Inspection Reports for
Memory Lane of Dexter
415 S CATALPA STREET, DEXTER, MO, 63841-2017
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
17.2 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
213% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
88% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 9
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding psychotropic drug use, medication error rates, food safety, pest control, and communicable disease prevention at Memory Lane of Dexter.
Findings
The facility failed to attempt gradual dose reductions for psychotropic drugs for multiple residents, had medication error rates exceeding 5%, failed to maintain food safety and pest control standards, and did not comply with tuberculosis screening requirements for employees.
Deficiencies (9)
F758 Psychotropic drugs: The facility failed to attempt gradual dose reductions for four residents receiving psychotropic medications as required by regulation.
F759 Medication errors: The facility's medication error rate was 6.9%, exceeding the 5% threshold, affecting two residents during medication administration.
F812 Food safety: The facility failed to store and distribute food under sanitary conditions, risking cross-contamination and food-borne illness.
F925 Pest control: The facility failed to maintain an effective pest control program, with multiple gnats observed in food storage and kitchen areas.
A4031 Communicable disease-Employees: The facility failed to follow appropriate infection prevention practices for tuberculosis screening of employees.
A4055 Safe/Effective Medication System: The facility did not maintain a safe and effective medication distribution and administration system.
A4061 Drug Regimen Review-Monthly: The facility failed to ensure monthly pharmacist or nurse review of each resident's drug regimen with proper documentation.
A6039 Inspect/Rodent Control: The facility failed to implement effective measures to minimize rodents, flies, cockroaches, and other insects on the premises.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain proper temperature controls as required.
Report Facts
Facility census: 64
Medication error opportunities: 29
Medication errors: 2
Medication error rate: 6.9
Residents sampled for psychotropic drug review: 5
Residents failing gradual dose reduction: 4
Employees failing TB screening: 3
Inspection Report
Life Safety
Census: 64
Capacity: 73
Deficiencies: 7
Date: Jan 17, 2025
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety regulations and related codes.
Findings
The facility failed to meet several Life Safety Code requirements including self-closing doors in hazardous areas, maintenance of sprinkler systems, and proper tagging and maintenance of portable fire extinguishers. Deficiencies had the potential to affect all residents and staff.
Deficiencies (7)
K223: The facility failed to ensure doors to hazardous areas had self-closing devices and no impediments to closing. Observations showed doors to oxygen tank storage, electrical panel rooms, and kitchen were held open improperly.
K321: Hazardous areas were not properly enclosed with self-closing or automatic-closing doors and fire barriers. A large opening was observed in the ceiling of the electrical panel and fire alarm equipment room.
K353: The sprinkler system was not maintained properly; sprinklers were dirty and had buildup of corrosion and foreign materials. Five sprinkler heads in the laundry were loaded with dust and debris.
K355: Portable fire extinguishers were not maintained according to NFPA 10 standards. One extinguisher outside the Director of Nursing's office lacked a current inspection tag.
A2008: Hazardous areas were not separated by at least one-hour fire-resistant construction and doors were not self-closing or automatic closing, violating state regulations.
A2016: Fire extinguishers lacked proper monthly pressure checks and labeling as required by NFPA 10 standards.
A2034: The sprinkler system was not properly tested and maintained in accordance with NFPA 25 standards.
Report Facts
Facility census: 64
Total licensed capacity: 73
Deficiencies cited: 7
Sprinkler heads observed: 5
Smoke compartments: 5
Inspection Report
Routine
Census: 64
Deficiencies: 4
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to medication management, food safety, pest control, and overall facility operations at Memory Lane of Dexter nursing home.
Findings
The facility was found deficient in multiple areas including failure to implement gradual dose reductions for psychotropic medications for several residents, medication administration errors related to insulin pen priming, improper food storage and sanitation practices leading to expired and unsealed food items, and an ineffective pest control program evidenced by the presence of gnats in food storage areas.
Deficiencies (4)
Failure to attempt gradual dose reductions (GDR) for psychotropic medications for four residents.
