Deficiencies (last 7 years)
Deficiencies (over 7 years)
11.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
113% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
67% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where one resident received another resident's medications.
Complaint Details
Complaint #2682543 regarding a medication error where Resident #1 received Resident #2's medications.
Findings
The facility failed to ensure Resident #1 remained free from accidents when Resident #1 received Resident #2's medications. The medication error occurred because staff were overwhelmed and did not properly verify the resident's identity before medication administration.
Deficiencies (1)
Facility staff failed to ensure one resident remained free from accidents when the resident received another resident's medications.
Report Facts
Facility census: 66
Medication dosages: 1500
Medication dosages: 75
Medication dosages: 200
Medication dosages: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Documented and involved in the medication error where Resident #1 received Resident #2's medications |
| Administrator | Interviewed regarding staff directions on medication administration | |
| DON | Director of Nursing interviewed regarding staff education on medication administration |
Inspection Report
Routine
Census: 65
Deficiencies: 5
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, medication management, infection control, facility maintenance, and antibiotic stewardship in the nursing facility.
Findings
The facility was found deficient in maintaining professional standards in medication transcription and administration, proper medication storage and destruction, kitchen ceiling maintenance, infection prevention practices including glucometer sanitation and PPE use, and implementation of an antibiotic stewardship program.
Deficiencies (5)
Failed to transcribe a treatment order for one resident and inaccurately transcribed a medication order for a Fentanyl patch for another resident.
Failed to destroy medications weekly and failed to store medications in locked compartments for 27 residents.
Failed to maintain the kitchen ceiling in good repair to prevent contamination of food items.
Failed to appropriately sanitize a multi-use glucometer between uses and failed to perform proper hand hygiene and glove changes during blood glucose checks; failed to use PPE for residents on enhanced barrier precautions.
Failed to implement an Antibiotic Stewardship Program with protocols and monitoring system.
Report Facts
Facility census: 65
Residents affected: 27
Medication counts: 23
Medication counts: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Nurse who obtained Fentanyl telephone order and entered it incorrectly into electronic MAR system | |
| Director of Nursing | DON | Responsible for reviewing and verifying orders, runs daily reports, and commented on deficiencies in medication transcription and infection control |
| Administrator | Provided statements on staff responsibilities and facility policies regarding medication orders, storage, and infection control | |
| Licensed Practical Nurse B | LPN | Observed failing to use approved disinfectant on glucometer and failing to use PPE during wound and catheter care |
| Licensed Practical Nurse A | LPN | Observed failing to perform hand hygiene and glove changes during blood glucose checks |
| Dietary Manager | DM | Aware of kitchen ceiling cracks and water leaks |
| Maintenance Director | Aware of kitchen ceiling cracks and water leaks, awaiting repairs |
Inspection Report
Life Safety
Census: 62
Capacity: 98
Deficiencies: 5
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including maintaining self-closing hazardous area doors, proper maintenance and testing of sprinkler systems, maintaining smoke barrier walls, and electrical system safety. These deficiencies have the potential to affect all facility occupants.
Deficiencies (5)
K321 Hazardous areas are not protected by self-closing, positive latching doors, allowing passage of smoke and fire. Facility census was 62 with a capacity of 98.
K353 Facility staff failed to inspect, test, and maintain wet and dry pipe sprinkler systems, including maintaining escutcheons free of dust and obstruction. Facility census was 62 with a capacity of 98.
K372 Facility staff failed to maintain two of five smoke barrier walls free of openings, allowing potential smoke passage between zones. Census was 62 with a capacity of 98.
K911 Facility staff failed to maintain electrical wiring in compliance with NFPA 70, including replacement of faulty receptacles with hospital grade receptacles. Census was 62 with a capacity of 98.
K923 Facility staff failed to ensure combustible materials were not stored within five feet of oxygen cylinders, increasing fire risk. Census was 62 with a capacity of 98.
Report Facts
Facility census: 62
Total capacity: 98
Deficiency count: 5
Inspection Report
Routine
Census: 64
Deficiencies: 6
Date: May 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care planning, medication administration, medication storage, dietary services, and resident safety including call light accessibility.
Findings
The facility was found deficient in multiple areas including failure to update and revise resident care plans, improper medication preparation and storage practices, use of expired blood sugar test strips, lack of qualified dietary management staff, failure to wear facial hair restraints in food service, improper dish drying procedures, and failure to ensure call lights were within reach of residents.
Deficiencies (6)
Failure to review and revise care plans for residents with cellulitis and medication noncompliance.
