Inspection Reports for
McKnight Place Extended Care
TWO MCKNIGHT PL, SAINT LOUIS, MO, 63124-1900
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
12.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
167% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 10
Date: Apr 9, 2025
Visit Reason
Annual survey exit conducted on April 9, 2025, to assess compliance with federal and state regulations at McKnight Place Extended Care.
Findings
The facility was found noncompliant in multiple areas including resident self-administration of medications, required notices and contact information, activities of daily living care, quality of care, pressure ulcer prevention and treatment, accident hazards, pharmacy services, and food safety. Deficiencies were documented with specific resident examples and policy review.
Deficiencies (10)
F554 Resident self-administration of medications was not properly authorized or assessed, with medications left at bedside without physician orders for Resident #15. The facility failed to follow acceptable nursing practices.
F574 The facility failed to provide accessible information on the State Long-Term Care Ombudsman program and State Survey Agency hotline number to residents and families.
F677 The facility failed to ensure activities of daily living were provided timely and appropriately to sampled residents, including toileting, nail care, and showers.
F684 The facility failed to ensure residents received personal attention and nursing care consistent with their condition, including skin assessments and timely ADL care.
F686 The facility failed to ensure one resident with a pressure wound received necessary treatments and care consistent with professional standards.
F689 The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, resulting in unsafe transfers and falls.
F695 The facility failed to provide respiratory care consistent with professional standards for one resident requiring tracheostomy care and CPAP therapy.
F755 The facility failed to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals.
F761 The facility failed to properly store all drugs and biologicals in locked compartments and maintain medication refrigerator temperature logs.
F812 The facility failed to maintain food safety requirements, including cleanliness of kitchen areas and proper food storage.
Report Facts
Resident census: 58
Sample size: 15
Inspection Report
Routine
Census: 58
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, pressure ulcer care, and skin integrity for residents at McKnight Place Extended Care.
Findings
The facility failed to provide timely assistance with activities of daily living to several residents, including toileting, nail care, and showering. Additionally, the facility did not ensure appropriate treatment and documentation for a resident's pressure ulcer wound.
Deficiencies (2)
F 0677: The facility failed to provide timely activities of daily living care, including toileting, nail care, and showers for multiple residents.
F 0686: The facility failed to provide appropriate pressure ulcer care and documentation for a resident with a Stage Two pressure wound.
Report Facts
Residents affected: 3
Residents affected: 1
Sample size: 15
Census: 58
Wound measurements: 1.5
Wound measurements: 2.5
Wound measurements: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) B | Provided statements regarding timely care and skin assessments | |
| Certified Nursing Assistant (CNA) C | Responded to resident's call for toileting assistance | |
| Certified Nursing Assistant (CNA) D | Assisted with resident transfer and perineum care | |
| Resident Care Supervisor | Responded to resident calls and assisted with care | |
| Director of Nursing (DON) | Provided expectations for timely care and wound management | |
| Social Service Director (SSD) | Discussed podiatry consent and resident care coordination | |
| Wound Nurse | Assessed resident's pressure wound and provided care recommendations | |
| Administrator | Stated expectations for ADL care and nail care | |
| Licensed Practical Nurse (LPN) H | Applied dressing to resident's pressure wound |
Inspection Report
Life Safety
Census: 59
Capacity: 70
Deficiencies: 3
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including the condition of cooking facilities, sprinkler system maintenance, and corridor doors.
Findings
The facility failed to maintain cleanliness of kitchen range hoods and filters, maintain sprinklers according to NFPA standards, and ensure corridor doors fit tightly to resist smoke passage. These deficiencies had the potential to affect residents and staff in multiple smoke compartments.
Deficiencies (3)
K324 Cooking Facilities: The facility failed to maintain cleanliness of kitchen range hoods and grease filters, resulting in grease buildup that could affect residents and staff in one of eight smoke compartments.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinklers in accordance with NFPA standards, including rusted and loaded sprinkler heads and gaps at escutcheon plates, affecting five of eight smoke compartments.
K363 Corridor - Doors: Corridor doors did not fit tightly within doorframes to resist smoke passage, with several doors not closing properly or having obstructions, affecting three of eight smoke compartments.
