harm with a few residents affected. Resident #20 sustained a fractured leg due to improper transfer. The investigation revealed lack of staff training, incomplete access to electronic records, and failure to implement elopement prevention interventions.
Findings
The facility failed to ensure a resident was safely transferred using a mechanical lift as required, resulting in a fractured leg. Staff lacked access to residents' electronic medical records, preventing proper care plan adherence. The facility also failed to prevent a cognitively impaired resident from eloping through a secured door without staff knowledge.
Deficiencies (3)
Failure to ensure safe transfer of resident resulting in fractured leg due to use of gait belt instead of mechanical lift and lack of staff assistance.
Failure to provide all nursing staff access to electronic medical records (Point Click Care) to review care plans and transfer status.
Failure to prevent cognitively impaired resident from eloping through secured door without staff knowledge.
Report Facts
Census: 52
Sample size: 14
Date of incident: Jun 29, 2024
Number of nursing staff signed in-service: 25
Number of active nursing employees not in-serviced: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Transferred resident improperly using gait belt without access to electronic medical records; suspended after incident |
| RN S | Registered Nurse | Assessed resident after transfer, administered pain medication, notified physician and administration |
| DON | Director of Nursing | Conducted staff in-service on access to transfer status in electronic records; acknowledged lack of staff access prior to incident |
| PT S | Physical Therapist | Provided therapy to resident; stated resident was not safe for stand to pivot transfers |
| OT T | Occupational Therapist | Provided therapy to resident; confirmed resident was mechanical lift only |
| CMT R | Certified Medication Technician / Human Resources | Responsible for new employee orientation and access to electronic records |
Inspection Report
Routine
Census: 44
Deficiencies: 3
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living assistance, medication administration, clinical record maintenance, and wound care management at Manchester Rehab and Healthcare Center.
Findings
The facility failed to ensure residents received showers according to their preferences and needs, resulting in poor hygiene for several residents. Medication error rates exceeded 5%, with missed doses observed. Clinical records for pressure ulcers were incomplete, lacking physician notes and proper documentation in medical records.
Deficiencies (3)
Failed to ensure five residents received showers in accordance with their needs and preferences.
Failed to ensure medication error rate was less than 5%, with 4 errors out of 42 opportunities.
Failed to maintain complete and accurately documented clinical records regarding pressure ulcers for one resident.
Report Facts
Census: 44
Medication error rate: 9.52
Sample size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Named in medication error finding for failing to administer prescribed medications |
| Director of Nursing | Director of Nursing | Interviewed regarding shower documentation and medication administration errors |
| Administrator | Administrator | Interviewed regarding expectations for shower scheduling and documentation |
| Assistant Director of Nursing | Assistant Director of Nursing | Filling in for wound nurse and responsible for wound care documentation |
Inspection Report
Routine
Census: 43
Deficiencies: 6
Date: Dec 5, 2023
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, grievance policies, medication administration, personal hygiene, activity programs, and medication error prevention at Manchester Rehab and Healthcare Center.
Findings
The facility failed to ensure residents' rights to dignified existence and communication, timely grievance follow-up, professional medication administration, adequate personal hygiene, sufficient activity programming, and timely medication administration for new admissions. Deficiencies were noted in staff response to residents calling out, grievance documentation, medication administration practices, nail care, activity engagement, and medication delivery.
Deficiencies (6)
Failure to honor residents' rights to dignified existence, self-determination, and communication, with staff ignoring residents calling out for assistance.
Failure to follow grievance policy with lack of follow-up and documentation for a resident's allegation of missing items.
Failure to ensure professional standards in medication administration, including nurses preparing medications and handing them to others to administer, and incomplete post-fall documentation.
Failure to provide adequate personal hygiene care, with residents observed having long, dirty fingernails and soiled clothing.
Failure to provide an ongoing activity program based on resident preferences, with insufficient activities during evenings and weekends and lack of one-on-one activities for bedbound residents.
