Inspection Reports for
Monarch Springs Wellness & Rehabilitation
894 LELAND AVE, UNIVERSITY CITY, MO, 63130-3239
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
38% 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: 45
Deficiencies: 1
Date: Dec 31, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's legal guardian of a change in condition and transfer to a hospital.
Complaint Details
The complaint investigation found that the resident had been hospitalized since 12/23/25 without notification to the guardian until two days later. The facility staff acknowledged the failure to notify and document the guardian contact.
Findings
The facility failed to notify the legal guardian of Resident #3 about the resident's hospital transfer and change in condition. Interviews and record reviews confirmed no documentation or notification was made to the guardian despite standard protocol.
Deficiencies (1)
F 0580: The facility failed to notify one resident's legal guardian of a change of condition and transfer to a hospital. Documentation showed no notification or follow-up call was made to the guardian as required by policy.
Report Facts
Residents present: 45
Sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to notify guardian and document change of condition |
| LPN B | Licensed Practical Nurse | Interviewed regarding notification protocol and guardian contact |
| Director of Nursing | Director of Nursing | Interviewed and acknowledged failure to notify guardian |
| Administrator | Administrator | Interviewed and agreed with Director of Nursing on failure to notify guardian |
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
The visit was conducted to address a past noncompliance related to accident hazards and supervision, specifically regarding an incident where a resident was not secured in bed and suffered injuries.
Findings
The facility failed to ensure one resident was free from accident hazards when a Certified Nurse Aide did not secure the resident in bed, resulting in the resident falling and sustaining head lacerations. The facility provided training and updated the resident's care plan to correct the deficiency.
Deficiencies (1)
F 689: The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident fell out of bed and suffered head lacerations because the Certified Nurse Aide did not secure the resident before leaving to answer another call.
Report Facts
Resident census: 44
Inspection Report
Census: 44
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
The inspection was conducted due to a past non-compliance incident involving a resident who fell out of bed and sustained head injuries.
Findings
The facility failed to ensure a resident was free from accident hazards when a Certified Nurse Aide did not secure the resident in bed before leaving, resulting in the resident falling and suffering head lacerations. The facility provided staff training and updated the resident's care plan to prevent recurrence.
Deficiencies (1)
F 0689: The facility failed to provide care and services to ensure one resident was free from accident hazards when a CNA failed to secure the resident in bed before leaving. The resident rolled off the bed and sustained two lacerations to the head.
Report Facts
Census: 44
Suture size: 6
Suture dimensions: 4
Suture dimensions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Failed to secure resident in bed before leaving, leading to resident fall |
| LPN B | Licensed Practical Nurse | Responded to resident fall and assisted with bleeding control |
Inspection Report
Routine
Census: 49
Deficiencies: 11
Date: Jul 12, 2024
Visit Reason
Routine inspection of Monarch Springs Wellness & Rehabilitation to assess compliance with regulatory standards including resident rights, environment, assessments, professional standards, medication management, food service, staffing, social work staffing, and infection control.
Findings
The facility had multiple deficiencies including serving food and beverages in disposable containers affecting resident dignity, unclean dining environments, inaccurate resident assessments, improper medication and wound care practices, incomplete nurse staffing postings, expired medications and supplies, poor food palatability and preparation practices, inadequate food storage and sanitation, open garbage dumpsters, lack of a full-time qualified social worker, and failure to implement a Legionella infection prevention program.
Deficiencies (11)
F 0550: The facility failed to promote a dignified dining experience by serving beverages in disposable cups and food on disposable plates to residents in one dining room.
F 0584: The facility failed to maintain a clean and comfortable environment in two dining rooms, with stained chairs, unclean walls, stained curtains, and unbalanced tables.
F 0641: The facility failed to ensure accuracy of Minimum Data Set assessments for one resident by not reflecting a completed PASARR Level II evaluation.
F 0658: The facility failed to provide services meeting professional standards by inaccurately checking a finger stick glucose level and failing to keep a clean field during wound care for two residents.
F 0732: The facility failed to post complete daily nurse staffing information, omitting night shift staffing data.
F 0761: The facility failed to ensure expired medications and supplies were removed and failed to keep treatment and medication carts locked.
F 0804: The facility failed to serve palatable food at safe temperatures for three residents, and lacked recipes or manufacturer instructions for some menu items.
F 0812: The facility failed to ensure cleanliness and proper labeling, dating, and storage of food in the kitchen and nourishment room, including unclean equipment and water leaks.
F 0814: The facility failed to ensure dumpster lids were kept closed when not in use, with garbage overflowing and on the ground.
F 0850: The facility failed to employ a full-time qualified social worker as required for a facility with more than 120 beds.
F 0880: The facility failed to implement an infection prevention and control program for Legionellosis, lacking risk assessment, water testing, and program awareness.
