Inspection Reports for
Morningside Center
1700 MORNINGSIDE DR, CHILLICOTHE, MO, 64601-1545
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
57% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Jan 14, 2026
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #1 slapped Resident #2, raising concerns about physical abuse within the facility.
Complaint Details
The complaint investigation was substantiated. Resident #1 slapped Resident #2 on the cheek on 12/21/2025. The facility took immediate action to separate the residents, notify family and physicians, and update care plans. Staff received in-service training on managing behaviors and abuse prevention.
Findings
The facility failed to protect Resident #2 from physical abuse by Resident #1. The incident was investigated, and both residents were assessed and separated. Staff were re-educated on managing aggressive behaviors and abuse prevention. Resident #1's care plan was updated to address aggressive behaviors, and the noncompliance was corrected by 12/24/2025.
Deficiencies (1)
Failure to protect a resident from physical abuse by another resident.
Report Facts
Facility census: 52
Date of incident: Dec 21, 2025
Date noncompliance corrected: Dec 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Witnessed raised voices during the incident but did not arrive in time to separate residents |
| RN A | Registered Nurse | Reported staff keep track of Resident #2 and described Resident #1 as immobile |
| Housekeeper A | Provided interview about resident-to-resident incidents and training | |
| Assistant Administrator | Acknowledged lack of prior care planning for Resident #1's aggressive behaviors and described subsequent monitoring and interventions | |
| Director of Nursing | DON | Documented Resident #1 had no obvious signs of distress after the incident |
Inspection Report
Life Safety
Census: 53
Capacity: 60
Deficiencies: 6
Date: Jan 23, 2025
Visit Reason
The survey was conducted to assess compliance with emergency preparedness and life safety code requirements at Morningside Center.
Findings
The facility failed to maintain an updated emergency preparedness plan and did not meet several life safety code requirements including vertical openings enclosure, fire alarm system testing and maintenance, sprinkler system maintenance, fire drills, corridor doors, and fire door operations. Deficiencies had the potential to affect all residents.
Deficiencies (6)
E004 Emergency Plan. The facility failed to update and maintain a comprehensive emergency preparedness plan affecting all residents. The plan lacked documentation of annual review and did not reflect current policies for evacuation, fire watch, cyber attack, COVID-19, and missing resident procedures.
K311 Vertical Openings - Enclosure. The facility had penetrations in the ceiling and plywood leading to the attic space, allowing potential smoke and fire spread. The maintenance coordinator was unaware of these penetrations.
K345 Fire Alarm System - Testing and Maintenance. The facility failed to ensure qualified personnel inspected and maintained the fire alarm system, with incomplete inspections and lack of proper sign-off.
K353 Sprinkler System - Maintenance and Testing. Sprinkler heads were obstructed or missing coverage in multiple areas, and required relocation and clearance maintenance. The facility failed to maintain proper sprinkler system conditions.
K712 Fire Drills. The facility failed to conduct fire drills at varied times and conditions, including weekends, and did not run drills on weekends as required, potentially affecting all residents.
K363 Corridor Doors. Corridor doors lacked positive latching and roller latches, and some doors did not have automatic flush bolts or proper hardware, compromising smoke barrier integrity.
Report Facts
Facility census: 53
Total capacity: 60
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 7
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident rights, dignity, and quality of care, including response times to call lights and resident grievances.
Complaint Details
The investigation was complaint-driven, focusing on resident rights violations, delayed call light responses, inadequate grievance handling, and deficiencies in care planning and infection control. The complaint was substantiated as evidenced by multiple findings.
Findings
The facility failed to ensure timely staff response to call lights, affecting resident dignity and care. Deficiencies were found in resident rights, family group participation, comprehensive care planning, discharge summaries, dialysis care, infection control, and documentation of grievances.
Deficiencies (7)
F550 Resident Rights: The facility failed to assure staff treated residents with dignity by not responding to call lights in a timely manner, affecting six of 13 sampled residents.
F565 Resident/Family Group and Response: The facility failed to ensure resident groups were organized and did not provide rationale or response to resident council grievances, affecting all residents.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timely updates.
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to obtain physician orders for code status for four residents and did not document residents' wishes regarding CPR.
F661 Discharge Summary: The facility failed to complete discharge summaries for discharged residents and follow their own discharge planning policy.