Failure to ensure a resident received ordered medications timely after admission, with a two-day delay in administration.
Report Facts
Residents sampled: 15
Census: 43
Deficiency count: 6
Days medication delayed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Described resident behavior and staff response related to communication and activities |
| CNA J | Certified Nursing Assistant | Reported on resident nail care and ADL assistance |
| Director of Nursing | Director of Nursing | Provided expectations for medication administration and fall policy adherence |
| Administrator | Administrator | Discussed grievance policy and activity program expectations |
| Registered Nurse I | Registered Nurse | Described medication administration process and pharmacy coordination |
| Activity Director | Activity Director | Discussed activity programming and staffing limitations |
Inspection Report
Routine
Census: 43
Deficiencies: 14
Date: Dec 5, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident rights, care planning, medication administration, staffing, activities, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified existence and communication, incomplete care plans, inadequate medication administration practices, insufficient RN staffing, inadequate activity programming, improper medication storage and labeling, and failure to maintain residents' personal hygiene.
Deficiencies (14)
Failed to ensure residents were afforded the right to a dignified existence, self-determination, and communication; staff often ignored residents calling out for assistance.
Failed to complete third party liability forms for final accounting of expired residents' funds within 30 days.
Failed to make nursing home survey results readily accessible to residents and representatives during lobby construction.
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) upon discharge from Medicare Part A services for sampled residents.
Failed to follow grievance policy; did not document or follow up on a resident's grievance regarding missing rings.
Failed to notify State Long-Term Care Ombudsman of resident transfers and discharges for 24 residents.
Failed to develop and implement complete, individualized care plans addressing specific resident needs for four residents.
Failed to ensure medication administration was performed by the nurse preparing the medication; medication was prepared by one nurse and administered by another. Also failed to complete post-fall documentation for one resident.
Failed to provide adequate personal hygiene care; residents observed with long, dirty fingernails and food on clothing.
Failed to provide an ongoing activity program based on resident preferences; activities were insufficient, especially evenings and weekends, and one-on-one activities were lacking.
Failed to staff the facility with a Registered Nurse at least 8 hours a day, 7 days a week; multiple days had no RN coverage or less than 8 hours.
Failed to ensure drugs and biologicals were labeled and stored per accepted standards; medication room door was often unlocked, medications and food were stored together, an opened vial of tuberculin PPD was undated, controlled substances lacked two locks, and expired insulin was not discarded.
Failed to ensure medication error rate was less than 5%; observed 2 medication errors out of 26 opportunities (7.69%) including failure to instruct resident to rinse mouth after inhaler use and leaving Miralax at bedside.
Failed to ensure resident was free from significant medication errors; one resident did not receive ordered medications for two days after admission.
Report Facts
Medication error rate: 7.69
Residents transferred to hospital: 24
Residents in sample: 15
RN coverage days missing or less than 8 hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Discussed resident care, medication administration, and activity program |
| RN I | Registered Nurse | Discussed medication administration practices and medication errors |
| DON | Director of Nursing | Discussed staffing, medication storage, care plans, and fall policy |
| Administrator | Facility Administrator | Discussed facility policies, staffing, and regulatory compliance |
| CNA J | Certified Nursing Assistant | Discussed resident hygiene and activity participation |
| ADON | Assistant Director of Nursing | Discussed care plans and medication storage |
| Staffing Coordinator | Certified Medication Technician | Discussed medication administration and medication room access |
| Maintenance Supervisor | Maintenance Supervisor | Discussed medication room door lock repair |
| Activity Director | Activity Director | Discussed activity program and resident participation |
Inspection Report
Enforcement
Census: 27
Deficiencies: 4
Date: May 1, 2023
Visit Reason
The inspection was conducted due to concerns about facility-initiated transfers and discharges of residents to other facilities without proper notice, documentation, or discharge planning, and related regulatory compliance issues.