Medication error rate exceeded 5%, with errors in insulin administration due to failure to prime insulin pens.
Failure to store and distribute food under sanitary conditions, including expired and unsealed food items and sticky residues in storage areas.
Failure to maintain an effective pest control program, with multiple gnats observed in food storage areas.
Report Facts
Residents affected: 4
Medication administration opportunities: 29
Medication errors: 2
Medication error rate: 6.9
Facility census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pharmacist E | Interviewed regarding initiation of gradual dose reductions on medications | |
| CMT D | Certified Medication Technician | Observed administering insulin without priming the insulin pen |
| Dietary Manager | Dietary Manager | Interviewed regarding expired food and pest control issues |
| Administrator | Administrator | Interviewed regarding expectations for medication management, food safety, and pest control |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for medication management and insulin pen priming |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 9
Date: Aug 17, 2023
Visit Reason
Annual inspection survey conducted at Memory Lane of Dexter to assess compliance with federal regulations including baseline care planning, accident hazards, food safety, infection control, and Legionella water management.
Findings
The facility was found deficient in developing and implementing baseline care plans for residents, maintaining water temperatures within safe ranges, ensuring food safety and sanitation, and infection prevention and control practices including medication administration. The facility also lacked proper Legionella water management documentation.
Deficiencies (9)
F655 Baseline Care Plan: The facility failed to ensure residents or their representatives received a written summary of the baseline care plan for three sampled residents. Documentation was missing for residents #47, #100, and #201.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to maintain water temperatures between 105 and 120 degrees Fahrenheit in resident rooms, exposing 19 residents to potential scalding hazards.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, including unclean refrigeration units, damaged freezer gaskets, and food debris in storage areas, risking cross-contamination and foodborne illness.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices during medication administration for sampled residents and lacked proper Legionella water management documentation and monitoring.
A3023 Hot Water 105-120 Degrees F: The facility did not maintain plumbing fixtures supplying hot water within the required temperature range of 105-120 degrees Fahrenheit.
A4086 Infection Control/Communicable Disease: The facility failed to implement acceptable infection control procedures to prevent the spread of communicable diseases.
A6012 Floor Surfaces: Floors and floor coverings in food preparation and storage areas were not maintained in good repair and cleanliness.
A6019 List Fixtures, Vent Covers, Décor Cleanable: Light fixtures, vent covers, and similar equipment were not maintained clean and in good repair.
A7067 Nonfood Contact Surfaces, Cleaned as Needed: Nonfood-contact surfaces were not cleaned as necessary to prevent accumulation of dust, dirt, and food particles.
Report Facts
Facility census: 47
Residents exposed to hot water hazard: 19
Sampled residents for baseline care plan review: 3
Sampled residents for infection control review: 6
Sampled residents for infection control review: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication administration infection control deficiency |
| CNA B | Certified Nursing Assistant | Named in infection control deficiency related to hand hygiene and resident care |
| CNA C | Certified Nursing Assistant | Named in infection control deficiency related to hand hygiene and resident care |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency related to hand hygiene and resident care |
| Administrator | Interviewed regarding baseline care plan and infection control deficiencies | |
| Director of Nursing | DON | Interviewed regarding infection control deficiencies |
Inspection Report
Life Safety
Census: 47
Deficiencies: 2
Date: Aug 17, 2023
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and electrical system regulations at Memory Lane of Dexter.
Findings
The facility failed to maintain proper separation of hazardous areas by fire barriers and did not ensure clear working space around electrical panels. Specific issues included multiple penetrations in the mechanical room ceiling and walls, a laundry room door that did not close completely, and water-filled mop buckets stored next to electrical panels.
Deficiencies (2)
K321 Hazardous Areas - The facility failed to maintain separation of high hazardous areas by fire barriers, affecting all residents and staff. Observations included penetrations filled with non-fire rated spray foam and a laundry room door that did not close completely.
K911 Electrical Systems - The facility failed to ensure electrical panels had clear working space for safe operation and maintenance. Water-filled mop buckets were observed next to electrical panels in the basement.
