Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
58 residents
Based on a April 2025 inspection.
Census over time
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 (ADL), pressure ulcer care, and overall resident care in the facility.
Findings
The facility failed to provide timely ADL care to three residents, including toileting, nail care, and showers. Additionally, one resident with a pressure wound did not receive appropriate wound care and treatment as ordered.
Deficiencies (2)
Failed to ensure activities of daily living were provided timely, including toileting, nail care, and showers for three residents.
Failed to provide necessary treatments and services to promote healing of a pressure wound for one resident.
Report Facts
Residents affected: 3
Residents affected: 1
Sample size: 15
Resident census: 58
Wound measurements: 1.5
Wound measurements: 2.5
Wound measurements: 0.5
Braden Scale score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Provided interviews regarding care expectations and wound care procedures |
| Certified Nursing Assistant C | Certified Nursing Assistant | Involved in toileting care and resident interaction during toileting deficiency observation |
| Certified Nursing Assistant D | Certified Nursing Assistant | Assisted with resident transfer and perineum care during pressure wound observation |
| Resident Care Supervisor | Observed and assisted with resident care during toileting and wound care incidents | |
| Director of Nursing | Director of Nursing | Provided interviews regarding care standards and wound care expectations |
| Wound Nurse | Wound Nurse | Provided wound assessment and care recommendations |
| Licensed Practical Nurse H | Licensed Practical Nurse | Applied wound dressing during observation |
| Administrator | Administrator | Provided interview on care expectations for ADLs and nail care |
Inspection Report
Routine
Census: 58
Deficiencies: 10
Date: Apr 9, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication management, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including medication self-administration policies, resident care and assistance with activities of daily living, accessibility of resident rights information, wound care, transfer safety, respiratory care, dialysis care, narcotic medication counts, medication storage, and food service hygiene.
Deficiencies (10)
Failed to follow acceptable nursing practice when staff left medication in one resident's room without a physician order for self-administration or for medications to be left at the bedside (Resident #15).
Failed to provide accessible information on the location of the State Long-Term Care Ombudsman program or the State Survey Agency hotline number that was readily available to residents.
Failed to ensure activities of daily living were provided timely and appropriately for three residents, including toileting, nail care, and showers.
Failed to ensure one resident had physician's orders for a wound dressing and failed to ensure skin assessments detailed all skin concerns for two residents.
Failed to ensure one resident received adequate assistance during transfers, including improper use of gait belt and failure to follow weight bearing restrictions.
Failed to ensure respiratory services were consistent with professional standards, including lack of physician orders for CPAP and improper oxygen and nebulizer management.
Failed to ensure one resident had physician's orders for dialysis care and dialysis communication logs were not completed for all appointments for one resident.
Failed to establish a system of records for all controlled drugs with sufficient detail to enable accurate reconciliation, with many narcotic shift counts missing one or both required signatures.
Failed to ensure drugs and biologicals in the medication room refrigerator were stored at proper temperature and free from food contamination.
Failed to ensure kitchen floors and ice cream freezer were clean and failed to ensure proper hair restraints were worn by kitchen staff.
Report Facts
Sample size: 15
Census: 58
Narcotic shift counts missing signatures: 20
Narcotic shift counts with only one signature: 34
Narcotic shift counts missing signatures: 7
Narcotic shift counts with only one signature: 7
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: May 31, 2024
Visit Reason
The inspection was conducted based on complaints regarding staff failing to provide care that maintained a resident's dignity and respect, and concerns about improper handling of an unwitnessed fall.
Complaint Details
The complaint involved allegations that staff failed to treat a resident with dignity and respect, including berating and yelling at the resident, and concerns about improper handling and assessment after an unwitnessed fall. The complaint was substantiated based on video evidence and interviews.
Findings
The facility failed to ensure staff treated a resident with dignity and respect, as evidenced by staff berating the resident and yelling after an unwitnessed fall. Additionally, the facility failed to properly assess and safely transfer the resident after the fall, with staff using improper techniques and exhibiting unprofessional behavior.
Deficiencies (2)
Failure to honor the resident's right to be treated with respect and dignity, including staff berating the resident for pressing the call light and asking for a soda.
Failure to properly assess and safely transfer a resident after an unwitnessed fall, including improper lifting techniques and unprofessional behavior by staff.
Report Facts
Census: 54
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings for berating resident, improper handling of resident's fall, and unprofessional behavior |
| CNA B | Certified Nurse Assistant | Named in findings for yelling at resident after fall and improper transfer technique |
| CNA C | Certified Nurse Assistant | Named in findings for yelling at resident after fall and improper transfer technique |
| Director of Nursing | Director of Nursing | Interviewed regarding receipt and handling of video evidence and facility policies |
| Administrator | Administrator | Interviewed regarding receipt and handling of video evidence and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident assessments, care planning, medication use, infection control, and immunizations.