Medication administration errors including pre-popping medications prior to timed pass and use of expired blood sugar test strips.
Failure to date opened multi-dose medication bottles and insulin vials; medications left unattended on medication cart.
Failure to employ a qualified full-time Director of Food and Nutrition Services.
Failure of dietary staff to wear facial hair restraints and failure to allow sanitized dishes to air dry before storage.
Failure to ensure call lights were within reach for three residents.
Report Facts
Facility census: 64
Medication cups prepared prior to medication pass: 40
Residents affected by medication administration deficiencies: 4
Residents affected by care plan deficiencies: 2
Residents affected by call light deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Named in medication administration and medication storage findings |
| LPN E | Licensed Practical Nurse | Named in medication administration and blood sugar testing findings |
| LPN H | Licensed Practical Nurse | Named in care plan and medication administration findings |
| Director of Nursing | Director of Nursing (DON) | Named in care plan, medication administration, and medication storage findings |
| Administrator | Facility Administrator | Named in care plan, medication administration, medication storage, and call light findings |
| DM | Dietary Manager | Named in dietary services and food safety findings |
| CNA F | Certified Nurse Aide | Named in call light findings |
| CNA G | Certified Nurse Aide | Named in call light findings |
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 6
Date: May 23, 2024
Visit Reason
The document is a Plan of Correction submitted by Maries Manor following a survey conducted on May 23, 2024, addressing deficiencies found during the inspection.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, professional standards in medication administration, labeling and storage of drugs and biologics, qualified dietary staff, food procurement and sanitation, and resident call system. Specific issues included failure to review and revise care plans timely, improper medication preparation and storage, expired test strips used for blood sugar testing, inadequate staffing qualifications, and failure to maintain call lights within reach of residents.
Deficiencies (6)
F657 Care Plan Timing and Revision: The facility failed to review and revise care plans timely and appropriately for residents with medication noncompliance and skin issues.
F658 Services Provided Meet Professional Standards: Staff failed to follow professional standards in medication preparation and administration, including pre-popping narcotics and using expired blood sugar test strips.
F761 Label/Store Drugs and Biologicals: Facility failed to store and label medications properly, including multi-dose medication bottles left unattended and expired or undated medications.
F801 Qualified Dietary Staff: Facility did not employ sufficient qualified dietary staff with required education and certifications.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to ensure food safety practices including proper hair restraints, dishwashing, and food storage.
F919 Resident Call System: Facility failed to ensure call lights were within reach for residents and nursing staff responded promptly.
Report Facts
Facility census: 62
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Hyatt | Administrator | Signed the Plan of Correction and mentioned in interviews regarding medication and facility policies |
| Director of Nursing | Mentioned in interviews regarding medication administration and staff expectations | |
| Licensed Practical Nurse E | Interviewed regarding blood sugar testing and medication labeling | |
| Certified Medication Technician C | Interviewed regarding medication preparation and administration | |
| Licensed Practical Nurse D | Interviewed regarding pre-popping medications and medication policies | |
| Dietary Manager | Interviewed regarding dietary staff qualifications and food safety policies | |
| Cook A | Observed and interviewed regarding food preparation and hair restraints | |
| Certified Nurse Aide F | Interviewed regarding resident call light placement | |
| Certified Nurse Aide G | Interviewed regarding resident call light placement |
Inspection Report
Routine
Census: 58
Capacity: 98
Deficiencies: 6
Date: Feb 24, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, medication management, infection control, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding and bathroom access, inadequate posting of abuse hotline information, poor environmental maintenance, unsafe medication storage and narcotic count discrepancies, unsanitary kitchen conditions and food storage practices, improper hand hygiene and infection control practices, and improper storage and maintenance of oxygen tubing and catheter drainage bags.
Deficiencies (6)
Failure to maintain resident dignity during feeding and bathroom access.
Failure to post telephone numbers for Adult Abuse and Neglect Hotline and Long-Term Care Ombudsman in accessible locations.
Failure to maintain a safe, clean, comfortable and homelike environment; including poor repair of walls, floors, and resident wheelchair condition.
Failure to ensure medications were stored properly and controlled medication counts were accurate.
Failure to maintain kitchen environment equipment in a clean and sanitary manner, protect light bulbs, properly store food, perform hand hygiene, sanitize sinks, and ensure ice machine drains through an air gap.
Failure to maintain an infection prevention and control program including improper hand hygiene, glove use, wound care, oxygen tubing storage, and catheter bag management.