Report Facts
Facility capacity: 70
Facility census: 59
Smoke compartments affected by cooking facility deficiency: 1
Smoke compartments affected by sprinkler deficiency: 5
Smoke compartments affected by corridor door deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Knittle | Administrator | Signed the report and plan of correction |
| Maintenance Director | Interviewed regarding cleaning and maintenance of range hoods and sprinkler system | |
| Executive Chef | Responsible for cleaning grease filters and monitoring cleanliness |
Inspection Report
Routine
Census: 58
Deficiencies: 11
Date: Apr 9, 2025
Visit Reason
Routine inspection of McKnight Place Extended Care to assess compliance with nursing practice, resident care, medication management, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to follow medication self-administration protocols, inadequate resident care for activities of daily living, incomplete skin and wound assessments and treatments, improper resident transfers, incomplete respiratory and dialysis orders and documentation, medication storage and narcotic count deficiencies, and food service hygiene violations.
Deficiencies (11)
F 0554: The facility failed to follow nursing practice when medication was left at the bedside of Resident #15 without a physician order for self-administration or bedside storage.
F 0574: The facility failed to provide accessible information on the State Long-Term Care Ombudsman program and State Survey Agency hotline to residents.
F 0677: The facility failed to provide timely activities of daily living care to three residents, including toileting, nail care, and showers.
F 0684: The facility failed to ensure one resident had physician orders for wound dressing and failed to complete detailed skin assessments for two residents.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident #10, including timely wound assessment, documentation, and treatment orders.
F 0689: The facility failed to ensure safe resident transfers for Resident #10, including improper use of gait belt and failure to follow weight bearing and transfer orders.
F 0695: The facility failed to provide safe and appropriate respiratory care for Resident #15, including lack of physician orders for CPAP and inconsistent oxygen therapy documentation.
F 0698: The facility failed to ensure Resident #10 had physician orders and dialysis communication logs for dialysis care and failed to ensure dialysis logs were completed for Resident #42 for all appointments.
F 0755: The facility failed to establish a system for controlled drug counts with two signatures at shift changes for medication carts.
F 0761: The facility failed to ensure medications in the medication room refrigerator were stored at proper temperatures and separated from food.
F 0812: The facility failed to maintain clean floors and equipment in the kitchen and failed to ensure staff wore proper hair restraints.
Report Facts
Residents affected: 58
Deficiency sample size: 15
Narcotic count shifts missing signatures: 20
Narcotic count shifts with only one signature: 34
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 2
Date: May 31, 2024
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations at McKnight Place Extended Care.
Findings
The facility was found deficient in respecting residents' dignity and personal property, and in providing adequate supervision and accident prevention. Specific staff behaviors were documented that compromised resident dignity and safety.
Deficiencies (2)
F 557 Respect and Dignity. The facility failed to ensure staff treated a resident with respect and dignity, including inappropriate verbal interactions and disregard for the resident's personal property and dignity.
F 689 Free of Accident Hazards/Supervision/Devices. The facility failed to properly assess and supervise a resident after an unwitnessed fall, resulting in potential harm and inadequate transfer techniques.
Report Facts
Resident census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Named in findings related to resident dignity and supervision failures | |
| CNA B | Named in findings related to resident dignity and supervision failures | |
| CNA C | Named in findings related to resident dignity and supervision failures | |
| Director of Nursing | Director of Nursing | Interviewed regarding video evidence and resident care |
| Administrator | Administrator | Interviewed regarding video evidence and resident care |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: May 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the treatment and care of Resident #1, focusing on dignity, respect, and proper handling after an unwitnessed fall.
Complaint Details
The complaint involved allegations that staff verbally berated Resident #1 and failed to provide dignified care. The investigation confirmed these allegations with video evidence and interviews. The resident had an unwitnessed fall, and staff improperly transferred him/her from the floor to the bed, failing to follow facility fall protocols and proper lifting policies.
Findings
The facility failed to ensure staff treated Resident #1 with dignity and respect, as evidenced by staff verbally berating the resident. Additionally, the facility failed to properly assess and safely transfer the resident after an unwitnessed fall, with staff using improper lifting techniques and exhibiting unprofessional behavior.