Report Facts
Residents affected: 49
Expired medications and supplies: 39
Expired dressings: 9
Expired covid-19 test kits: 12
Expired ceiling tiles: 12
Unbalanced dining room tables: 3
Unclean dining room chairs: 14
Unclean dining room chairs: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication expiration and blood sugar testing deficiencies |
| LPN2 | Licensed Practical Nurse | Named in medication cart locking and expired supplies deficiencies |
| LPN3 | Licensed Practical Nurse | Named in medication cart locking and wound care deficiencies |
| Director of Nursing | Director of Nursing | Named in medication administration and wound care deficiencies |
| Dietary Manager | Dietary Manager | Named in food service, recipe, and sanitation deficiencies |
| Registered Dietitian | Registered Dietitian | Named in food service and sanitation deficiencies |
| Administrator | Facility Administrator | Named in multiple interviews confirming deficiencies and observations |
| Social Service Director | Social Service Director | Named in social work staffing deficiency |
| Maintenance Director | Maintenance Director | Named in Legionella infection control deficiency and dining room maintenance |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in dining room cleanliness deficiency |
| Receptionist 1 | Receptionist | Named in nurse staffing posting deficiency |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 10
Date: Jul 12, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services.
Complaint Details
The survey was a Recertification and Complaint survey conducted from 07/09/24 to 07/12/24. The facility was found not to be in substantial compliance. Specific complaint details are not separately stated but are integrated into the findings.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to resident rights, safe environment, accuracy of assessments, professional standards of care, nurse staffing information, labeling and storage of drugs and biologicals, food safety, social worker qualifications, infection control, and other regulatory requirements.
Deficiencies (10)
F550 Resident Rights. The facility failed to promote a dignified dining experience by serving beverages in disposable cups and food on disposable plates for one resident and other residents in the dining room.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a clean and comfortable environment in two dining rooms, including stained chairs, unclean walls, and unclean window curtains.
F641 Accuracy of Assessments. The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident, placing residents at risk of unmet care needs.
F658 Services Provided Meet Professional Standards. The facility failed to provide services based on acceptable standards of practice, including inaccurate blood glucose monitoring and wound care for two residents.
F732 Posted Nurse Staffing Information. The facility failed to ensure daily posted nurse staffing information was complete and accurate, missing data for night shift staff.
F761 Label/Store Drugs and Biologicals. The facility failed to ensure expired medications and supplies were removed from medication rooms and treatment carts, posing a risk to residents.
F804 Nutritive Value/Appear, Palatable/Prefer Temp. The facility failed to serve food that was palatable and at proper temperature for three of four residents reviewed.
F814 Dispose Garbage and Refuse Properly. The facility failed to ensure dumpster container lids were kept closed, creating a potential breeding place for insects and rodents.
F850 Qualifications of Social Worker >120 Beds. The facility failed to employ a full-time qualified social worker for a facility with more than 120 beds.
F880 Infection Prevention & Control. The facility failed to implement adequate infection control measures, including Legionellosis prevention and control, risking resident safety.
Report Facts
Survey Census: 49
Sample Size: 23
Supplemental Residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R24 | Resident involved in dining service deficiency observations | |
| R3 | Resident involved in assessment and care plan deficiencies | |
| R8 | Resident involved in wound care and assessment deficiencies | |
| LPN1 | Licensed Practical Nurse | Named in medication administration and medication room deficiencies |
| DON | Director of Nursing | Named in medication administration and infection control deficiencies |
| DM | Dietary Manager | Named in food service and sanitation deficiencies |
| Administrator | Named in multiple deficiencies and plan of correction oversight | |
| Registered Dietitian | RD | Named in food service and sanitation deficiencies |
| Housekeeping Supervisor | HKS | Named in environmental cleanliness deficiencies |
| Social Service Director | SSD | Named in social worker qualification deficiency |
| Human Resource Manager | HRM | Named in nurse staffing information deficiency |
Inspection Report
Life Safety
Census: 49
Capacity: 130
Deficiencies: 12
Date: Jul 10, 2024
Visit Reason
A Life Safety Code survey was conducted to assess compliance with fire safety and emergency preparedness regulations at Ackert Park Skilled Nursing & Rehabilitation Center.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including emergency lighting, exit signage, vertical openings enclosure, hazardous areas separation, fire alarm system testing, sprinkler system installation, corridor doors maintenance, and electrical system upkeep. The facility lacks emergency lighting in stairwells and battery powered lighting in some areas, and has issues with exit signage and door latching.
Deficiencies (12)
E015 Emergency Preparedness Plan lacked policies and procedures for sewage and waste disposal and subsistence needs for staff and residents including alternate energy sources. The facility failed to incorporate these into their Emergency Preparedness Program.
E026 The facility failed to include Emergency Preparedness Program policies and procedures to provide care under an 1135 waiver, including duties of caregivers and specialized medical needs of residents.
K281 The facility failed to ensure emergency lighting was provided in accordance with NFPA 101, including stairwell lighting and emergency battery powered lighting, affecting 49 residents.