Report Facts
Facility census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding door closure adjustment and electrical panel safety |
Inspection Report
Routine
Census: 47
Deficiencies: 5
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide written baseline care plan summaries to residents or their representatives, unsafe water temperatures in resident rooms posing scalding risks, unsanitary food storage and preparation conditions, inadequate infection prevention and control practices during medication administration and resident care, and lack of a documented Legionella water management program.
Deficiencies (5)
Failure to ensure residents or their representatives received a written summary of the baseline care plan within 48 hours of admission.
Water temperatures in nine resident room sinks exceeded safe limits (above 120 degrees F), increasing risk of scalding injuries.
Failure to store and distribute food under sanitary conditions, including presence of dented cans, frost buildup, grime, and debris in food storage and preparation areas.
Failure to maintain infection control practices during medication administration and resident care, including bare hand contact with medications and improper glove use during peri care.
Failure to implement and document a Legionella water management program to prevent growth and spread of Legionella bacteria.
Report Facts
Residents affected: 3
Residents affected: 19
Facility census: 47
Dented cans: 5
Baking pans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication administration infection control deficiency. |
| CNA B | Certified Nursing Assistant | Named in improper glove use during meal service. |
| CNA C | Certified Nursing Assistant | Named in improper glove use and hand hygiene during peri care for Resident #29. |
| CNA D | Certified Nursing Assistant | Named in improper glove use and hand hygiene during peri care for Resident #29. |
| Maintenance Supervisor | Named in water temperature monitoring and Legionella prevention deficiencies. | |
| Administrator | Provided statements regarding baseline care plan policy, water temperature issues, food storage concerns, infection control, and Legionella prevention. | |
| Director of Nursing | Director of Nursing | Provided statements regarding infection control practices. |
| Dietary Manager | Provided statements regarding kitchen sanitation and food storage deficiencies. | |
| Dietary Aide E | Provided statements regarding kitchen cleaning. | |
| Registered Dietician | Provided statements regarding kitchen refrigeration and food storage issues. |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Census: 21
Deficiencies: 10
Date: Jul 1, 2021
Visit Reason
The document is a Plan of Correction submitted by Dexter Living Center following a survey conducted from 06/28/2021 to 07/01/2021. It addresses deficiencies identified during the inspection.
Findings
The facility failed to implement comprehensive care plans tailored to individual resident needs, ensure professional standards in care and treatment of skin areas, maintain qualified activity professionals, prevent pressure ulcers, ensure safe transfer techniques, designate a full-time Director of Nursing, properly label and store medications, maintain food safety, and implement infection control procedures.
Deficiencies (10)
F 656: The facility failed to develop and implement comprehensive care plans tailored to individual resident needs, including interventions for urinary tract infections and incontinence.
F 658: The facility failed to ensure care and treatment of an opened skin area for one resident, including lack of documentation and notification to the physician.
F 680: The facility failed to have a qualified activity professional to direct activities for residents.
F 686: The facility failed to report, assess, and treat open wounds for two residents consistent with professional standards.
F 689: The facility failed to ensure safe transfer techniques for one resident, including proper use of sit-to-stand lift equipment.
F 727: The facility failed to designate a Registered Nurse to serve as Director of Nursing on a full-time basis.
F 761: The facility failed to date multi-dose vials after opening, discard expired medications, and dispose of discontinued medications properly.
F 812: The facility failed to procure, store, prepare, serve, and sanitize food in accordance with professional standards, including storing expired and unlabeled food items.
F 880: The facility failed to establish and maintain an infection prevention and control program, including hand hygiene and glove use during incontinence care.
F 883: The facility failed to provide and document pneumococcal immunizations for all residents who opted to receive one.
