Inspection Reports for
Manchester Rehab and Healthcare Center
312 SOLLEY DR, BALLWIN, MO, 63021-5248
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
26.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
384% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
54% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
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
Plan of Correction
Census: 53
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Manchester Rehab and Healthcare Center following an incident involving a resident falling backward in a wheelchair during transport on 10/25/2024.
Findings
The facility failed to ensure the resident environment was free of accident hazards by not properly securing the resident's wheelchair during transport, resulting in the resident falling and sustaining a small gash to the head. The facility conducted an investigation, provided education, and corrected the deficiency on 10/25/2024.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to properly secure the resident's wheelchair during transport, causing the resident to fall backward and sustain a head injury. The facility initiated an investigation and provided education to staff and drivers on proper securement.
Report Facts
Resident census: 53
Incident date: Oct 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Worker A | Involved in transporting resident and securing wheelchair during incident | |
| Activity Director | Involved in transporting resident, providing first aid, and investigation | |
| Administrator | Notified of incident and involved in follow-up and investigation |
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
Plan of Correction
Census: 49
Deficiencies: 2
Date: Sep 20, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to professional standards of care, specifically regarding comprehensive care plans and admission orders following a resident's hospital discharge.
Findings
The facility failed to ensure professional standards of care by admitting a resident without physician's orders and not providing prescribed medications, resulting in the resident being sent to the hospital. The facility also lacked a policy for obtaining physician orders at admission and had incomplete admission documentation and medication administration records.
Deficiencies (2)
F658 Services Provided Meet Professional Standards. The facility admitted a resident without physician's orders and failed to provide prescribed medications, resulting in the resident being sent to the hospital. The facility lacked a policy for obtaining physician orders at admission and had incomplete admission documentation.
A4051 19 CSR 30-85.042(42) Res Diagnosis/Orders Upon Admission. The facility did not obtain the resident's primary diagnosis and written orders for immediate care at admission, citing the deficiency at F658 with a higher classification due to the extent of the violation.
Report Facts
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Named in interviews regarding admission process and notification of physician |
| Registered Nurse A | RN | Authored admission assessment and involved in medication order verification |
| Licensed Practical Nurse B | LPN | Documented resident assessments and hospital transfer |
| Certified Medication Technician E | CMT | Interviewed regarding medication administration and electronic records |
| Certified Nurse Aide F | CNA | Interviewed about resident meal tray delivery |
| Certified Nurse Aide G | CNA | Interviewed about resident meal tray delivery |
| Administrator | Administrator | Interviewed regarding admission process and discharge paperwork |
| Regional Corporate Nurse | Regional Corporate Nurse | Interviewed about admission nurse priorities and medication orders |
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
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Jul 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident sustaining a fractured leg during a transfer and concerns about resident safety and supervision.
Complaint Details
The complaint investigation was substantiated, involving a resident who sustained a fractured leg during a transfer without a mechanical lift and a cognitively impaired resident who eloped from the facility without staff knowledge.
Findings
The facility failed to ensure residents' safety during transfers, adequate staff access to electronic medical records, and proper supervision to prevent elopement. Deficiencies included failure to follow mechanical lift policies, update care plans, and prevent a cognitively impaired resident from leaving the facility unsupervised.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure a resident's safety during transfer without using a mechanical lift, resulting in a fractured leg. The facility also failed to ensure staff had access to residents' electronic medical records and failed to prevent a cognitively impaired resident from eloping.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: The facility failed to provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, as evidenced by a resident eloping without staff knowledge.
Report Facts
Sample size: 14
Census: 52
Resident #: 20
Resident #: 19
BIMS score: 13
Date of incident: Jun 29, 2024
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 3
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, medication administration, and clinical records at Manchester Rehab and Healthcare Center.
Findings
The facility failed to ensure five residents received showers according to their preferences and had a medication error rate exceeding 5%. Additionally, the facility did not maintain complete and accessible clinical records, including wound care documentation.
Deficiencies (3)
F677: The facility failed to ensure five residents who required assistance with activities of daily living received showers according to their needs and preferences. Shower schedules were assigned by room number, not resident preference, and shower sheets were incomplete or missing.
F759: The facility failed to maintain a medication error rate below 5%, with 4 errors out of 42 opportunities resulting in a 9.52% error rate. Medication administration policies were not fully followed, including missed doses of aspirin and multivitamins.
F842: The facility failed to maintain complete, accurate, and accessible clinical records for residents, including wound care documentation. Wound reports and physician notes were often missing from medical records and not properly uploaded or maintained.
Report Facts
Resident census: 44
Medication error rate: 9.52
Medication errors: 4
Medication opportunities: 42
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
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Jan 16, 2024
Visit Reason
The inspection was conducted due to a complaint alleging that a resident was hit in the head by a male nurse, triggering an investigation into abuse and failure to properly investigate and report the allegation.