K293 The facility failed to ensure exit directional signs were installed and exit signs contained directional arrows, affecting up to 8 residents on the second floor.
K311 The facility failed to maintain vertical openings enclosure in accordance with NFPA 101, including a hole in an exit stairway door and latching mechanisms on linen chute doors, affecting 49 residents.
K321 The facility failed to maintain hazardous areas with proper fire barriers and self-closing doors, including storage rooms and boiler rooms, affecting 49 residents on the first floor.
K341 The facility failed to ensure fire alarm system photo electric smoke detectors were properly located and maintained, affecting 16 residents on the third floor.
K345 The facility failed to complete required fire alarm system testing and maintenance, including smoke detection sensitivity tests, affecting 49 residents.
K351 The facility failed to ensure sprinkler heads were installed and maintained according to NFPA 13 standards, affecting 16 residents in the area.
K363 The facility failed to maintain corridor doors to resist passage of smoke and ensure proper latching hardware, affecting 49 residents and staff.
K911 The facility failed to maintain the electrical system in accordance with NFPA 99, including severe water damage to switch gear and sump pump malfunctions, affecting 49 residents.
K923 The facility failed to properly store compressed oxygen tanks in accordance with NFPA 99, affecting 10 residents and staff on the first floor.
Report Facts
Occupied beds: 49
Licensed beds: 130
Oxygen cylinders: 24
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 2
Date: Jun 18, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and means of egress requirements, specifically focusing on emergency exit doors and obstruction issues.
Findings
The facility failed to maintain emergency exit doors free of obstructions, with a resident bed blocking an emergency exit door on the 200 Hall. Maintenance and administrative staff acknowledged the issue and the need to keep emergency exits clear at all times.
Deficiencies (2)
K211 Means of egress were obstructed by a resident bed blocking an emergency exit door on the 200 Hall, violating NFPA 101 requirements.
A3001 The building was not substantially constructed and maintained in good repair, as evidenced by the deficiency cited at K211.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding moving the bed blocking the emergency exit door | |
| Administrator | Interviewed about maintenance staff moving beds and responsibility for emergency exits |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 3
Date: May 2, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to transfer and discharge requirements and comprehensive care planning at Ackert Park Skilled Nursing & Rehabilitation Center.
Findings
The facility failed to provide an appropriate involuntary transfer discharge for a sampled resident and did not revise or update care plans after behavioral events. The facility also failed to implement psychiatric or therapeutic services recommended in hospital summaries and did not document interventions related to resident behaviors.
Deficiencies (3)
F622 Transfer and Discharge Requirements: The facility failed to provide a resident with an appropriate involuntary transfer discharge when transferring one sampled resident to the hospital and would not allow return. Documentation and communication requirements for transfers were not met.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to revise or update one resident's care plan after verbal and/or physical aggression, failed to update interventions, and failed to train staff on proper implementation of care plans.
F742 Treatment/Services Mental/Psychosocial Concerns: The facility failed to ensure appropriate treatment and services to address resident behavior triggers and aggression, and failed to develop interventions to deter aggressive behavior toward others.
Report Facts
Census: 51
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: May 2, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide an appropriate involuntary transfer discharge for a resident who was transferred to the hospital and not allowed to return.
Complaint Details
The complaint involved a resident who was involuntarily transferred to the hospital after aggressive behaviors, including attacking a receptionist. The resident was not allowed to return despite filing an appeal. The facility failed to document attempts to meet the resident's needs prior to discharge and did not update the care plan or implement recommended psychiatric resources.
Findings
The facility failed to provide proper documentation and procedures for involuntary transfer or discharge of a resident with aggressive behaviors. The resident's care plan was not updated after behavioral incidents, and recommended psychiatric resources were not implemented. Staff did not adequately monitor or address behavior triggers, and the facility did not revise interventions after repeated aggressive episodes.
Deficiencies (3)
F0622: Facility failed to provide adequate documentation and justification for involuntary transfer or discharge of a resident with aggressive behavior. The resident was transferred to the hospital and not allowed to return despite an appeal.
F0656: Facility failed to develop and implement a complete care plan that meets all the resident's needs, including timely updates after behavioral incidents and proper staff training on interventions.
F0742: Facility failed to provide appropriate treatment and services to a resident with mental disorder by not adequately monitoring behavior triggers or developing interventions to prevent aggressive behaviors.
Report Facts
Residents present during inspection: 51
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist F | Receptionist | Witnessed resident's aggressive behavior and reported incident to Administrator and DON |
| Administrator | Facility Administrator | Provided interviews regarding resident's behavior, transfer, and care plan issues |
| Certified Medication Technician D | CMT | Provided information on resident's behavior and care needs during interview |
| CNA C | Certified Nursing Assistant | Provided information on resident's behavior management and care needs during interview |
| Social Worker H | Social Worker | Involved in resident's positive support contract and family communication |
| Director of Nursing | DON | Notified of resident's aggressive incidents and involved in care planning |
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 2
Date: Jul 13, 2023
Visit Reason
The visit was an abbreviated survey conducted to address an Immediate Jeopardy (IJ) situation related to failure in ensuring proper cardiopulmonary resuscitation (CPR) and Do Not Resuscitate (DNR) code status documentation for residents.