Report Facts
Facility census: 58
Facility capacity: 98
Controlled medication count discrepancy: 9.5
Number of loose pills observed: 52
Number of residents affected by deficiencies: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in findings related to feeding dignity, bathroom access, glove use, and catheter bag handling |
| LPN C | Licensed Practical Nurse | Named in findings related to feeding dignity, medication counts, wound care, glove use, and oxygen tubing |
| Maintenance Director | Named in findings related to bathroom door locking and kitchen lighting maintenance | |
| Administrator | Named in findings related to posting requirements, environmental issues, medication storage, and infection control | |
| Director of Nursing | DON | Named in findings related to feeding dignity, posting requirements, environmental issues, medication storage, and infection control |
| Maintenance Supervisor | Named in findings related to maintenance log and prioritization of repairs | |
| Licensed Practical Nurse L | Licensed Practical Nurse | Named in findings related to medication cart cleanliness and narcotic counts |
| Dietary Manager | DM | Named in findings related to kitchen sanitation, food storage, hand hygiene, and ice machine maintenance |
| Certified Nurse Aide I | CNA | Named in infection control observation |
| Certified Nurse Aide J | CNA | Named in infection control observation |
| Nurse Aide K | NA | Named in infection control observation |
| Minimum Data Set Coordinator | MDS Coordinator | Named in infection control training and policy discussion |
Inspection Report
Annual Inspection
Census: 58
Capacity: 98
Deficiencies: 22
Date: Feb 24, 2023
Visit Reason
Annual state survey conducted to assess compliance with federal and state regulations for nursing facility licensing and certification.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity during feeding, inadequate posting of required telephone numbers, unsafe and unclean environment, improper medication storage and handling, and infection control issues. The facility submitted a plan of correction addressing these deficiencies.
Deficiencies (22)
F550 Resident Rights: Facility staff failed to maintain resident dignity during feeding assistance and denied bathroom access to a resident. Facility census was 58.
F575 Required Postings: Facility failed to post telephone numbers for Adult Abuse and Neglect Hotline and Long-Term Care Ombudsman in accessible locations. Facility census was 58.
F584 Safe/Clean/Comfortable Environment: Facility failed to maintain a safe, clean, and homelike environment with multiple maintenance issues and damaged equipment. Facility census was 58.
F761 Label/Store Drugs and Biologicals: Facility failed to store medications securely and maintain accurate narcotic counts. Facility census was 58.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: Facility failed to maintain food safety standards including improper food storage, unclean kitchen equipment, and inadequate cleaning schedules.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and glove use, and proper oxygen tubing storage. Facility census was 58.
A3001 19 CSR 30-85.032(2) Building Maintenance: Facility building not maintained in good repair with multiple cited maintenance issues.
A3046 19 CSR 30-85.032(46) Towel & Washcloth Requirements: Facility failed to provide clean towels and washcloths as required.
A4064 19 CSR 30-85.042(55) Medication Storage: Facility failed to store medications properly in locked compartments.
A4086 19 CSR 30-85.042(77) Infection Control/Communicable Disease: Facility failed to implement infection control procedures to prevent spread of infection.
A6015 19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Facility failed to maintain clean walls, ceilings, doors, and windows.
A6016 19 CSR 30-87.020(16) Wall/Ceiling Covering-Sealed & Cleanable: Facility failed to maintain cleanable wall and ceiling coverings.
A6017 19 CSR 30-87.020(17) Wall Surfaces Cleanable: Facility failed to maintain smooth, nonabsorbent, and cleanable wall surfaces.
A6019 19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: Facility failed to maintain clean light fixtures, vent covers, and decorative materials.
A7002 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: Facility failed to ensure staff properly wash hands and fingernails.
A7015 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility failed to protect food from contamination and maintain proper temperatures.
A7016 19 CSR 30-87.030(14) Food-Clean Containers, Storage, Covers: Facility failed to store food in clean covered containers.
A7017 19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected: Facility failed to store food above the floor to prevent contamination.
A7042 19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap: Facility failed to maintain ice storage and dispensing equipment free from contamination.
A7097 19 CSR 30-87.030(95) Shielding to Protect Food From Broken Glass: Facility failed to provide shielding to protect food from broken glass.
A8007 19 CSR 30-88.010(7) Res Rights/Rules Posted, Alz Unit Info: Facility failed to post required resident rights and Alzheimer's unit information.
A8030 19 CSR 30-88.010(29) Dignity/Privacy: Facility failed to ensure resident dignity and privacy in treatment and care.