Findings
The facility was found deficient in completing timely quarterly Minimum Data Set (MDS) assessments for residents, developing comprehensive care plans addressing specific medication needs, limiting PRN antipsychotic medication orders to 14 days without physician evaluation, ensuring proper hand hygiene during catheter care, and offering pneumococcal vaccinations to eligible residents.
Deficiencies (5)
Failed to ensure quarterly Minimum Data Set (MDS) assessments were completed at least every three months for 3 residents (#27, #46, #58).
Failed to ensure the comprehensive care plan addressed care and monitoring related to the use of Ativan and apixaban for Resident #43.
Failed to ensure antipsychotic medication prescribed on an as-needed (PRN) basis was limited to a 14-day duration without physician's documented evaluation for Resident #44.
Failed to ensure staff followed infection control standards for hand hygiene during catheter care for Resident #46.
Failed to ensure Resident #46 was offered a pneumococcal vaccination as required.
Report Facts
Residents reviewed for medication: 5
Residents reviewed for immunizations: 5
Residents reviewed for catheter care: 1
Residents reviewed for MDS assessments: 3
BIMS score: 6
BIMS score: 11
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Signed progress note related to Resident #44's medication review |
| LPN #3 | Licensed Practical Nurse | Observed during catheter care for Resident #46 and admitted to not performing hand hygiene between glove changes |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Mar 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property and unsafe resident transfer practices at the facility.
Complaint Details
The complaint involved a Certified Nurse Aide (CNA E) who stole $600 from Resident #1 by forging a check. The resident discovered the unauthorized check and reported it. The police investigated, and CNA E was charged with forgery and theft. The facility concluded it was an isolated incident. Additionally, Resident #2 was injured when a CNA attempted a mechanical lift transfer without assistance, causing the lift to tip and injure the resident.
Findings
The facility failed to protect residents from misappropriation of property when a staff member stole $600 from a resident. Additionally, the facility failed to ensure safe resident transfers using mechanical lifts, resulting in a resident injury due to a lift tipping over when used without proper staff assistance.
Deficiencies (2)
Failed to ensure residents were free from misappropriation of funds or property by staff stealing from a resident.
Failed to ensure safe resident transfers using mechanical lifts, resulting in resident injury due to lift tipping over when used without required staff assistance.
Report Facts
Residents affected: 3
Amount stolen: 600
Census: 57
Staff assist required: 2
Residents per CNA: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Aide | Named in the theft of resident funds and subsequent police investigation. |
| CNA A | Certified Nurse Aide | Involved in mechanical lift incident causing resident injury. |
| Nurse B | Nurse | Responded to resident injury from mechanical lift incident. |
| Administrator | Facility Administrator | Assisted resident with police report and provided statements regarding incidents. |
| Director of Nursing | Director of Nursing (DON) | Oversaw facility policies and training related to abuse and mechanical lifts. |
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, medication administration, infection control, resident transfers, hospice care coordination, and food service sanitation at McKnight Place Extended Care.
Findings
The facility failed to update care plans to reflect residents' current needs, did not follow physician orders for treatments and device use, failed to follow manufacturer instructions for mechanical lifts, improperly labeled and stored insulin, did not maintain sanitary food preparation practices, failed to collaborate adequately with hospice providers, and did not consistently follow infection control protocols including hand hygiene and catheter care.
Deficiencies (7)
Failure 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 sampled residents.
Failure to follow physician orders by not applying positioning devices, nutritional supplements, TED hose, and lymphadema wraps as ordered for residents.
Failure to follow manufacturer's recommendations during resident transfers with Hoyer lift by closing lift legs during transfers, reducing stability.
Failure to label insulin vials and pens with opening dates and discard expired insulin according to manufacturer recommendations.
Failure to collaborate with hospice providers in developing coordinated care plans for residents receiving hospice services.
Failure to follow infection control practices including hand hygiene during resident care and keeping catheter tubing and drainage bags off the floor.
Failure to prepare and serve food under sanitary conditions, including not changing gloves or washing hands between tasks and touching food and utensils with soiled gloves or bare hands.
Report Facts
Residents affected: 5
Sample size: 14
Census: 56
Insulin expiration days: 28
Insulin expiration days: 30
Medication administration times: 3
Weight measurements: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan updates, infection control, hospice care coordination, and medication labeling |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding insulin expiration |
| Certified Nurse Aides A, B, C, E, G, H, I | Certified Nurse Aides (CNAs) | Observed and interviewed regarding resident transfers, infection control, and catheter care |
| Cook K | Cook | Observed and interviewed regarding food preparation and sanitary practices |
| Dietary Aide J | Dietary Aide | Observed regarding food handling practices |
| Patient Care Supervisor F | Patient Care Supervisor | Observed and interviewed regarding infection control practices |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Observed and interviewed regarding infection control and catheter care |
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