Findings
The facility failed to ensure basic life support including CPR was provided per resident choice and physician orders. The facility also failed to maintain accurate and congruent documentation of residents' code statuses, including DNR orders, for multiple residents.
Deficiencies (2)
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to ensure CPR and code status documentation were accurate and consistent with resident wishes and physician orders for multiple residents.
A4075 Nursing Care per Resident Condition: The facility did not provide personal nursing care consistent with residents' conditions and current acceptable nursing practice, related to the deficiency cited at F678.
Report Facts
Resident census: 37
Residents investigated for advanced directives: 37
Residents with failed ordered code status: 2
Residents with incongruent code status documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator in Training and Director of Nursing (DON) | Provided interview statements regarding code status procedures and audits | |
| Certified Nurse Aide (CNA) A | Interviewed about knowledge of resident code status location | |
| Licensed Practical Nurse (LPN) B | Interviewed about code status location and CPR initiation | |
| Restorative Aide (RA) C | Interviewed about monthly printouts of resident code statuses | |
| Certified Medication Aide (CMT) D | Interviewed about responsibility for updating code status documentation |
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure basic life support, including CPR, would be provided according to residents' code status and physician orders.
Findings
The facility failed to have a system to ensure resident code statuses were obtained, accurately documented, and matched residents' wishes. Specifically, code status orders were missing or inconsistent for several residents, leading to an immediate jeopardy level deficiency that was later removed after corrective action.
Deficiencies (1)
F 0678: The facility failed to ensure basic life support, including CPR, was provided according to resident's code status and physician orders. The facility lacked a system to obtain, document, and ensure congruency of code statuses for residents, resulting in discrepancies for 4 residents.
Report Facts
Residents present during inspection: 37
Residents with code status issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) A | Reported knowledge about code status binder location and usage | |
| Licensed Practical Nurse (LPN) B | Described procedure for finding resident code status and initiating CPR if unclear | |
| Restorative Aide (RA) C | Described monthly receipt of resident code status printout and binder usage | |
| Certified Medication Aide (CMT) D | Described checking code status binder and MAR for resident code status | |
| Administrator in Training and Director of Nursing (DON) | Explained facility policies on code status, documentation, audits, and corrective actions | |
| Administrator | Confirmed POS audits and expectations for code status documentation |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Jun 5, 2023
Visit Reason
The inspection was conducted due to a complaint alleging physical and verbal abuse and involuntary confinement of Resident #1 by a Certified Nursing Assistant (CNA A) during lunch on 5/14/23.
Complaint Details
The complaint alleged that on 5/14/23, CNA A physically assaulted Resident #1 by hitting him/her in the head and forcibly restraining him/her in the dining room. The Dietary Supervisor witnessed the incident but did not immediately report it. Nurse C was informed but did not take immediate protective action. The CNA was allowed to finish the shift. The facility investigation was initiated after an anonymous statement was submitted by the Dietary Supervisor. The allegation was substantiated with evidence of improper handling and failure to protect the resident.
Findings
The facility failed to protect Resident #1 from abuse when CNA A was observed hitting and forcibly restraining the resident. The Dietary Supervisor and Dietary Aide witnessed the abuse but failed to intervene or report immediately. Nurse C did not separate the resident from the CNA or report the allegation promptly. The CNA was allowed to complete the shift. The facility's abuse policies lacked clear procedures for protecting residents after abuse allegations.
Deficiencies (2)
F 0600: The facility failed to protect Resident #1 from physical and verbal abuse by CNA A, who hit the resident in the head and forcibly restrained him/her during lunch on 5/14/23. Dietary staff witnessed the abuse but did not intervene or report immediately. Nurse C did not separate the resident from the CNA or report the allegation promptly, allowing the CNA to finish the shift.
F 0610: The facility failed to respond appropriately to the abuse allegation by not initiating immediate corrective actions, failing to separate the resident from the alleged abuser, and allowing the CNA to continue working pending investigation.
Report Facts
Census: 38
Residents sampled: 6
Residents assigned to CNA: 13
Risperidone dosage: 0.5
Risperidone dosage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Nurse | Failed to separate resident from CNA and report abuse allegation immediately |
| CNA A | Certified Nursing Assistant | Alleged abuser who hit and forcibly restrained Resident #1 |
| Dietary Supervisor | Dietary Supervisor | Witnessed abuse but failed to intervene or report immediately; authored anonymous statement |
| DA B | Dietary Aide | Witnessed incident but did not report immediately |
| Director of Nursing | Director of Nursing (DON) | Notified after incident; initiated investigation |
| Administrator | Facility Administrator | Notified of incident and investigation; provided statements on expectations |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 4
Date: Jun 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse by a Certified Nursing Assistant (CNA) hitting a resident in the dining room on 5/14/23.