Report Facts
Facility census: 58
Total capacity: 98
Deficiencies cited: 19
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: May 22, 2022
Visit Reason
The inspection was conducted due to a complaint investigation related to infection prevention and control practices, specifically regarding staff mask usage during the COVID-19 pandemic.
Complaint Details
The complaint was substantiated based on observations and interviews showing staff noncompliance with mask-wearing policies during the COVID-19 pandemic.
Findings
The facility failed to use appropriate infection control procedures to prevent the spread of COVID-19, as staff were observed not wearing facemasks properly or at all while in the building. Multiple staff members were seen without masks or wearing masks incorrectly during the inspection.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, as staff did not wear facemasks appropriately to prevent disease transmission.
A4086 Infection Control/Communicable Disease: The facility did not meet the requirement to report communicable diseases within seven days as required by Missouri regulations.
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Cross | Administrator | Named in relation to the plan of correction and interviews regarding mask policy enforcement |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Census: 62
Deficiencies: 2
Date: Jun 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess infection prevention and control compliance related to COVID-19 protocols.
Findings
The facility was found to be in compliance with federal infection control regulations except for failures in hand hygiene, sanitizing equipment, and proper use of personal protective equipment (PPE) by staff. Observations and interviews revealed multiple instances of staff not performing hand hygiene between glove changes and not sanitizing equipment after resident use.
Deficiencies (2)
F880 Infection Prevention & Control: Staff failed to perform hand hygiene between glove changes and failed to sanitize equipment after resident use. Staff also failed to properly wear PPE related to COVID-19 infection control measures.
A4085 Infection Control/Communicable Disease: The facility failed to meet infection control regulations requiring reporting of communicable diseases to the state within seven days. This deficiency is classified as Class II.
Report Facts
Facility census: 62
Inspection Report
Plan of Correction
Census: 65
Deficiencies: 5
Date: Mar 6, 2020
Visit Reason
The document is a Plan of Correction submitted by Maries Manor following a survey conducted on 03/06/2020. It addresses deficiencies cited during the inspection related to medication management, infection control, and employee tuberculosis screening.
Findings
The facility was found deficient in meeting professional standards for medication management, infection prevention and control, and employee tuberculosis screening. Specific issues included expired medications, improper medication storage, failure to wash hands between resident care, and incomplete tuberculosis screening documentation for employees.
Deficiencies (5)
F658: The facility failed to meet professional standards by allowing expired medications, improperly labeled stock, and opened medications without dates in medication carts and drawers.
F880: The facility failed to establish and maintain an infection prevention and control program, including failure to ensure hand hygiene and glove use between resident care.
A4029: The facility failed to develop and implement policies to ensure employees were screened for communicable diseases, including incomplete tuberculosis screening documentation.
A4054: The facility failed to maintain a safe and effective medication system as evidenced by deficiencies referenced in F658.
A4085: The facility failed to implement infection control procedures to prevent the spread of communicable diseases, referencing deficiencies in F880.
Report Facts
Facility census: 65
Employees files reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Named in tuberculosis screening deficiency for not being employed by the facility | |
| Certified Nursing Assistant B | Named in tuberculosis screening deficiency for incomplete PPD testing documentation | |
| Dietary Aide C | Named in tuberculosis screening deficiency for incomplete PPD testing documentation | |
| Certified Medication Technician F | Named in infection control deficiency for failure to wash hands during medication pass | |
| Licensed Practical Nurse | Named in medication management deficiency for medication cart checks | |
| Director of Nursing | Named in infection control and tuberculosis screening deficiencies for oversight responsibilities | |
| Administrator | Named in infection control and tuberculosis screening deficiencies for oversight responsibilities | |
| Certified Nurse Assistant J | Named in infection control deficiency for failure to wash hands before and after resident care |
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 6, 2020
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The Emergency Preparedness portion of the survey did not result in deficiencies. The facility met the applicable provisions of the 2012 Life Safety Code and related reference documents. No state licensure deficiencies were cited.
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 6
Date: Feb 22, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for Maries Manor nursing facility.
Findings
The facility was found deficient in multiple areas including financial security, abuse and neglect policies, comprehensive care plans, hygiene and grooming assistance, psychotropic medication management, and immunization protocols. Plans of correction were submitted to address these deficiencies.
Deficiencies (6)
F570: The facility failed to purchase a surety bond sufficient to assure security of all resident funds. The resident trust fund account balance required a bond of $49,256.84 but the current bond was $45,000.00.