Deficiencies (2)
F 0557: The facility failed to honor the resident's right to be treated with respect and dignity when staff berated Resident #1 for pressing the call light, removing his/her brief, and asking for a soda.
F 0689: The facility failed to assess Resident #1 and properly transfer him/her from the floor to the bed after an unwitnessed fall, resulting in unsafe handling and unprofessional staff behavior.
Report Facts
Census: 54
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings for verbally berating resident and improper handling after fall |
| CNA B | Certified Nurse Assistant | Named in findings for verbally berating resident and improper handling after fall |
| CNA C | Certified Nurse Assistant | Named in findings for verbally berating resident and improper handling after fall |
Inspection Report
Life Safety
Census: 57
Capacity: 70
Deficiencies: 5
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code survey to assess compliance with federal and state regulations, including fire safety and emergency preparedness communication plans.
Findings
The facility failed to develop and maintain an emergency preparedness communication plan including staff contact information. Life safety deficiencies were found related to delayed egress door locking, portable fire extinguishers maintenance, corridor door closures, and electrical system testing and documentation.
Deficiencies (5)
E030: The facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all staff. The plan lacked a list of names and contact information and a location for staff phone numbers.
K222: The facility failed to ensure delayed egress exit doors near resident rooms 121 and 320 released and opened without delay during fire alarm activation, posing a risk to occupants in smoke compartments.
K355: Portable fire extinguishers were not properly installed, maintained, or inspected monthly. Several extinguishers lacked current inspection tags and monthly checks were not documented.
K363: Corridor doors failed to maintain closure without impediment, with several doors propped open, risking smoke compartment integrity during a fire.
K918: The facility failed to properly maintain and document weekly and monthly inspections and testing of the emergency power system, including generator load testing and transfer switch inspections.
Report Facts
Facility capacity: 70
Resident census: 57
Deficiency counts: 5
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Oct 11, 2023
Visit Reason
The document is a Plan of Correction submitted following a Recertification Survey and Complaint Survey conducted from October 9 to October 11, 2023, at McKnight Place Extended Care.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities. Deficiencies included failure to complete timely quarterly Minimum Data Set (MDS) assessments for residents, incomplete comprehensive care plans addressing medication monitoring, improper use of psychotropic medications including PRN orders, and inadequate infection prevention and control practices.
Deficiencies (5)
F638 Quarterly Review Assessment: The facility failed to ensure quarterly MDS assessments were completed timely for 3 residents (#27, #46, and #58).
F656 Develop/Implement Comprehensive Care Plan: The facility failed to ensure comprehensive care plans addressed monitoring of Ativan and apixaban medications for 1 resident (#43).
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to limit PRN antipsychotic medication orders to 14 days and ensure physician evaluation for continuation for 1 resident (#44).
F880 Infection Prevention & Control: The facility failed to ensure staff followed infection control standards for hand hygiene and catheter care for 1 resident (#46).
F883 Influenza and Pneumococcal Immunizations: The facility failed to ensure 1 resident (#46) was offered pneumococcal vaccination and properly documented immunization status.
Report Facts
Residents with missing quarterly MDS assessments: 3
Residents sampled for medication review: 5
Residents reviewed for PRN antipsychotic medication: 1
Residents reviewed for infection control: 1
Residents reviewed for pneumococcal vaccination: 1
Inspection Report
Routine
Deficiencies: 5
Date: Oct 11, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident assessments, care planning, medication use, infection control, and immunization policies at McKnight Place Extended Care.
Findings
The facility failed to complete quarterly Minimum Data Set (MDS) assessments timely for 3 residents, did not develop comprehensive care plans addressing specific medications for 1 resident, allowed prolonged use of PRN antipsychotic medication without proper physician evaluation for 1 resident, failed to ensure proper hand hygiene during catheter care for 1 resident, and did not offer pneumococcal vaccination to 1 resident as required.
Deficiencies (5)
F0638: The facility failed to ensure quarterly MDS assessments were completed timely for 3 residents (#27, #46, and #58).
F0656: The facility failed to develop a comprehensive care plan addressing the use of Ativan and apixaban for Resident #43.
F0758: The facility failed to limit PRN antipsychotic medication orders to 14 days without documented physician evaluation for Resident #44.