Complaint Details
The complaint investigation was substantiated. The CNA was observed hitting a resident multiple times and using forceful actions. The facility failed to protect the resident and did not properly investigate or report the incident in a timely manner.
Findings
The facility failed to ensure a resident was free from physical and verbal abuse and involuntary confinement. The facility also failed to implement immediate corrective actions and properly investigate the alleged abuse incident.
Deficiencies (4)
F600 Freedom from Abuse and Neglect: The facility failed to prevent physical and verbal abuse by a CNA hitting a resident and did not separate the CNA from residents pending investigation.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to initiate immediate corrective actions, failed to report the incident timely, and allowed the CNA to continue working during the investigation.
A4074 Protective Oversight, Voluntary Leave: The facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave as required.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement policies to prohibit mistreatment, neglect, and abuse of residents and to report such incidents to the department.
Report Facts
Census: 38
Residents sampled: 6
Residents assigned to CNA: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in abuse incident hitting Resident #1 |
| Nurse C | Nurse | Witnessed incident and involved in investigation |
| DA B | Dietary Aide | Witnessed incident and reported abuse |
| DS | Dietary Supervisor | Witnessed incident and reported abuse |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and involved in investigation |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Informed of incident and resident's behavior |
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 1
Date: Dec 16, 2022
Visit Reason
The inspection was conducted to investigate compliance with regulations regarding the handling of deceased residents' funds and contacting the Department of Social Services (DSS) upon resident death.
Findings
The facility failed to properly document the use of deceased residents' trust funds for funeral expenses and bed hold fees. The facility did not submit required accounting within 60 days and used funds without appropriate authorization.
Deficiencies (1)
19 CSR 30-88.020(11) Death of Resident, Contact DSS. The facility failed to document contacting DSS and did not provide final accounting of resident trust fund balances within 60 days for deceased residents. The facility also used funds for bed hold fees without proper authorization.
Report Facts
Census: 34
Resident trust fund account balance: 2381.37
Resident trust fund account balance: 355.47
Resident trust fund account balance: 3025.19
Resident trust fund account balance: 30
Resident trust fund account balance: 2346.71
Flight confirmation cost: 440.2
Flight confirmation cost: 279.98
Balance due for funeral goods and services: 3867
Receipt cost: 40.93
Receipt cost: 12.13
Receipt cost: 67.38
Facility check amount: 2381.37
Bed hold fee: 2346.71
Inspection Report
Routine
Census: 36
Capacity: 130
Deficiencies: 10
Date: Dec 9, 2022
Visit Reason
Routine inspection to assess compliance with regulatory requirements including medication administration, resident accommodations, MDS assessments, pharmaceutical services, food safety, staffing qualifications, infection control, and equipment maintenance.
Findings
The facility had multiple deficiencies including failure to assess medication self-administration, inadequate accommodation of resident needs, untimely MDS transmissions, pharmaceutical service lapses including narcotic reconciliation errors, improper medication storage, food safety violations, lack of qualified social worker, inconsistent infection control practices, incomplete COVID-19 vaccination among staff, and malfunctioning mechanical lift equipment.
Deficiencies (10)
F 0554: Facility failed to ensure medication self-administration was assessed for Resident #279, who had medications left at bedside without a physician order for self-administration.
F 0558: Facility failed to reasonably accommodate Resident #3's needs by not providing a wheelchair that met positioning requirements.
F 0640: Facility failed to complete and submit Minimum Data Set (MDS) assessments timely for Residents #13, #8, and #22.
F 0755: Facility failed to maintain accurate pharmaceutical records and reconcile controlled substances for Residents #19, #22, and #180, with missing documentation and unaccounted doses.
F 0761: Facility failed to ensure controlled substances were stored in locked compartments, medications were labeled properly, expired medications were removed, and emergency drug kit was locked.
F 0812: Facility failed to remove dented cans, maintain food and refrigerator temperature logs, sanitize thermometers between food items, and perform proper hand hygiene during meal service.
F 0850: Facility failed to employ a qualified full-time social worker with a bachelor's degree as required for a facility licensed for more than 120 beds.
F 0880: Facility failed to consistently implement infection control measures including proper PPE use entering COVID-19 positive resident's room and while handling soiled laundry.
F 0888: Facility failed to ensure all staff were fully vaccinated against COVID-19 or had a qualifying exemption, with one dietary aide unvaccinated until suspension.
F 0908: Facility failed to maintain mechanical lift equipment in safe operating condition; one lift was malfunctioning and staff failed to report or remove it from use promptly.