Report Facts
Facility census: 21
Sampled residents: 12
Sampled residents: 3
Sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Collins | Administrator | Signed the Plan of Correction and referenced in interviews |
| Certified Nursing Assistant (CNA) A | Interviewed regarding resident care and activities | |
| Certified Nursing Assistant (CNA) B | Interviewed and observed providing care to residents | |
| Licensed Practical Nurse (LPN) D | Interviewed and observed regarding wound care and medication | |
| Registered Nurse (RN) C | Interviewed regarding resident wound observation | |
| Registered Nurse (RN) H | Designated skin nurse and involved in wound care | |
| Certified Medication Technician (CMT) | Observed medication administration | |
| Nurse Aide (NA) E | Observed delivering meals and assisting residents | |
| Dietary Manager (DM) | Interviewed regarding food handling and sanitation |
Inspection Report
Life Safety
Census: 21
Deficiencies: 6
Date: Jul 1, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain exits free of obstructions and failed to maintain functioning egress doors, which could delay residents and staff in an emergency. Additionally, the facility did not maintain high hazardous areas free of penetrations through smoke barriers.
Deficiencies (6)
K211 Means of Egress - General: The facility failed to maintain exits free of obstructions, evidenced by a blocked kitchen entrance door. The facility census was 21.
K222 Egress Doors: The facility failed to maintain functioning egress doors, including the front entrance door that did not release properly, potentially delaying evacuation. The facility census was 21.
K321 Hazardous Areas - Enclosure: The facility failed to maintain high hazardous areas free of penetrations through smoke barriers, with three holes observed in the basement mechanical room ceiling and wall.
A2008 Hazardous Areas: Hazardous areas were not separated by at least one-hour fire-resistant construction as required, referencing K321.
A2041 Door Locks: Door locks did not meet requirements for being operable from the inside by a simple device, referencing K222.
A2046 Corridor Requirements: Corridors were not maintained free of obstruction, equipment, or supplies, and doors to resident rooms swung into the corridor, referencing K211.
Report Facts
Facility census: 21
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 21
Deficiencies: 10
Date: Jul 1, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and the quality of care provided at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to implement individualized care plans, inadequate wound care and treatment, lack of qualified activities professional, unsafe transfer techniques, absence of a full-time Director of Nursing, improper medication management, unsanitary food handling practices, infection control lapses, and failure to provide and document pneumococcal vaccinations.
Deficiencies (10)
Failed to implement care plans with specific interventions tailored to meet individual needs for residents with UTIs and skin issues.
Failed to ensure care and treatment of an opened skin area for a resident.
Failed to have a qualified activities professional to direct activities to residents.
Failed to report, assess, and treat open wounds appropriately for residents.
Failed to ensure safe transfer techniques for a resident using a sit to stand lift.
Failed to designate a Registered Nurse as Director of Nursing on a full-time basis.
Failed to date multi-dose vials after opening, discard expired medications, and dispose of discontinued medications.
Failed to store and distribute food under sanitary conditions, increasing risk of cross-contamination and food-borne illness.
Failed to provide care in a manner to prevent infection, including failure to change gloves and wash/sanitize hands between clean and dirty tasks during incontinence care.
Failed to provide and document pneumococcal vaccinations for a resident after consent was given.
Report Facts
Facility census: 21
Deficiencies cited: 10
Medication expiration dates: 3
Food temperature logs: 12
Dishwasher sanitizer checks: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in wound care and skin assessment deficiencies |
| RN H | Registered Nurse | Named in wound care and skin assessment deficiencies |
| CNA B | Certified Nurse Assistant | Named in incontinence care and infection control deficiencies |
| CNA F | Certified Nursing Assistant | Named in infection control and food handling deficiencies |
| NA E | Nursing Assistant | Named in safe transfer and food handling deficiencies |
| LPN I | Licensed Practical Nurse | Named in medication management deficiencies |
| Administrator | Provided expectations and comments on multiple deficiencies | |
| MDS Coordinator | Provided information on care planning and wound care | |
| Dietary Manager | Named in food handling deficiencies |
Inspection Report
Routine
Deficiencies: 0
Date: Sep 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
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 for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/27/20 to assess compliance with CMS and CDC recommended practices and related 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
Annual Inspection
Census: 27
Deficiencies: 16
Date: Aug 15, 2019
Visit Reason
Annual inspection survey conducted from 08/12/2019 to 08/15/2019 to assess compliance with federal and state regulations for Dexter Living Center.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, comprehensive care plans, activity programs, pharmacy services, infection control, and food safety. Deficiencies affected multiple residents and involved failure to maintain sanitary conditions, incomplete care plans, lack of qualified activity professional, medication administration errors, and inadequate infection prevention practices.