F0880: The facility failed to ensure staff performed hand hygiene between glove changes during catheter care for Resident #46.
F0883: The facility failed to offer pneumococcal vaccination to Resident #46 as required by policy.
Report Facts
Residents reviewed for MDS assessment timeliness: 3
Residents reviewed for medication issues: 5
Resident affected by care plan deficiency: 1
Resident affected by PRN medication deficiency: 1
Resident affected by infection control deficiency: 1
Resident affected by vaccination deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Responsible for ensuring MDS assessments completion; acknowledged being behind on assessments. | |
| Director of Nursing (DON) | Responsible for signing and submitting MDS assessments; unaware of extent of delays; expected timely care plans. | |
| Administrator | Expected MDS assessments and care plans to be completed timely; stated nurses should follow infection control standards. | |
| Licensed Practical Nurse (LPN) #3 | Observed failing to perform hand hygiene between glove changes during catheter care. | |
| Pharmacist | Recommended discontinuation of PRN antipsychotic medication after 14 days; stated physician evaluation required. | |
| LPN #11 | Licensed Practical Nurse | Signed medical note regarding Resident #44's medication stability. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Mar 6, 2023
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident property and concerns about safe resident transfers using mechanical lifts.
Complaint Details
The complaint involved allegations of theft and misappropriation of resident property by staff. The investigation substantiated that a former CNA stole a resident's check for $600. The resident was refunded by the bank. The facility failed to investigate other thefts reported by the resident. The complaint also included concerns about unsafe resident transfers leading to injury.
Findings
The facility failed to protect residents from misappropriation of property by staff, resulting in theft of a resident's check by a former CNA. Additionally, the facility failed to ensure safe mechanical lift transfers, leading to a resident injury when a CNA attempted a Hoyer lift transfer without assistance, causing lacerations requiring sutures.
Deficiencies (2)
F 0602: The facility failed to protect residents from misappropriation of property when a CNA stole a resident's check for $600. The resident kept checks unsecured and the facility did not provide a locked drawer or lockbox. The theft was reported and investigated, resulting in police involvement and CNA termination.
F 0689: The facility failed to ensure safe resident transfers using a mechanical Hoyer lift. A CNA attempted a lift transfer without assistance, causing the lift to tip forward and injure the resident with lacerations requiring sutures. The facility lacked complete manufacturer instructions in policy and did not assess staff competency adequately.
Report Facts
Census: 57
Amount stolen: 600
Number of residents affected: 1
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Aide | Former employee who stole a resident's check and was charged with forgery |
| CNA A | Certified Nurse Aide | Employee who attempted unsafe Hoyer lift transfer causing resident injury |
| Nurse B | Nurse | Responded to resident injury after Hoyer lift incident and provided care |
| Administrator | Facility Administrator | Assisted resident with police report and provided statements regarding incidents |
| Director of Nursing | Director of Nursing (DON) | Oversaw investigation and training related to lift use and misappropriation allegations |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Mar 6, 2023
Visit Reason
The inspection was conducted due to allegations of misappropriation/exploitation of resident property and failure to ensure resident safety during transfers using mechanical lifts.
Complaint Details
The complaint involved allegations of misappropriation of resident property by a Certified Nurse Aide (CNA E) who forged a resident's check and used the funds for personal expenses. The allegation was substantiated with police reports and interviews. Additionally, there was a failure to ensure safe transfers using mechanical lifts, causing injury to a resident.
Findings
The facility failed to ensure residents were free from misappropriation of property by staff and failed to provide adequate supervision and assistance during mechanical lift transfers, resulting in injury to a resident.
Deficiencies (2)
CFR 483.12: The facility failed to ensure residents were free from misappropriation of resident property when staff misappropriated funds from a resident. The census was 57.
CFR 483.25(d)(1)(2): The facility failed to ensure staff transferred residents safely using mechanical lifts, resulting in injury to a resident during a Hoyer lift transfer.