Report Facts
Residents affected: 36
Total licensed beds: 130
Residents reviewed for medication self-administration: 16
Residents reviewed for accommodation of needs: 3
Residents reviewed for MDS transmission: 3
Residents reviewed for narcotic medication reconciliation: 18
Staff total: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication administration and narcotic reconciliation findings |
| Certified Medication Technician #8 | Certified Medication Technician | Named in medication administration findings |
| Certified Nurse Aide #9 | Certified Nurse Aide | Named in mechanical lift and medication administration findings |
| Certified Nurse Aide #16 | Certified Nurse Aide | Named in mechanical lift and infection control findings |
| Director of Nursing #1 | Director of Nursing | Named in multiple findings including medication, MDS, narcotic reconciliation, infection control, and equipment maintenance |
| Administrator | Facility Administrator | Named in multiple findings including medication, MDS, narcotic reconciliation, infection control, and equipment maintenance |
| Pharmacist #15 | Consultant Pharmacist | Named in pharmaceutical services findings |
| Dietary Manager | Dietary Manager | Named in food safety and infection control findings |
| Housekeeper #10 | Housekeeper | Named in infection control PPE findings |
| Housekeeping Manager | Housekeeping Manager | Named in infection control PPE findings |
| Laundry Staff #20 | Laundry Staff | Named in infection control PPE and laundry handling findings |
| Social Service Designee | Social Service Designee | Named in social worker qualification findings |
| Maintenance Director | Maintenance Director | Named in mechanical lift maintenance findings |
| Dietary Aide #17 | Dietary Aide | Named in COVID-19 vaccination deficiency |
Inspection Report
Recertification
Census: 36
Capacity: 130
Deficiencies: 10
Date: Dec 9, 2022
Visit Reason
A Recertification Survey and Complaint Survey was conducted from 12/06/2022 to 12/09/2022 to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements, with deficiencies cited in medication administration, reasonable accommodations, resident assessments, pharmacy services, food safety, infection control, and equipment maintenance.
Deficiencies (10)
F554 Resident Self-Admin Meds-Clinically Appropriate: The facility failed to ensure medication self-administration was clinically appropriate for Resident #279, with medications left at bedside without proper assessment.
F558 Reasonable Accommodations Needs/Preferences: The facility failed to ensure Resident #3's right to receive services with reasonable accommodations, including wheelchair positioning and equipment.
F640 Encoding/Transmitting Resident Assessments: The facility failed to complete and submit timely Minimum Data Set (MDS) assessments for residents #13, #8, and #22.
F755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to provide pharmaceutical services ensuring drug records were accurate and reconciled for narcotic medications for residents #19, #22, and #180.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure controlled substances were stored in locked compartments and medications were properly labeled and stored.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to maintain proper food storage, temperature logs, and sanitation practices, affecting 33 of 36 residents receiving food.
F850 Qualifications of Social Worker >120 Beds: The facility failed to employ a qualified social worker on a full-time basis for its licensed 130 beds.
F880 Infection Prevention & Control: The facility failed to consistently implement infection control measures including PPE use, isolation procedures, and staff vaccination compliance.
F888 COVID-19 Vaccination of Facility Staff: The facility failed to ensure all staff were fully vaccinated or had approved exemptions for COVID-19 vaccination.
F908 Essential Equipment, Safe Operating Condition: The facility failed to maintain mechanical lifts in safe operating condition, affecting nine residents using lifts for transfers.
Report Facts
Facility census: 36
Licensed beds: 130
Residents reviewed for narcotic medication discrepancies: 18
Residents with narcotic medication discrepancies: 3
Residents reviewed for MDS assessments: 3
Residents reviewed for medication self-administration: 16
Residents affected by food safety deficiency: 33
Residents using mechanical lifts: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) #1 | Director of Nursing | Named in medication administration, MDS assessment, narcotic medication discrepancies, and infection control findings |
| Certified Medication Technician (CMT) #8 | Certified Medication Technician | Interviewed regarding medication administration for Resident #279 |
| Licensed Practical Nurse (LPN) #6 | Licensed Practical Nurse | Interviewed and observed regarding medication administration and narcotic counts |
| Certified Nurse Aide (CNA) #9 | Certified Nurse Aide | Interviewed regarding medication left in resident rooms and mechanical lift use |
| Administrator | Administrator | Provided statements on medication policies, accommodation needs, and plan of correction |
| Pharmacist #15 | Pharmacist | Interviewed regarding pharmacy services and medication cart audits |
| Dietary Aide (DA) #3 | Dietary Aide | Interviewed regarding food temperature logs and food safety |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding food safety and temperature logs |
| Housekeeper #10 | Housekeeper | Observed and interviewed regarding infection control and cleaning practices |
| Maintenance Director | Maintenance Director | Interviewed regarding mechanical lift maintenance and repairs |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 2
Date: Oct 12, 2021
Visit Reason
Annual survey conducted to assess compliance with federal regulations regarding resident care and facility operations at Ackert Park Skilled Nursing & Rehabilitation Center.