Complaint Details
The complaint involved an allegation that a resident was hit in the head by a male nurse. The allegation was reported by the resident's sibling to the facility's Marketing Director during a hospital visit. The facility failed to interview the resident or family member and did not notify the state agency within the required timeframe. The facility suspended all male nurses and interviewed residents who reported feeling safe. The allegation was substantiated as the facility acknowledged failures in investigation and reporting.
Findings
The facility failed to thoroughly investigate the abuse allegation by not interviewing the resident or the resident's family member and failed to report the suspected abuse to the state agency within the required two-hour timeframe. The facility suspended all male nurses pending investigation and interviewed residents who reported feeling safe.
Deficiencies (2)
F 0607: The facility failed to follow their abuse policy by not thoroughly investigating an allegation of a resident being hit in the head by a male nurse, including failure to interview the resident and the resident's sibling who reported the allegation.
F 0609: The facility failed to report an allegation of resident abuse to the Department of Health and Senior Services within the required two-hour timeframe.
Report Facts
Census: 45
Residents interviewed: 10
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marketing Director | Reported the abuse allegation and communicated with Administrator and DON | |
| Director of Nursing (DON) | Received abuse allegation report, suspended male nurses, and conducted interviews | |
| Administrator | Responsible for coordinating investigation and reporting; admitted failure to interview resident/family and notify state agency |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Jan 16, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging resident abuse involving a male nurse hitting a resident in the head.
Complaint Details
The complaint alleged a resident was hit in the head by a male nurse. The facility did not thoroughly investigate or report the allegation timely. Interviews with staff, residents, and family members were incomplete or missing. The resident was discharged to the hospital during the investigation. The state agency was not notified within the required timeframe.
Findings
The facility failed to thoroughly investigate the allegation of abuse, did not report the incident within required timeframes, and lacked documentation of interviews and investigation steps. The resident was discharged to the hospital, and the facility did not notify the state agency as required.
Deficiencies (2)
F607: The facility failed to develop and implement adequate abuse and neglect policies and procedures, including thorough investigation and reporting of alleged abuse incidents.
F609: The facility failed to report an allegation of resident abuse to the Department of Health and Senior Services within the required two-hour timeframe.
Report Facts
Resident census: 45
Residents interviewed: 10
Male workers interviewed: 4
Completion date for plan of correction: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Bella | Signed the plan of correction form | |
| Marketing Director | Visited resident in hospital, reported allegation, and communicated with Administrator and Director of Nursing | |
| Director of Nursing | Director of Nursing | Involved in investigation and communication regarding the abuse allegation |
| Administrator | Administrator | Responsible for coordinating investigation and communication regarding the abuse allegation |
Inspection Report
Life Safety
Census: 43
Capacity: 137
Deficiencies: 12
Date: Dec 5, 2023
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code investigation to assess compliance with federal, state, and local emergency preparedness and fire safety regulations.
Findings
The facility failed to update its emergency preparedness plan annually and lacked a written communication plan. Deficiencies were found in emergency power systems, building construction standards, egress door locking systems, hazardous area separations, sprinkler system maintenance, fire extinguisher maintenance, electrical wiring, and smoke barrier doors. These deficiencies had the potential to affect all residents and staff.
Deficiencies (12)
E004 Emergency Plan. The facility failed to update the emergency preparedness plan annually, with the last update dated 4/1/20, risking occupant safety.
E029 Development of Communication Plan. The facility failed to include a written communication plan in the emergency preparedness plan, lacking policies on staff coordination during emergencies.
E030 Names and Contact Information. The facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all staff and entities.
E041 Hospital CAH and LTC Emergency Power. The facility failed to implement emergency power system inspection, testing, and maintenance requirements, and lacked information on emergency generator components.
K161 Building Construction Type and Height. The facility failed to maintain construction standards with proper smoke resistant and fire resistance rated ceilings and walls, affecting two of three smoke compartments.
K222 Egress Doors. The facility failed to maintain egress exit doors equipped with special locking arrangements that remained engaged during fire alarm activation, affecting six of seven smoke compartments.
K321 Hazardous Areas - Enclosure. The facility failed to ensure hazardous areas were separated by fire-resistant construction and equipped with self-closing devices, affecting ten smoke compartments.
K353 Sprinkler System - Maintenance and Testing. The facility failed to maintain sprinkler heads free of debris and obstructions and failed to maintain a sprinkler wrench in the spare cabinet.
K355 Portable Fire Extinguishers. The facility failed to ensure portable fire extinguishers were installed, inspected, and maintained in accordance with NFPA 10 standards.
K372 Subdivision of Building Spaces - Smoke Barrier. The facility failed to maintain smoke barriers to provide the required fire resistance rating, affecting six of seven smoke compartments.
K374 Subdivision of Building Spaces - Smoke Barrier Doors. The facility failed to ensure smoke barrier doors closed fully and did not exceed maximum clearance allowed between door edges.