Report Facts
Resident census: 57
Amount misappropriated: 600
Number of residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Aide | Named in misappropriation and mechanical lift transfer findings |
| Nurse B | Nurse | Observed resident injuries and assisted in care |
| Nurse A | Nurse | Involved in mechanical lift incident with resident |
| Administrator | Administrator | Involved in investigation and plan of correction |
| Director of Nursing | Director of Nursing (DON) | Provided information on mechanical lifts and investigation |
Inspection Report
Abbreviated Survey
Census: 44
Deficiencies: 1
Date: Feb 4, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 02/02/2021 through 02/04/2021. The survey included review of compliance with accident hazards, supervision, and resident safety related to a prior incident.
Findings
The facility was found to be in compliance with COVID-19 emergency preparedness requirements. However, a deficiency was identified related to a Certified Nursing Assistant inappropriately transferring a resident requiring two-person assistance, resulting in a fractured leg and large skin tears.
Deficiencies (1)
F689: The facility failed to ensure the resident received care in a safe environment when a Certified Nursing Assistant inappropriately transferred a resident requiring two-person assistance, resulting in a fractured leg and large skin tears.
Report Facts
Sample size: 3
Census: 44
Incident date: Apr 23, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in the finding for inappropriate resident transfer |
| ADON | Assistant Director of Nursing | Became aware of the violation and took action |
| LPN E | Licensed Practical Nurse | Involved in wound care and interview regarding the incident |
| DON | Director of Nursing | Conducted interview related to CNA orientation and transfer policy |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 12/16/2020 through 12/29/2020 to assess compliance with CMS and CDC recommended practices and federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from 11/12/2020 through 11/24/2020 to assess compliance with CMS and CDC recommended practices.
Complaint Details
This was a complaint investigation related to infection control. No deficiencies were cited as a result of the complaint investigation.
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
Abbreviated Survey
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted from 08/20/2020 through 08/26/2020 to assess 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
Routine
Deficiencies: 0
Date: Jun 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 06/29/2020 through 06/30/2020 to assess the facility's 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 to prepare for COVID-19 and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 2
Date: May 27, 2020
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically related to COVID-19 infection control practices and compliance with CMS and CDC guidelines.
Findings
The facility failed to fully implement the CMS/CDC recommended infection control process, including inadequate policies for isolation duration and management of residents with possible COVID-19 symptoms. The facility's infection control guidelines lacked specific procedures for transmission-based precautions and COVID-19 preparedness.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to fully implement an infection prevention and control program as required by CMS/CDC, including inadequate isolation procedures and lack of guidance on transmission-based precautions and COVID-19 symptom management.
A4085 Infection Control/Communicable Disease: The facility did not meet the Missouri Department of Health regulation requiring reporting of communicable diseases within seven days, as evidenced by the deficiency cited at F880.
Report Facts
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenda Knittel | Administrator | Signed the deficiency and plan of correction documents |
Inspection Report
Routine
Census: 56
Deficiencies: 7
Date: Mar 10, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, physician orders, infection control, medication management, resident transfers, hospice services, and food safety at McKnight Place Extended Care.
Findings
The facility failed to update care plans to reflect residents' current needs, did not consistently follow physician orders for treatments and devices, failed to follow manufacturer recommendations for mechanical lifts, improperly labeled and stored insulin, failed to maintain sanitary food preparation practices, did not collaborate adequately with hospice providers, and failed to follow infection control policies including hand hygiene and catheter care.
Deficiencies (7)
F 0657: The facility failed to update care plans to include falls, anticoagulant use and monitoring, cardiac pacemaker, chest drain, compression stockings, oxygen therapy, orthotic devices, nutritional needs, and long term care status for five of 14 sampled residents.
F 0658: The facility failed to ensure all physician orders were followed by not applying positioning devices, nutritional supplements, TED hose, and lymphadema wraps as ordered for three residents.
F 0689: The facility failed to follow manufacturer's recommendations during three of four resident transfers with a Hoyer lift by closing the legs of the lift during transfer instead of keeping them open for stability.
F 0761: The facility failed to ensure staff followed policy and professional standards for labeling and discarding insulin vials and pens; several insulin vials and pens were opened and not dated.
F 0812: The facility failed to ensure staff prepared and served food under sanitary conditions by not changing gloves and washing hands, touching surfaces of plates and utensils with soiled gloves and bare hands, and touching food with soiled gloves.
F 0849: The facility failed to collaborate with hospice in developing a coordinated plan of care for residents receiving hospice services; hospice documentation was incomplete and facility care plans did not reflect hospice involvement.