Findings
The facility was found deficient in ensuring call lights were in working order for multiple residents and in providing adequate treatment and services to prevent and heal pressure ulcers. The deficiencies involved failure to maintain call light systems and inadequate wound care documentation and treatment.
Deficiencies (2)
F558 Reasonable Accommodations Needs/Preferences: Facility staff failed to provide reasonable accommodations by not ensuring call lights were in working order for multiple sampled residents. The call lights did not illuminate or sound alarms, and residents could not reach them.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: Facility failed to ensure residents received care to prevent and treat pressure ulcers, including assessment, documentation, notification of physician, and appropriate wound care for a resident with a Stage IV pressure ulcer.
Report Facts
Sample size: 21
Census: 48
Residents affected: 5
Residents affected: 1
Inspection Report
Routine
Deficiencies: 0
Date: Jan 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 12/29/2020 through 01/04/2021 to assess compliance with CMS and CDC recommended practices and federal emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: Aug 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted on 08/27/2020 to investigate complaints related to resident privacy and infection control practices during the COVID-19 pandemic.
Complaint Details
The investigation was triggered by a complaint from Resident #1 regarding exposure of their COVID-19 positive status through signage on their room door, violating privacy rights. The complaint was substantiated based on observations and interviews.
Findings
The facility failed to ensure residents' medical diagnoses confidentiality, exposing private health information publicly. The infection prevention and control program was inadequate, with staff failing to properly use and dispose of PPE, leading to potential COVID-19 transmission risks.
Deficiencies (2)
F583 Personal Privacy/Confidentiality of Records: The facility failed to protect residents' medical diagnosis confidentiality, exposing private health information of seven COVID-19 positive residents through signage and other means.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program, including improper PPE use and disposal by staff in COVID-19 positive resident rooms.
Report Facts
Residents positive for COVID-19: 7
Census: 63
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 05/20/2020 through 05/26/2020 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 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Date: Mar 5, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident injury caused by improper transfer using a mechanical lift.
Complaint Details
The complaint investigation substantiated neglect when a resident was improperly transferred using a mechanical lift without assistance, resulting in a fall and injury. The incident was not reported to the Department of Health and Senior Services as required.
Findings
The facility failed to keep one of three sampled residents free from neglect when a certified nurse aide improperly transferred the resident using a mechanical lift without assistance, resulting in the resident falling and sustaining a head laceration. The facility's abuse policies were reviewed and found to be undated, and the incident was not reported to the Department of Health and Senior Services as required.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent neglect when a certified nurse aide transferred a resident using a mechanical lift without a second person's assistance, causing the resident to fall and sustain a head laceration.
A8025 Report A/N to DHSS/DMH When Needed: The facility did not report the incident of neglect to the Department of Health and Senior Services as required.
Report Facts
Resident census: 65
Deficiencies cited: 2
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 5
Date: Aug 19, 2019
Visit Reason
The inspection was an annual survey of Ackert Park Skilled Nursing & Rehabilitation Center to assess compliance with federal regulations including accident hazards, dialysis care, food safety, infection control, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to ensure proper disposal of razors, inadequate dialysis care documentation and communication, unsafe food storage temperatures, infection control lapses, and failure to maintain safe operating conditions of equipment such as refrigerators and freezers.
Deficiencies (5)
F689: The facility failed to ensure proper disposal of used razors for residents, allowing razors to be found in resident rooms and unlocked shower areas.
F698: The facility failed to routinely assess, monitor, and document dialysis care for residents, including lack of physician orders and communication with dialysis centers.
F812: The facility failed to maintain safe food storage temperatures and remove dented cans, risking resident safety.
F880: The facility failed to follow infection prevention and control practices, including inadequate glove changing, handwashing, and cleaning procedures, leading to potential infection risks.
F908: The facility failed to maintain mechanical and electrical equipment, including walk-in refrigerator and freezer, which were not properly repaired or cleaned, risking resident safety.
Report Facts
Resident census: 66
Sample size: 17
Inspection Report
Life Safety
Census: 66
Capacity: 130
Deficiencies: 8
Date: Aug 19, 2019
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code investigation to assess compliance with federal, state, and local emergency preparedness and fire safety regulations.
Findings
The facility failed to update their emergency preparedness plan annually and did not maintain the fire alarm system, sprinkler system, smoke barriers, corridor doors, and evacuation plan in compliance with applicable regulations. Multiple deficiencies were cited that had the potential to affect all residents and staff.
Deficiencies (8)
E004: The facility failed to update their emergency preparedness plan at least annually. The annual review sheet was blank with no signatures or dates listed.
K345: The facility failed to maintain the fire alarm system with an annual inspection and did not correct multiple malfunctions including non-electrically supervised horn/strobes and smoke detectors that did not respond to smoke tests.
K353: The facility failed to maintain sprinkler heads free of debris and ensure sprinkler escutcheon plates were in place and tightly sealed, with multiple sprinkler heads showing gaps, corrosion, and dust.