F607: The facility failed to implement abuse and neglect policies and procedures, including conducting required Nurse Aide Registry checks for three employees prior to employment.
F658: The facility failed to maintain professional standards of care by not following physician orders for thickened liquids for a resident with dysphagia.
F677: The facility failed to assist three residents with hygiene and grooming, including showering and hair combing, as evidenced by resident interviews and care plan reviews.
F758: The facility failed to perform gradual dose reductions on psychotropic medications and did not provide appropriate diagnoses for residents receiving these medications.
F883: The facility failed to offer or administer influenza and pneumococcal vaccinations to residents as required by policy and regulation.
Report Facts
Facility census: 77
Surety bond amount required: 49256.84
Surety bond amount approved: 45000
Plan of correction completion date: Most corrective actions completion date is 2019-03-29
Inspection Report
Life Safety
Census: 77
Capacity: 98
Deficiencies: 2
Date: Feb 22, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including sprinkler system maintenance and smoke barrier construction.
Findings
The facility failed to maintain complete and verifiable documentation of sprinkler system installation, inspection, and testing. Additionally, the facility did not maintain smoke barrier walls free of openings to provide the required fire resistance rating.
Deficiencies (2)
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to provide complete and verifiable documentation of the sprinkler systems installation and testing, and observed corrosion and damage on sprinkler heads.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Facility staff failed to maintain three of five smoke barrier walls free of openings to provide at least a one-half hour fire resistance rating.
Report Facts
Facility census: 77
Total capacity: 98
Number of quick response sprinkler pendants observed: 15
Number of sprinkler pendants replaced: 44
Number of smoke barrier walls not maintained: 3
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 7
Date: Apr 27, 2018
Visit Reason
The inspection was the annual survey of Maries Manor nursing facility to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in developing and implementing person-centered baseline and comprehensive care plans, timely updating care plans with measurable goals, medication regimen review, infection control, and proper documentation of wound care and psychotropic medication use. The facility submitted a plan of correction to address these deficiencies.
Deficiencies (7)
F655 Baseline Care Plan: The facility failed to develop a person-centered baseline care plan within 48 hours of admission for sampled residents. The facility census was 75.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop measurable goals and interventions for comprehensive care plans for sampled residents. The facility census was 75.
F657 Care Plan Timing and Revision: The facility failed to update care plans with changes in residents' needs for sampled residents. The facility census was 75.
F658 Services Provided Meet Professional Standards: The facility failed to stage wounds according to guidelines and failed to obtain or document physician orders for oxygen and medication administration for sampled residents. The facility census was 75.
F756 Drug Regimen Review: The facility failed to conduct monthly drug regimen reviews and document pharmacist recommendations for sampled residents. The facility census was 75.
F758 Free from Unnecessary Psychotropic Medications: The facility failed to monitor and document appropriate use of psychotropic medications for sampled residents. The facility census was 75.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program to prevent spread of infections and failed to provide incontinence care to prevent infection for sampled residents. The facility census was 75.
Report Facts
Facility census: 75
Inspection Report
Life Safety
Census: 75
Capacity: 98
Deficiencies: 7
Date: Apr 27, 2018
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Maries Manor.
Findings
The facility failed to develop and implement an effective emergency preparedness communication plan with residents and their families. Multiple deficiencies were found related to fire safety, including doors not resisting smoke passage, lack of functioning exhaust ventilation, absence of carbon monoxide detectors, and failure to conduct required fire drills.
Deficiencies (7)
E035: The facility failed to develop and implement a method for sharing emergency preparedness information with residents and their families. This failure could delay emergency response procedures.
E039: The facility failed to conduct required emergency preparedness exercises, including a full-scale community-based exercise and proper documentation of drills.
K363: Doors leading to corridors were not solid, did not resist smoke passage, and lacked positive latching, preventing containment of fire and smoke.
K521: Facility staff failed to provide functioning exhaust ventilation units to vent odors and oxygen storage closets, affecting air quality and safety.
K524: Facility failed to install electronically supervised carbon monoxide detectors in smoke compartments where direct vent gas fireplaces were located.
K712: Facility staff failed to conduct fire drills quarterly on all shifts as required, potentially delaying emergency response.
K761: Facility failed to inspect, test, and maintain rated and non-rated egress doors, risking equipment failure and delayed evacuation.
Report Facts
Facility census: 75
Total capacity: 98
Number of fire drills conducted: 2
Number of fire drills conducted: 2
Fire drills required: 12
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