F 0880: The facility failed to follow infection control policies by not practicing appropriate hand hygiene during resident contact for four residents and failed to keep catheter tubing and drainage bags off the floor for two residents.
Report Facts
Census: 56
Deficiencies cited: 7
Insulin expiration days: 28
Insulin expiration days: 30
Hoyer lift legs open: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Mentioned in infection control and catheter care findings |
| CNA E | Certified Nurse Aide | Mentioned in infection control hand hygiene deficiency |
| PCS F | Patient Care Supervisor | Mentioned in infection control hand hygiene deficiency |
| Cook K | Cook | Mentioned in food preparation sanitary practices deficiency |
| DA J | Dietary Aide | Mentioned in food preparation sanitary practices deficiency |
| DON | Director of Nursing | Provided interviews on care plan updates, infection control, hospice collaboration, and Hoyer lift use |
| LPN A | Licensed Practical Nurse | Mentioned in insulin labeling and expiration interview |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 7
Date: Mar 10, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for McKnight Place Extended Care.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, services provided meeting professional standards, free of accident hazards, label/store drugs and biologicals, food procurement and sanitation, infection prevention and control, and hospice services. Deficiencies were documented with corrective plans of action.
Deficiencies (7)
F657 Care Plan Timing and Revision: Facility failed to ensure care plans were updated to reflect residents' current needs including falls, anticoagulants, cardiac pacemaker, compression stockings, oxygen therapy, orthotic devices, nutritional needs, and long term care status.
F658 Services Provided Meet Professional Standards: Facility failed to ensure all physician orders were followed including positioning devices and nutritional supplements for residents.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to follow manufacturer’s recommendations during resident transfers with a Hoyer lift, risking resident safety.
F761 Label/Store Drugs and Biologicals: Facility failed to follow policy and professional standards for labeling and discarding insulin vials and pens; medication rooms observed with deficiencies.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to ensure proper food handling and sanitation practices including glove use, hand hygiene, and food protection.
F849 Hospice Services: Facility failed to ensure hospice care met professional standards including coordination, documentation, and delineation of duties between hospice and facility staff.
F880 Infection Prevention & Control: Facility failed to establish and maintain an infection prevention and control program including hand hygiene, isolation precautions, and catheter care.
Report Facts
Sample size: 14
Resident census: 56
Inspection Report
Life Safety
Census: 56
Capacity: 70
Deficiencies: 2
Date: Mar 10, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain smoke barrier doors so they closed securely and prevented gaps exceeding 1/8th of an inch, affecting two of eight smoke compartments. Specifically, smoke doors near room 120 did not close flush and left a 1/4 inch gap, violating NFPA 101 and NFPA 80 standards.
Deficiencies (2)
K374: The facility failed to maintain smoke barrier doors so they closed securely and prevented gaps exceeding 1/8th of an inch, affecting two of eight smoke compartments. Smoke doors near room 120 left a 1/4 inch gap during the fire alarm test.
A2054: Each smoke section must be separated by one-hour fire-rated walls and doors that are at least 20-minute fire rated, self-closing, and close automatically upon fire alarm activation. This regulation is not met as evidenced by the deficiency cited at K374.
Report Facts
Resident census: 56
Facility capacity: 70
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 6
Date: May 10, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for McKnight Place Extended Care.
Findings
The facility was found deficient in multiple areas including management of personal funds, required postings, pressure ulcer prevention and treatment, nurse staffing information posting, food safety, and pest control. Deficiencies were documented with specific examples and interviews.
Deficiencies (6)
F567 Protection/Management of Personal Funds: The facility failed to ensure residents were not limited in the amount they could deposit into the resident trust account and did not have an interest bearing account for deposits over $100. Census was 57.
F575 Required Postings: The facility failed to provide accessible information on the State Long-Term Care Ombudsman program or State Survey Agency that residents could read without assistance. Census was 57.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: The facility failed to monitor one resident for pressure ulcer development and failed to routinely administer treatments as ordered. Census was 57.