K511 Utilities - Gas and Electric. The facility failed to maintain electrical wiring in compliance with the National Electrical Code NFPA 70, affecting four of seven smoke compartments.
Report Facts
Facility capacity: 137
Resident census: 43
Deficiency counts: 12
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
Complaint Investigation
Census: 27
Deficiencies: 5
Date: May 1, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to follow transfer and discharge policies for several residents and to provide proper notice and documentation.
Complaint Details
The complaint investigation found substantiated violations related to improper transfer and discharge procedures, failure to notify responsible parties, and inadequate documentation and communication during resident transfers and discharges.
Findings
The facility failed to follow its transfer and discharge policies for six of 13 sampled residents, did not notify a responsible party for one resident's discharge, and failed to provide a 30-day discharge notice for six residents. The facility also failed to ensure proper documentation and communication during transfers and discharges.
Deficiencies (5)
F622 Transfer and Discharge Requirements: The facility failed to follow transfer and discharge policies for six of 13 sampled residents and did not notify a responsible party for one resident's discharge.
A4016 No Adverse Effect-Resident Health/Safety/Property: The facility failed to ensure residents were not adversely affected by transfer and discharge practices, resulting in a Class I violation.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide a 30-day discharge notice to six residents prior to transfer or discharge.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to follow a resident's care plan and gait belt policy, resulting in a witnessed fall.
F835 Administration: The facility failed to administer care in a manner that enables it to use resources effectively and maintain residents' well-being, including failure to provide proper discharge planning and notification.
Report Facts
Resident census: 27
Sampled residents: 13
Residents with transfer/discharge issues: 6
Residents with missing 30-day discharge notice: 6
Resident discharges to Sister Facility A: 12
Residents DC'd from center: 5
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 a complaint investigation regarding abuse by a Certified Nurse Aide (CNA E) toward Resident #2, including threats and physical harm.
Complaint Details
The complaint was substantiated based on interviews, observations, and documentation. The facility took corrective action including terminating CNA E and implementing abuse prevention policies.
Findings
The facility failed to ensure Resident #2 was free from abuse by CNA E, who grabbed and threatened the resident causing bruising. The facility conducted an investigation, terminated CNA E, and substantiated the abuse allegation.
Deficiencies (1)
F 600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent verbal and physical abuse by CNA E toward Resident #2, resulting in bruising and fear. Staff failed to report the abuse promptly.
Report Facts
Resident census: 41
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Aide | Named in abuse allegation against Resident #2 |
| Administrator A | Administrator | Substantiated the allegation of abuse |
| DON C | Director of Nurses | Involved in investigation and reporting |
| ADON | Assistant Director of Nurses | Involved in investigation and reporting |
| SSD | Social Services Director | Involved in investigation and reporting |
| COTA | Certified Occupational Therapy Assistant | Reported abuse and interviewed resident |
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
Life Safety
Census: 49
Capacity: 137
Deficiencies: 7
Date: Mar 1, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations, focusing on building rehabilitation and fire safety standards.
Findings
The facility failed to obtain plan approval prior to repairs and renovations, and did not maintain appropriate construction standards including smoke resisting partitions and doors. Deficiencies had the potential to affect all building occupants and multiple smoke compartments.
Deficiencies (7)
K111 Building Rehabilitation: The facility replaced flooring, baseboards, handrails, lighting, and painted without obtaining plan approval prior to repairs and renovations on two floors. This deficiency affected all building occupants.
K161 Building Construction Type and Height: The facility failed to maintain proper smoke resisting and fire resistance rated ceilings and walls as required by the Life Safety Code. This deficiency affected occupants in four of ten smoke compartments.
K321 Hazardous Areas - Enclosure: The facility failed to ensure hazardous areas were separated by smoke resisting partitions and doors equipped with self-closing devices. This deficiency affected residents and staff in three of ten smoke compartments.
K363 Corridor Doors: The facility failed to maintain corridor doors to resist the passage of smoke and ensure doors were self-closing. This deficiency affected residents and staff in two of ten smoke compartments.
A1003 Construction Plan - Written Approval: Facilities must begin construction only after receiving written approval of plans. The facility did not comply with this requirement as evidenced by deficiencies cited at K111.
A2008 Hazardous Areas: Hazardous areas must be separated by fire-resistant construction and doors must be self-closing or automatic closing. The facility did not meet this requirement as evidenced by deficiency at K321.
A3001 Substantially Constructed/Maintained: The building must be substantially constructed and maintained in good repair. The facility failed to meet this requirement as evidenced by deficiencies at K161 and K363.
Report Facts
Facility capacity: 137
Resident census: 49
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 2
Date: Feb 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer prevention and treatment, and sufficient nursing staff at West County Care Center.
Findings
The facility failed to provide care consistent with professional standards to prevent and treat pressure ulcers in one resident, resulting in an unstageable pressure ulcer. The facility also failed to maintain sufficient nursing staff to meet resident needs, leading to delayed care and medication administration.