K363: Corridor doors were not maintained to resist fire and smoke passage; some doors lacked proper latching, sealing, and closing mechanisms, including an open grate in the oxygen room.
K372: The facility failed to maintain smoke barriers to provide the required fire resistance rating, with unsealed penetrations and damaged smoke barrier walls.
K374: The facility failed to maintain smoke barrier doors in proper working order, preventing them from closing completely during fire alarm activation.
K711: The facility failed to provide a complete fire evacuation and relocation plan, lacking a call to 911 and other required elements.
K741: The facility failed to properly dispose of smoking materials in the designated smoking area, with cigarette butts found scattered in multiple locations.
Report Facts
Facility capacity: 130
Resident census: 66
Inspection Report
Routine
Census: 66
Deficiencies: 5
Date: Aug 19, 2019
Visit Reason
Routine inspection to assess compliance with health and safety regulations including accident prevention, dialysis care, food safety, infection control, and equipment maintenance.
Findings
The facility was found deficient in multiple areas including improper disposal of used razors, inadequate dialysis site assessments and documentation, unsafe food storage temperatures and use of dented cans, poor infection control practices, catheter care deficiencies, and maintenance issues with walk-in refrigerator and freezer.
Deficiencies (5)
F 0689: The facility failed to ensure proper disposal of used razors for two residents, posing accident hazards.
F 0698: The facility failed to routinely assess, monitor, and document dialysis shunt sites for two residents receiving dialysis.
F 0812: The facility failed to maintain safe food storage temperatures in the walk-in refrigerator and failed to remove dented cans from food supply.
F 0880: Facility staff failed to follow infection control practices including hand hygiene, catheter care, and use of shared combs and brushes.
F 0908: The facility failed to maintain walk-in refrigerator and freezer in good repair, resulting in unsafe temperatures and frost buildup.
Report Facts
Resident census: 66
Sample size: 17
Dialysis residents sampled: 2
Dented cans observed: 9
Walk-in refrigerator temperature readings: 48
Walk-in refrigerator temperature readings: 50
Walk-in refrigerator temperature readings: 49.5
Catheter tubing length on floor: 20
Inspection Report
Life Safety
Census: 66
Deficiencies: 6
Date: Nov 6, 2018
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 hazardous areas with required fire barriers, maintain kitchen range hood to NFPA standards, maintain a fully operational fire alarm system, maintain portable fire extinguishers properly, maintain smoke barriers, and ensure proper installation of gas-fired equipment and heating devices. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (6)
K321 Hazardous Areas - The facility failed to maintain hazardous areas with a one-hour fire barrier, affecting all residents, staff, and occupants. Observations showed live electrical panels and doors without self-closers.
K324 Cooking Facilities - The facility failed to maintain the kitchen range hood to NFPA standards, including missing grease filters and lack of monthly checks on the wet chemical suppression system.
K344 Fire Alarm - The facility failed to maintain a fully operational fire alarm system, with a communication failure code displayed and delayed repair actions.
K355 Portable Fire Extinguishers - Fire extinguishers were improperly mounted above 60 inches from the floor, exceeding NFPA height requirements.
K372 Smoke Barrier - The facility failed to maintain smoke barrier walls free from penetrations, affecting fire safety in one smoke zone.
K522 HVAC Heating Device - The facility failed to maintain gas-fired equipment with proper intake air ventilation, risking carbon monoxide accumulation.
Report Facts
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Brencisk | Administrator | Signed the report and plan of correction |
Inspection Report
Annual Inspection
Census: 66
Capacity: 130
Deficiencies: 6
Date: Nov 6, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for Ackert Park Skilled Nursing & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including management of personal funds, comprehensive care plans, accident hazards, and pain management. Several residents' care plans were not updated to reflect current needs, and environmental safety issues such as water temperature and use of side rails were noted.
Deficiencies (6)
F567 Protection/Management of Personal Funds: The facility failed to provide and make available personal funds on an ongoing basis for all residents for which the facility held funds. The resident bank was not available on weekends or federal holidays.
F657 Care Plan Timing and Revision: The facility failed to ensure residents' care plans reflected current needs, including pain, depression, dementia, weight loss, and use of medical devices. Several residents' care plans were not updated to include significant changes or interventions.
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff followed physician orders, including proper use of hand splints and medication administration for residents.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to maintain water temperatures within safe limits and did not properly assess or guide staff in the use of side rails, posing potential hazards to residents.
F697 Pain Management: The facility failed to adequately assess and manage pain for residents, including failure to follow up on ineffective pain medication and to document pain assessments properly.
F838 Facility Assessment: The facility failed to conduct and document a comprehensive facility-wide assessment addressing resident population needs, staff competencies, physical environment, and emergency preparedness.
Report Facts
Census: 66
Total Capacity: 130
Sample Size: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Brennick | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Unnamed Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plans, pain management, and resident care |
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