F732 Posted Nurse Staffing Information: The facility failed to post required nurse staffing information including actual hours worked and failed to ensure posting was accessible to residents, visitors, and staff. Census was 57.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to date and label opened food items, maintain cleanliness in walk-in freezer, and discard dented canned food items. Census was 57.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control system when multiple gnats were observed in the main kitchen over several days. Census was 57.
Report Facts
Resident census: 57
Inspection Report
Life Safety
Census: 57
Capacity: 70
Deficiencies: 3
Date: May 7, 2019
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and related regulations.
Findings
The facility failed to meet several Life Safety Code requirements including protection of cooking equipment, maintenance of fusible link dampers in the HVAC system, and annual testing of electrical receptacles in resident rooms. Deficiencies had the potential to affect all residents.
Deficiencies (3)
K324 Cooking Facilities: The facility failed to ensure cooking equipment was protected according to NFPA 96 standards. Two of four suppression nozzles on the range hood were uncovered and lacked caps.
K521 HVAC: The facility failed to maintain fusible link dampers in the air handling system, with no documented inspection or lubrication for at least four years. This deficiency could affect all occupants.
K914 Electrical Systems - Maintenance and Testing: The facility failed to assess electrical receptacles in resident rooms for physical integrity, grounding, polarity, and retention force annually. Several rooms had non-hospital grade receptacles without testing documentation.
Report Facts
Facility capacity: 70
Resident census: 57
Number of uncovered suppression nozzles: 2
Total suppression nozzles: 4
Number of residents' rooms with non-hospital grade receptacles: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding nozzle caps and fusible link dampers | |
| Food and Nutrition Manager | Responsible for ensuring fire suppression nozzle caps are covered |
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 9
Date: Jun 21, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, privacy, care standards, nutritional adequacy, and food safety at McKnight Place Extended Care.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, privacy and confidentiality of records, professional standards in care plans, nutritional adequacy of menus, and food safety practices. Specific issues included failure to treat residents with respect, failure to protect privacy, transcription errors in physician orders, and improper food preparation and storage.
Deficiencies (9)
F550 Resident Rights: The facility failed to ensure staff treated residents with respect and dignity, including incidents of staff entering rooms without knocking and inappropriate interactions by private duty aides.
F583 Privacy and Confidentiality: The facility failed to protect residents' personal privacy and medical records, including posting private information on resident room walls and failure to remove such information from public view.
F658 Services Provided Meet Professional Standards: The facility failed to transcribe physician orders accurately and clarify blood pressure parameters for medication administration.
F803 Menus Meet Resident Needs/Preparation: The facility failed to prepare pureed food according to nutritional recipes and failed to include all menu items during meal service.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: The facility failed to store drying dishware in a sanitary manner and failed to ensure proper handwashing and dishwashing procedures.
A4053 Written Orders; Restraints: No medication, treatment, or diet was given without a lawful written order as required.
A5001 Nutritional Needs Met, Assess Resident, Inform Doctor: Residents were not consistently provided with nutritious, properly prepared, and appropriately seasoned food.
A7088 Store Equipment/Utensils to Prevent Contamination: Cleaned and sanitized utensils and equipment were improperly stored above the floor, risking contamination.
A8030 Dignity/Privacy: Residents were not consistently treated with consideration, respect, and full recognition of dignity and individuality.
Report Facts
Resident census: 60
Deficiency cited: 9
Inspection Report
Life Safety
Census: 60
Capacity: 70
Deficiencies: 3
Date: Jun 21, 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 regulations.
Findings
The facility failed to meet several Life Safety Code requirements including delayed egress locking arrangements, fire alarm system testing and maintenance, and sprinkler system installation and coverage. Deficiencies were observed in door locking mechanisms, fire alarm panel security, and sprinkler coverage in resident room restrooms and elevator shafts.
Deficiencies (3)
K222: The facility failed to ensure a magnetically locked delayed egress door released within 15 seconds of applied pressure, risking occupant safety in eight smoke compartments.
K345: The facility failed to maintain the fire alarm system in compliance with NFPA 72, allowing unauthorized personnel access to silence and reset the fire alarm panels, potentially delaying emergency response.
K351: The facility failed to provide fire sprinkler coverage in all resident room restrooms and the hydraulic elevator shaft, affecting four of eight smoke compartments.
Report Facts
Facility capacity: 70
Resident census: 60
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