Deficiencies (2)
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to ensure one resident received care to prevent and treat pressure ulcers, resulting in an unstageable pressure ulcer with moisture associated skin damage (MASD).
F725 Sufficient Nursing Staff: The facility failed to maintain sufficient nursing staff to meet resident needs, resulting in delayed medication administration, treatments, and inadequate care for multiple residents.
Report Facts
Resident census: 50
Sample size: 4
Staffing schedule counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in staffing shortage and care delay findings |
| Director of Nursing | Director of Nursing | Named in staffing shortage and care delay findings |
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 9
Date: Nov 15, 2022
Visit Reason
The inspection was conducted to investigate and document deficiencies related to the facility's administration and payment practices to vendors, as well as compliance with regulatory requirements.
Findings
The facility failed to ensure timely payments to various vendors including pharmacy, laboratory, dietitian, and other service providers, resulting in outstanding balances. The facility also failed to maintain a safe and comfortable environment, provide adequate perineal care, and ensure proper documentation and implementation of advance directives and physician orders.
Deficiencies (9)
F835 Administration. The facility management company failed to ensure payments were issued or issued timely to vendors providing services to residents. The census was 42.
A3023 Hot Water 105-120 Degrees F. The facility failed to maintain plumbing fixtures supplying hot water within the required temperature range of 105 to 120 degrees Fahrenheit. This deficiency is Class II.
A4075 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with residents' conditions and acceptable nursing practice. This deficiency is Class II.
A6012 Floor Surfaces. The facility failed to maintain floors and floor coverings in good repair and clean condition. This deficiency is Class III.
A6015 Walls/Ceilings/Doors/Windows Clean. The facility failed to maintain walls, ceilings, doors, and windows in good repair and clean condition. This deficiency is Class III.
A8010 Advance Directive Requirements. The facility failed to comply with requirements to inform residents or their representatives about advance directives and maintain related documentation. This deficiency is Class III.
F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directive. The facility failed to ensure physician orders for code status were obtained and documented for two residents. The census was 46.
F677 ADL Care Provided for Dependent Residents. The facility failed to provide adequate perineal care for one of three sampled residents. The census was 46.
F684 Quality of Care. The facility failed to provide appropriate perineal care and ensure staff washed residents' perineal areas properly. The census was 46.
Report Facts
Census: 42
Census: 46
Outstanding balance: 46558.52
Outstanding balance: 46230.84
Outstanding balance: 28414.29
Outstanding balance: 5528.52
Outstanding balance: 3800
Outstanding balance: 18698.8
Outstanding balance: 1929.27
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 6
Date: Sep 13, 2022
Visit Reason
Annual federal inspection survey of West County Care Center to assess compliance with professional standards of care, staffing, dietary services, and written orders.
Findings
The facility failed to meet professional standards of care related to oxygen administration without physician orders and had deficiencies in dietary staffing and food service supervision. Multiple regulatory requirements were not met, including lack of a qualified dietary manager and insufficient dietary support staff.
Deficiencies (6)
F658: The facility failed to follow professional standards of care by administering oxygen without physician orders for six residents requiring oxygen therapy.
F801: The facility failed to employ a qualified dietary manager or clinically qualified nutrition professional for one food service kitchen serving all residents.
F802: The facility failed to provide sufficient dietary support personnel to safely and effectively carry out food and nutrition services, resulting in untimely meal service affecting all residents.
A4054: No medication, treatment, or diet shall be given without a written order; restraint orders must be followed. This was not met as evidenced by deficiencies cited at F658.
A5014: Personnel must be sufficient and properly trained to assure adequate food preparation and service. This was not met as evidenced by deficiencies cited at F802.
A5015: Facilities must employ a food service supervisor with overall supervisory responsibility for dietary services. This was not met as evidenced by deficiencies cited at F801.
Report Facts
Resident census: 49
Sample size: 10
Plan of correction completion date: Corrective actions to be completed by 2022-10-03
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Allen | CEO | Signed the statement of deficiencies and plan of correction |
| Cook F | Dietary staff responsible for food preparation and kitchen management; quit during inspection period | |
| Regional Dietary Manager (RDM) | Contracted dietary manager overseeing kitchen staffing and operations | |
| Director of Nursing (DON) | Provided information on oxygen orders and dietary staffing challenges | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding oxygen saturation monitoring and documentation |
Inspection Report
Life Safety
Census: 49
Capacity: 137
Deficiencies: 2
Date: Sep 13, 2022
Visit Reason
The inspection was conducted to assess compliance with NFPA code regarding oxygen cylinder storage and gas equipment safety at West County Care Center.
Findings
The facility failed to maintain oxygen cylinder storage according to NFPA code, with cylinders not properly chained or supported and stored on the floor instead of in holders or racks. This deficient practice had the potential to affect all occupants in one of seven smoke compartments.
Deficiencies (2)
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage according to NFPA code. Cylinders were not chained or supported and were stored on the floor instead of in holders or racks.