Deficiencies (16)
F584 Safe/Clean/Comfortable/Homelike Environment: Facility failed to maintain sanitary, orderly, and comfortable interior affecting multiple residents, including paint scraped off walls and broken sink stopper.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to implement individualized care plans with specific interventions for residents, including anticoagulant medication management.
F657 Care Plan Timing and Revision: Facility failed to revise and update care plans for residents with dementia and other conditions, lacking interventions for activities and medication use.
F679 Activities Meet Interest/Needs Each Resident: Facility failed to provide ongoing activity program meeting needs of Special Care Unit residents, with no organized activities observed.
F680 Qualifications of Activity Professional: Facility lacked a qualified activities professional to direct resident activities, affecting all residents; activity director was not fully trained.
F688 Increase/Prevent Decrease in ROM/Mobility: Facility failed to provide services to prevent positioning decline for a resident with limited mobility, including proper use of positioning devices.
F755 Pharmacy Svcs/Procedures/Pharmacist/Records: Facility failed to administer routine anxiety medication timely and maintain accurate medication records for a resident.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to store and distribute food under sanitary conditions, increasing risk of cross-contamination and food-borne illness.
F880 Infection Prevention & Control: Facility failed to maintain infection control practices for multi-use glucometers, affecting multiple residents and staff.
A4029 Communicable Disease-Employees: Facility failed to correctly screen employees for tuberculosis, exposing residents to risk; two employees lacked required TB testing.
A3038 Furniture/Equip, Provide Comfort & Safety: Facility failed to maintain furniture and equipment in good condition, affecting resident comfort and safety.
A4054 Safe/Effective Medication System: Facility failed to maintain a safe and effective medication system, contributing to medication errors.
A4074 Nursing Care per Res Condition: Facility failed to provide personal attention and nursing care consistent with residents' conditions.
A4080 Restorative Nursing, Res Out of Bed: Facility failed to provide restorative nursing to maintain residents' strength and mobility, allowing residents to remain out of bed without medical contraindication.
A7013 Food-Safe, Obtain From Appropriate Sources: Facility failed to procure food in sound condition and from approved sources, risking resident safety.
A8013 Right to Plan Care/Refuse Treatment: Facility failed to ensure residents' rights to participate in care planning and refuse treatment were respected and documented.
Report Facts
Facility census: 27
Deficiencies cited: 15
Inspection Report
Life Safety
Census: 27
Deficiencies: 4
Date: Aug 15, 2019
Visit Reason
The survey was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to maintain functioning exit doors and high hazardous areas free from penetration, which potentially affected all residents and staff. Specific deficiencies included delayed egress locking arrangements and inadequate door closures in hazardous areas.
Deficiencies (4)
K222: The facility failed to maintain functioning exit doors as required by NFPA 101. The employee entrance fire exit door did not release with the fire alarm.
K321: The facility failed to maintain high hazardous areas free from penetration. Observed holes in the ceiling and missing door closures and knobs blocked passage and compromised fire barriers.
A2007: Openings between floors were not properly fire-stopped with suitable noncombustible material, violating fire safety regulations.
A2041: Door locks did not meet requirements; only one lock permitted per door and must be operable from inside without special knowledge or effort.
Report Facts
Facility census: 27
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 6
Date: Aug 29, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Dexter Living Center.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, failure to follow physician's orders for fluid restrictions, inadequate incontinent care, and infection prevention and control practices. Deficiencies were documented with specific resident examples and interviews with staff.