Findings
The facility failed to follow transfer and discharge policies for multiple residents, including failure to provide 30-day discharge notices, failure to document reasons for transfers, failure to provide discharge summaries and post-discharge plans, and failure to ensure residents' belongings and medically necessary equipment accompanied them. Residents were heavily recruited to transfer to a sister facility amid rumors of facility closure. The facility also failed to use proper transfer equipment and procedures for some residents, resulting in a fall and unsafe transfers.
Deficiencies (4)
Failure to follow facility-initiated transfer and discharge requirements for six of 13 sampled residents, including failure to provide 30-day discharge notice and notify responsible parties.
Failure to provide timely notification to residents and representatives before transfer or discharge, including appeal rights, for six of 13 sampled residents.
Failure to follow resident care plan and use proper transfer equipment, resulting in a witnessed fall of one resident and unsafe transfer of another resident without a gait belt.
Failure to administer care in a manner that enables effective and efficient use of resources, including inappropriate facility-initiated transfers without proper notice, reason, or discharge planning, and failure to ensure residents' belongings and medically necessary equipment accompanied them.
Report Facts
Residents discharged to Sister Facility A: 12
Sample size: 13
Facility census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator H | Administrator for Sister Facility A | Encouraged residents to transfer to Sister Facility A and was involved in recruitment and transfer discussions |
| Corporate Consultant C | Spoke with residents about transfer options and reassured residents amid rumors of facility closure | |
| Senior Clinical Liaison | Spoke with residents and responsible parties regarding transfer choices and assisted with transition | |
| Employee E | Witnessed Administrator H telling Resident #100 about facility closing and transfer to Sister Facility A | |
| Director of Nursing (DON) | Director of Nursing | Provided information about resident transfers, transfer documentation, and care plan compliance |
| Director of Rehab (DOR) | Director of Rehabilitation | Reported confusion about transfers and recruitment of residents to Sister Facility A |
| Certified Nursing Assistant (CNA) A | Certified Nursing Assistant | Involved in transfer of Resident #2 and Resident #4, reported use of gait belt policy |
| Certified Nursing Assistant (CNA) B | Certified Nursing Assistant | Involved in transfer of Resident #2 and Resident #4, reported use of gait belt policy |
| Physical Therapy Assistant (PTA) C | Physical Therapy Assistant | Reported resident transfer status and education of nursing staff on transfers |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Apr 5, 2023
Visit Reason
The inspection was conducted due to an allegation of abuse involving a Certified Nurse Aide (CNA E) who was reported to have grabbed a resident's arm, threatened to break it, and caused bruising and fear in the resident. The investigation was initiated following a complaint and reports from staff and residents.
Complaint Details
The complaint involved Resident #2 who was abused by CNA E on 1/25/23. The abuse included grabbing and twisting the resident's arm, threatening to break it, hitting the resident's forehead, and mistreating the resident's stuffed toy dog. The resident was fearful and delayed reporting due to threats. Staff witnesses failed to report the abuse immediately. The allegation was substantiated after investigation.
Findings
The facility substantiated the allegation that CNA E abused Resident #2 by grabbing and twisting the resident's arm, threatening harm, and mistreating the resident's stuffed toy dog. The abuse was witnessed by staff who failed to report it immediately. The facility took corrective actions including staff in-service and termination of CNA E's employment. The resident had bruises and scratches consistent with the abuse described.
Deficiencies (1)
Failure to protect a resident from abuse by a staff member who grabbed and twisted the resident's arm, threatened harm, and caused bruising and fear.