A2010 Oxygen Storage: Oxygen storage was not in accordance with NFPA 99. Permanent racks or fasteners were not used to prevent accidental damage or dislocation of oxygen cylinders. Safety caps were not intact except when cylinders were in use.
Report Facts
Facility capacity: 137
Resident census: 49
Plan of correction completion date: Oct 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Plunk | CEO | Signed the deficiency statement and plan of correction |
Inspection Report
Follow-Up
Census: 48
Deficiencies: 2
Date: May 17, 2022
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies related to resident allergies, preferences, and substitutes in food service.
Findings
The facility failed to post menus or offer alternative menu items to residents who could not or preferred not to eat the meal served. This deficiency remained uncorrected at the follow-up visit, affecting multiple residents.
Deficiencies (2)
Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5) Food that accommodates resident allergies, intolerances, and preferences was not provided. The facility failed to post menus or offer alternative menu items to residents who could not or preferred not to eat the meal served.
19 CSR 30-85.052(6) Substitutes, Nutritive Value If a resident refuses food served, appropriate substitutes of similar nutritive value shall be offered. This regulation is not met as evidenced by the deficiency cited at F806.
Report Facts
Resident census: 48
Resident census: 46
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 9
Date: Mar 10, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 03/09/2022 through 03/10/2022. The document includes a plan of correction responding to deficiencies cited during the survey.
Findings
The facility was found in compliance with 42 CFR 483.73 related to emergency preparedness. Deficiencies were cited related to management of personal funds, including failure to maintain records of personal possessions, lack of written authorization for withdrawals, failure to reconcile resident trust accounts monthly, and failure to provide final accounting of personal funds within five days of discharge. Additionally, the facility failed to meet staff COVID-19 vaccination requirements.
Deficiencies (9)
19 CSR 30-88.010(36) Personal Clothing/Possessions: The facility failed to maintain a record of personal possessions for two residents out of a sample of four. The facility census was 42.
Protection/Management of Personal Funds CFR(s): 483.10(f)(10)(ii): The facility failed to obtain written authorization for money withdrawals for four residents out of a sample of seven and failed to withdraw the correct monthly surplus for five residents. The facility census was 42.
19 CSR 30-88.020(2) Resident Fund Use: The operator or designee must use resident funds exclusively for the resident's use and only with written authorization. This regulation was not met as evidenced by deficiencies cited at F567.
19 CSR 30-88.020(3) Resident Funds Statement Required: Residents must be provided a statement explaining policies and rights regarding personal funds. This regulation was not met as evidenced by deficiencies cited at F567.
19 CSR 30-88.020(9) Resident Funds Reconciled Monthly: Resident funds must be reconciled monthly with statements provided quarterly. This regulation was not met as evidenced by deficiencies cited at F568.
19 CSR 30-88.020(10) Discharge Requirement Within 5 Days: Residents must receive an up-to-date accounting of personal funds and possessions within five days of discharge. This regulation was not met as evidenced by deficiencies cited at F569.
Accounting and Records of Personal Funds CFR(s): 483.10(f)(10)(iii): The facility failed to reconcile resident trust accounts monthly. The facility census was 42.
Notice and Conveyance of Personal Funds CFR(s): 483.10(f)(10)(iv)(v): The facility failed to provide final accounting of resident personal funds within five days of discharge for four residents. The facility census was 42.
COVID-19 Vaccination of Facility Staff CFR(s): 483.80(i): The facility failed to ensure 100% of staff were fully vaccinated or exempted from COVID-19 vaccination requirements. The facility census was 42.
Report Facts
Facility census: 42
Staff total: 53
Staff partially or fully vaccinated: 38
Staff with granted exemption: 10
Staff with no vaccination or exemption: 5
Deficiencies cited: 9
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Date: May 10, 2021
Visit Reason
The inspection was conducted as an Immediate Jeopardy (IJ) complaint investigation triggered by multiple resident elopements and safety concerns.
Complaint Details
The complaint investigation was initiated due to multiple elopements of cognitively impaired residents, including one resident who suffered knee trauma after eloping. The investigation confirmed the facility's failure to provide adequate supervision and staffing, resulting in an Immediate Jeopardy that was removed after corrective actions.
Findings
The facility failed to provide adequate supervision to prevent elopement of cognitively impaired residents, resulting in multiple elopements and injuries. Additionally, the facility failed to maintain sufficient nursing staff to ensure resident safety and proper supervision.
Deficiencies (4)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision to prevent elopement of three cognitively impaired residents, resulting in injuries and unsafe conditions.
F725 Sufficient Nursing Staff: The facility failed to maintain appropriate staffing levels and supervision, resulting in inadequate care and oversight of residents, including failure to document incidents and falls.
A4044 Nursing Staff Sufficient/Qualified: The facility did not employ sufficient nursing personnel with appropriate qualifications to provide nursing and related services to all residents.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide adequate protective oversight and supervision for residents on voluntary leave, contributing to elopement risks.