Deficiencies (6)
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with interventions for fluid restrictions for two residents. The facility census was 34.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician's orders for fluid restriction on two residents, with no monitoring or documentation of fluid restriction.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide adequate incontinent care for four sampled residents and one outside the sample, with observations of soiled pads and inadequate cleaning.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices to prevent infection transmission for four sampled residents and one outside the sample.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies F658 and F690.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection, as evidenced by deficiency F880.
Report Facts
Facility census: 34
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 5
Date: Jul 27, 2018
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for Dexter Living Center.
Findings
The facility failed to provide restorative nursing services to sampled residents and maintain an effective pest control program. Additionally, the facility did not properly screen new employees for tuberculosis in a timely manner.
Deficiencies (5)
F684 Quality of care: The facility failed to provide restorative nursing services for two of three sampled residents, including failure to provide required restorative nursing treatments and documentation.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, evidenced by presence of flies in the dining room affecting multiple residents.
A4029 Communicable Disease-Employees: The facility failed to screen three of seven new employees for tuberculosis in a timely manner as required by state regulations.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. Refer to F684.
A6039 Inspect/Rodent Control: Effective measures to minimize presence of rodents, flies, cockroaches, and other insects were not utilized. Refer to F925.
Report Facts
Facility census: 34
Residents sampled: 3
Residents affected by pest control deficiency: 8
Employees not screened for TB timely: 3
Inspection Report
Life Safety
Census: 34
Deficiencies: 7
Date: Jul 27, 2018
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Dexter Living Center.
Findings
The facility failed to provide a clear pathway to safety due to delayed-egress locking arrangements and failed to conduct monthly inspections of the kitchen hood fire suppression system. Additionally, the facility did not properly prohibit flammable decorations and did not store oxygen tanks in accordance with NFPA 99 standards.
Deficiencies (7)
K222: The facility failed to provide a clear pathway to safety out of the building due to delayed-egress locking arrangements. The right exit door by the business office/therapy exit did not release when the fire alarm was sounded.
K355: The facility failed to provide monthly inspections of the kitchen hood fire suppression system, which was last serviced by an outside company in March 2018.
K753: The facility failed to prohibit the use of flammable decorations including candles with wicks, creating a fire hazard. Two candles were observed on a table in Room #106.
K923: The facility did not store oxygen tanks in accordance with NFPA 99 by failing to secure tanks to prevent accidental damage or dislocation and by mixing empty and full tanks in the oxygen storage room.
A2010: Oxygen storage was not in compliance with NFPA 99, 1999 edition, as evidenced by the issues noted in K923.
A2016: Fire extinguishers were not maintained in accordance with NFPA 10, 1998 edition, as evidenced by the lack of monthly inspections of the kitchen hood fire suppression system noted in K355.
A2041: Door locks did not meet NFPA 101, 2000 edition, requirements as only one lock was permitted on any one door, as noted in K222.
Report Facts
Facility census: 34
Date of survey: Jul 27, 2018
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Date: May 3, 2018
Visit Reason
The inspection was conducted in response to complaint #MO141754 regarding roof leaks causing stained ceiling tiles and water damage in resident rooms and common areas.
Complaint Details
Complaint #MO141754 was investigated and substantiated based on observations of roof leaks and stained ceiling tiles in multiple resident rooms and common areas.
Findings
The facility failed to maintain a safe, functional, sanitary, and comfortable environment due to roof leaks causing stained and missing ceiling tiles in multiple areas. The roof leaks affected resident rooms, dining areas, corridors, and the business office.
Deficiencies (3)
F 921: The facility failed to maintain the roof, resulting in leaks and stained or missing ceiling tiles in resident rooms, corridors, and dining areas. This condition posed a risk to all residents as evidenced by multiple observations and interviews.
A3001: The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2). This deficiency references the roof and ceiling issues noted under F921.
A6015: Walls, ceilings, doors, and windows were not clean and maintained in good repair as required by 19 CSR 30-87.020(15). This deficiency also references the roof and ceiling issues noted under F921.
Report Facts
Resident census: 32
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