Report Facts
Residents present: 41
Date of alleged incident: Jan 25, 2023
BIMS score: 9
BIMS score: 15
Bruise size: 0.8
Bruise size: 3
Bruises observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Aide | Named as the staff member who abused Resident #2 by grabbing and twisting the arm, threatening harm, and mistreating the resident's stuffed toy dog. |
| Administrator A | Administrator | Facility Administrator at time of incident who substantiated the allegation of abuse and took corrective action. |
| DON C | Director of Nursing | Interviewed resident and documented bruises; involved in investigation. |
| COTA | Certified Occupational Therapy Assistant | Reported the abuse to Administrator, DON, ADON, and SSD after observing bruises and hearing resident's account. |
| SSD | Social Services Director | Received report from COTA, interviewed resident and other witnesses, and participated in investigation. |
| ADON | Assistant Director of Nurses | Participated in interviews and investigation of abuse allegation. |
| WCN | Wound Care Nurse | Conducted skin assessments and documented bruises and scratches on resident. |
| Housekeeper F | Housekeeper | Witnessed the abuse incident but did not report it immediately. |
| CNA G | Certified Nurse Aide | Witnessed employee arguing with resident and mistreating resident's toy; reported incident after being contacted by ADON. |
Inspection Report
Routine
Census: 60
Deficiencies: 20
Date: Feb 25, 2020
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including residents' rights, restraint use, care planning, quality of care, activities, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to update residents' code status forms annually, improper use and documentation of restraints, incomplete care plans for hospice residents, failure to follow physician orders and professional standards of care, inadequate monitoring and documentation of blood glucose testing and weights, failure to provide adequate personal care and activities, medication errors including missed insulin doses, incomplete controlled substance counts, failure to maintain infection control measures including TB testing and catheter care, and failure to maintain facility cleanliness and staffing documentation.
Deficiencies (20)
Failed to ensure residents' code status forms were updated annually, legible, and matched physician orders.
Failed to ensure one resident remained free from restraints and obtain physician's order for restraint use.
Failed to update care plans to reflect hospice services and collaboration for residents receiving hospice care.
Failed to follow physician orders and professional standards of care for multiple residents including bone stimulation therapy, blood sugar checks, oxygen administration, fluid restrictions, and documentation of resident deaths.
Failed to provide adequate personal care including showers and fingernail care for residents.
Failed to provide individualized activities to meet residents' interests and needs.
Failed to provide appropriate wound care and follow physician orders for wound treatment.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failed to provide restorative therapy services as ordered for residents.
Failed to adequately assess falls and follow fall management policy, including investigation and neuro checks.
Failed to secure dangerous chemicals and razors on secured unit and failed to follow proper Hoyer lift procedures.
Failed to ensure appropriate catheter care, obtain orders for catheter use, care and changing, and monitor for urinary tract infections.
Failed to ensure Certified Nurse Assistants received required annual 12 hour in-service training.
Failed to post daily nurse staffing information with all required details including facility name, census, and hours worked.
Failed to maintain kitchen floors free from food debris and failed to sufficiently air dry dishes before use.
Failed to review and update Facility Assessment annually as required.
Failed to provide yearly Tuberculin Skin Test or screening for residents and new employees as per policy.
Failed to ensure PRN psychotropic medications were re-evaluated after 14 days of use.
Failed to ensure residents remained free from significant medication errors including missed insulin doses.
Failed to ensure licensed pharmacist documented physician review and action on irregularities identified during monthly medication regimen reviews.
Report Facts
Missed insulin doses: 4
Missed narcotic counts: 67
Missed CNA in-service hours: 5
Missed TST annual screening: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse M | Night Shift Charge Nurse | Named in insulin administration failure and narcotic count findings |
| Nurse L | Day Shift Charge Nurse | Named in insulin administration failure |
| Director of Nurses | Director of Nursing (DON) | Named in multiple findings including insulin administration, medication regimen review, fall management |
| Certified Occupational Therapy Assistant E | COTA | Named in Hoyer lift transfer observation |
| Certified Nurse Assistant B | CNA | Named in Hoyer lift transfer observation |
| Certified Nurse Assistant C | CNA | Named in Hoyer lift transfer observation |
| Dietary Manager | Dietary Manager | Named in kitchen cleanliness and dish drying findings |
| Administrator | Facility Administrator | Named in staffing and TB testing findings |
| Corporate Nurse | Corporate Nurse | Named in multiple findings including insulin administration, medication regimen review, catheter care |
Report
January 16, 2024
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