Report Facts
Census: 53
Elopement Risks: 15
Elopement Risk Levels: 5
Elopement Risk Levels: 2
Elopement Risk Levels: 8
Fall Risk Score: 22
Wandering Risk Score: 14
Inspection Report
Routine
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 12/04/2020 through 12/16/2020 to assess compliance with CMS and CDC recommended practices and federal emergency preparedness 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
Census: 42
Deficiencies: 3
Date: Oct 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 10/15/2020 through 10/20/2020 to assess compliance with infection control and accident prevention regulations.
Findings
The facility was found to be in compliance with some regulations but failed to ensure adequate supervision and assistive devices to prevent accidents for two of three sampled residents. Infection prevention and control deficiencies were also identified related to hand hygiene, PPE use, and COVID-19 protocols.
Deficiencies (3)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents by not providing safe transfers for two of three sampled residents.
F880 Infection Prevention & Control: The facility failed to provide infection control measures including proper hand hygiene, PPE use, and posting appropriate signage in the COVID-19 positive unit.
F885 Reporting-Residents, Representatives & Families: The facility failed to provide cumulative updates to residents, representatives, and families within required timeframes following confirmed COVID-19 cases.
Report Facts
Census: 42
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in findings related to improper transfer, hand hygiene, PPE use, and infection control deficiencies | |
| Director of Nursing | DON | Interviewed regarding gait belt use and infection control policies |
| Assistant Director of Nursing | ADON | Interviewed regarding gait belt use and infection control policies |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 09/22/2020 through 09/28/2020 to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 09/01/2020 through 09/02/2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
The complaint investigation related to infection control was not substantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 06/03/2020 through 06/04/2020 to assess compliance with CMS and CDC recommended practices and federal emergency preparedness 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
Life Safety
Census: 60
Capacity: 137
Deficiencies: 12
Date: Feb 25, 2020
Visit Reason
The inspection was conducted as an emergency preparedness investigation and life safety code survey at West County Care Center.
Findings
The facility failed to update its emergency preparedness plan annually and did not meet several life safety code requirements including delayed-egress door locking arrangements, fire alarm system maintenance, sprinkler system inspections, smoke barrier doors, smoking regulations, and electrical receptacle testing.
Deficiencies (12)
E004 Emergency preparedness plan was not updated annually as required, with no documented update or review since 11/2/17.
K222 Delayed-egress exit doors lacked required signage and failed to release and open during fire alarm activation, affecting multiple smoke compartments.
K345 Fire alarm system semi-annual inspection was not completed due to an open invoice with the inspection company.
K353 Sprinkler system lacked quarterly inspections for two of four quarters and did not maintain adequate spare sprinkler heads.
K374 Smoke barrier doors did not close fully during fire alarm tests, with visible gaps compromising smoke compartment integrity.
K741 Smoking regulations were not met as the facility failed to properly dispose of ashtray contents in designated smoking areas.
K914 Electrical receptacles in patient sleeping areas were not tested annually, with some rooms missing documentation of testing.
A2019 Fire alarm system was not maintained in accordance with NFPA 72, 1999 edition.
A2034 Sprinkler system was not inspected, maintained, and tested as required for facilities with pre-2007 installations.
A2054 Smoke section walls and doors did not meet fire-rated separation requirements.
A2057 Ashtrays in designated smoking areas were not disposed of properly, violating safety regulations.
A3001 Building was not substantially constructed and maintained in good repair, with violations of health care occupancy standards.
Report Facts
Facility capacity: 137
Resident census: 60
Dates of inspections: Feb 20, 2020
Plan of correction completion dates: Mar 27, 2020
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 |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 19
Date: Feb 25, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations and evaluate resident care and facility operations.
Findings
The facility was found to have multiple deficiencies related to resident care, documentation, medication management, infection control, and staff training. Several deficiencies were classified as Class II and Class III, indicating varying levels of severity.
Deficiencies (19)
F578 - The facility failed to ensure residents' code status forms were updated annually and matched physician orders. This affected four sampled residents.
F604 - The facility failed to ensure residents were free from chemical restraints and that restraint assessments and orders were properly documented.
F657 - The facility failed to update residents' care plans to reflect hospice diagnoses and services, affecting multiple residents receiving hospice care.
F658 - The facility failed to provide or arrange professional services for residents, including timely assessments and care plan updates.
F679 - The facility failed to provide individualized activities to meet residents' interests and needs, affecting the psychosocial well-being of residents.
F684 - The facility failed to provide person-centered care and ensure residents with wounds received appropriate treatment and documentation.
F686 - The facility failed to ensure residents received appropriate wound care and documentation, including notification of physicians for changes in condition.
F688 - The facility failed to provide restorative nursing services as directed and failed to perform required assessments and documentation.
F689 - The facility failed to ensure residents were free from accident hazards and failed to implement fall prevention interventions.
F690 - The facility failed to maintain continence care and ensure residents with catheters received appropriate care and monitoring.
F730 - The facility failed to provide mandatory nurse aide in-service education and maintain documentation of training hours.
F732 - The facility failed to maintain accurate nursing staffing information and post required staffing data.
F755 - The facility failed to maintain accurate controlled substance records and ensure proper handling of narcotics.
F756 - The facility failed to conduct monthly drug regimen reviews for residents and document findings.
F758 - The facility failed to ensure attending physicians reviewed residents' medical records monthly and address irregularities.
F760 - The facility failed to ensure residents were free from significant medication errors and properly managed psychotropic medications.
F812 - The facility failed to maintain safe food service conditions, including cleanliness of kitchen floors and proper food storage.
F838 - The facility failed to ensure the Facility Assessment was updated and reviewed annually as required.
F880 - The facility failed to implement an effective infection prevention and control program, including TB screening and staff testing.
Report Facts
Sampled residents: 15
Census: 60
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Dec 26, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged resident abuse and neglect involving resident-to-resident altercations.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and incident investigations showing resident-to-resident abuse and inadequate facility response.
Findings
The facility failed to follow its Abuse, Neglect and Exploitation policy by not thoroughly investigating and monitoring resident-to-resident abuse incidents. Two residents were involved in altercations, and the facility did not adequately document or evaluate the incidents or monitor the residents afterward.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent resident-to-resident abuse and did not conduct a thorough investigation or monitoring of the incidents involving two residents.
A8023 Develop/Implement Abuse/Neglect Policies: The facility did not develop and implement adequate policies to prohibit mistreatment, neglect, and abuse of residents, as evidenced by the deficiency cited at F600.
Report Facts
Census: 55
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Jun 27, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at West County Care Center.
Complaint Details
The complaint investigation was substantiated based on evidence of abuse and failure to follow abuse prevention policies.
Findings
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident and a certified nurse aide. Documentation and interviews revealed bruising consistent with abuse, and the facility did not follow its abuse prevention policy.
Deficiencies (2)
F610: The facility failed to thoroughly investigate an allegation of physical abuse involving a resident and a certified nurse aide. Documentation and interviews showed bruising and inconsistent staff responses, and the employee was suspended pending investigation.
A8023: The facility did not develop and implement written policies and procedures prohibiting mistreatment, neglect, and abuse of residents. This regulation was not met as evidenced by the deficiency cited at F610.
Report Facts
Staff present during Abuse/Neglect inservice: 14
Bruise size: 7
Bruise size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Nurse | Confirmed nursing note and resident reliability during interview. |
| CNA M | Certified Nurses Aide | Named in abuse allegation and suspension pending investigation. |
| Nurse O | Nurse | Provided written statement and interviewed regarding abuse allegation. |
| Nurse C | Nurse | Conducted resident interviews and confirmed details of abuse investigation. |
| Administrator | Conducted investigation and provided statements about abuse allegation. |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 6
Date: May 24, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for West County Care Center.
Findings
The facility was found deficient in multiple areas including management of personal funds, professional standards of care, treatment of pressure ulcers, medication administration, bedrails safety, staffing, and in-service training. Several residents were affected by these deficiencies.
Deficiencies (6)
F567 Protection/Management of Personal Funds. The facility failed to ensure residents' requests for funds less than $100 were honored on weekends for 56 residents. No posting of banking hours was observed.
F658 Services Provided Meet Professional Standards. The facility failed to notify physicians timely of elevated blood pressure and ensure medications were administered as ordered for residents #25 and #52.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers. The facility failed to ensure three of four residents with pressure ulcers received treatments as ordered and proper documentation was lacking.
F700 Bedrails. The facility failed to assess residents for risk of entrapment and ensure proper installation and maintenance of bedrails for six residents. Gaps were not measured and consent was missing.
F727 RN 8 Hrs/7 days/Wk, Full Time DON. The facility failed to employ a full-time Director of Nursing or designate a registered nurse to serve as DON for an extended period.
F730 Nurse Aide Perform Review-12 hr/yr In-Service. The facility failed to ensure nurse aides received at least 12 hours of in-service education annually based on individual performance reviews.
Report Facts
Resident census: 60
Residents affected by personal funds deficiency: 56
Residents with pressure ulcers: 4
Residents sampled for bedrails: 15
Certified nurse aides: 26
Inspection Report
Life Safety
Census: 60
Capacity: 137
Deficiencies: 10
Date: May 24, 2019
Visit Reason
The inspection was conducted as an emergency preparedness investigation and life safety code survey to assess compliance with emergency preparedness policies and fire safety regulations.
Findings
The facility failed to follow emergency preparedness policies during a tornado warning, affecting 20 residents. Multiple life safety deficiencies were cited including blocked fire exits, lack of self-closing doors on hazardous area storage rooms, sprinkler system maintenance issues, and failure to maintain smoke barriers and fire drills.
Deficiencies (10)
E013 Development of emergency preparedness policies and procedures was deficient as staff failed to follow tornado warning procedures affecting 20 residents.
K211 Means of egress were obstructed by a steam table blocking a fire exit, affecting all occupants using the west dining room fire exits.
K321 Hazardous areas lacked self-closing doors, including storage rooms with combustibles and medical records room, posing fire safety risks.
K353 Sprinkler system maintenance was deficient; sprinkler heads were not maintained free of debris and some were missing escutcheon plates.
K372 Smoke barriers were not maintained; penetrations were not sealed with fire rated materials and fire rating was not listed on some materials.
K374 Smoke barrier doors failed to close upon fire alarm activation, affecting two smoke zones including the front lobby.
K712 Fire drills were not completed on each shift quarterly for two of four quarters reviewed, failing to meet requirements.
K918 Electrical system maintenance was deficient; weekly generator checks were not fully documented for multiple months.
K919 Electrical equipment maintenance was deficient; multiple electrical outlets and face plates were cracked, missing, or damaged.
K923 Oxygen storage was not maintained according to NFPA code; cylinders were mixed improperly and not stored separately as required.
Report Facts
Facility capacity: 137
Resident census: 60
Residents potentially affected: 20
Fire drills completed: 2
Fire drills required: 4
Weekly generator checks documented: 2
Weekly generator checks required: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding tornado warning policy and fire safety deficiencies; signed plan of correction | |
| Nurse B | Interviewed about resident movement during tornado warning | |
| Nurse C | Interviewed about assisting residents during tornado warning | |
| Director of Maintenance | Interviewed about sprinkler system maintenance and fire drill documentation | |
| Director of Nursing | Mentioned in relation to tornado warning staff confusion | |
| Housekeeping Director | Responsible for auditing fire exit clearance and trash placement | |
| Maintenance Assistant | Interviewed about oxygen cylinder storage |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 12
Date: Apr 23, 2018
Visit Reason
The inspection was the annual survey of West County Care Center to assess compliance with federal and state regulations.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights to vote, inadequate quality of care leading to a resident's injury and death, failure to provide appropriate mobility and accident prevention services, medication errors, inadequate nurse staffing information posting, and infection control issues.
Deficiencies (12)
F550 Resident Rights: The facility failed to ensure residents had the opportunity to exercise their right to vote, affecting multiple residents during the April 2018 election.
F684 Quality of Care: The facility failed to provide services to promote the highest practical physical well-being, resulting in a resident falling, sustaining injury, and subsequent death.
F688 Mobility: The facility failed to ensure residents with limited mobility received appropriate treatment and services to prevent further decline, including proper use of braces.
F689 Free of Accident Hazards: The facility failed to ensure residents were free from accident hazards and received adequate supervision and assistance to prevent accidents.
F690 Bowel/Bladder Incontinence: The facility failed to provide appropriate services and assistance to maintain continence for residents with bowel and bladder incontinence.
F693 Tube Feeding Management: The facility failed to ensure residents fed by enteral means received appropriate treatment and services to restore oral eating skills and prevent complications.
F700 Bed Rails: The facility failed to ensure proper assessment, installation, use, and maintenance of bed rails to prevent entrapment and injury.
F732 Posted Nurse Staffing Information: The facility failed to post required nurse staffing information daily in a clear and accessible manner.
F759 Medication Errors: The facility failed to ensure medication error rates were less than 5%, with documented errors resulting in a 10.2% error rate.
F811 Feeding Assistants: The facility failed to ensure feeding assistants completed state-approved training before feeding residents with complicated feeding problems.
F812 Food Safety: The facility failed to follow proper food safety requirements, including handwashing, thaw date monitoring, and food handling procedures.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection control program to prevent the spread of communicable diseases and infections.
Report Facts
Resident census: 67
Sample size: 24
Medication error rate: 10.2
Medication error opportunities: 49
Inspection Report
Life Safety
Census: 67
Capacity: 137
Deficiencies: 4
Date: Apr 23, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents, including annual door inspections, sprinkler system maintenance, smoke barrier construction, and electrical system testing.
Findings
The facility failed to conduct a complete annual door inspection, maintain sprinkler escutcheon plates, ensure smoke barriers met fire resistance ratings, and provide documentation of electrical inspections. These deficiencies had the potential to affect all occupants in the building.
Deficiencies (4)
K211 Means of Egress - General: The facility failed to conduct a complete annual door inspection, including doors equipped with delayed egress function and smoke doors.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler escutcheon plates, resulting in gaps and missing plates that could delay sprinkler activation.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers to provide the required 1/2-hour fire resistance rating, with holes and unsealed penetrations observed.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to ensure electrical inspection documentation was available and did not provide a remote manual stop station for the generator.
Report Facts
Facility capacity: 137
Resident census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Ormsbee | LNHA | Signed the inspection report and plan of correction |
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