F698 Dialysis: The facility failed to ensure communication between staff and dialysis residents, complete required documentation, and provide necessary assessments and monitoring.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention program, including TB testing for volunteers and staff education.
Report Facts
Facility census: 52
Sampled residents: 13
Residents affected by call light delays: 6
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Harris Ann Melton | Administrator | Signed the statement of deficiencies and plan of correction |
| RN A | Registered Nurse | Interviewed regarding call light response times |
| RN B | Registered Nurse | Interviewed regarding call light response times |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding call light response times |
| Director of Nursing | Director of Nursing | Interviewed regarding call light response times and care plan |
| Assistant Administrator | Assistant Administrator | Interviewed regarding call light response times and resident council |
| Activity Director | Activity Director | Interviewed regarding resident council meetings |
| Social Services Designee | Social Services Designee | Interviewed regarding discharge planning and resident council |
| MDS Coordinator | MDS/Care Plan Coordinator | Interviewed regarding care plans and discharge planning |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 7
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to complaints regarding delayed response to call lights, failure to follow up on resident grievances, incomplete care planning for dialysis needs, lack of physician orders for code status, inadequate dialysis care communication, and failure to follow infection control guidelines for volunteers.
Complaint Details
The complaint investigation focused on delayed call light responses, resident grievances not addressed, inadequate dialysis care planning and communication, missing physician orders for code status, and infection control lapses with volunteers.
Findings
The facility failed to ensure timely response to call lights affecting multiple residents, did not follow up or provide rationale for resident council grievances, failed to develop a comprehensive care plan addressing dialysis needs for a resident, lacked physician orders for code status for four residents, failed to document assessments before and after dialysis and communication with the dialysis center, and allowed volunteers to provide services without TB skin testing.
Deficiencies (7)
Failure to respond to call lights in a timely manner affecting six of 13 sampled residents.
Failure to follow up with resident grievances and provide rationale or response to resident council.
Failure to develop and implement a comprehensive care plan addressing dialysis needs for Resident #106.
Failure to complete a discharge summary and follow discharge planning policy for Resident #55.
Failure to obtain physician orders for code status for four residents (#26, #22, #51, #16).
Failure to ensure communication and documentation of assessments before and after dialysis for Resident #106.
Failure to follow infection control guidelines by allowing volunteers to provide services without TB skin testing.
Report Facts
Residents affected by call light delay: 6
Facility census: 52
Residents sampled: 13
Residents with missing code status orders: 4
Inspection Report
Life Safety
Census: 55
Capacity: 60
Deficiencies: 9
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to meet several Life Safety Code requirements including means of egress, sprinkler system maintenance and testing, smoke barrier doors, building system categories, and emergency generator testing and documentation. Deficiencies affected the safety of residents, staff, and visitors.
Deficiencies (9)
K211 Means of Egress - General: The facility failed to ensure one exit was easily identifiable due to a mural over the exit door, affecting one of six exits.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler system inspection reports and did not perform required air leakage tests, affecting all residents, staff, and visitors in the existing portion.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to ensure one doorway in a smoke barrier wall was protected, with doors open to different smoke compartments and lacking self-closing/automatic closing devices.
K901 Fundamentals - Building System Categories: The facility failed to ensure all building systems were assigned a risk assessment category and documented according to NFPA 99, potentially affecting all residents, staff, and visitors.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to document monthly emergency generator testing and transfer times, affecting all residents, staff, and visitors.
A1135 Emergency Lights, Generator for Life Support: The facility failed to maintain emergency lighting and generator documentation as required by NFPA 99.
A2034 Sprinkler System-Test/Maintain: The facility failed to inspect, maintain, and test the sprinkler system in accordance with requirements.
A2037 Exit Requirements: The facility failed to maintain at least two unobstructed exits remote from each other, including removal of a mural over an exit door.
A2054 Smoke Section Walls/Doors: The facility failed to ensure smoke section walls and doors met fire rating and self-closing requirements.
Report Facts
Deficiencies cited: 9
Census: 55
Total Capacity: 60
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 5
Date: Jun 2, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing home care, including review of care plans, medication administration, safety measures, and facility policies.
Findings
The facility was found deficient in developing and implementing comprehensive care plans, assessing and using bed rails appropriately, maintaining a medication error rate below 5%, and ensuring food safety and quality assurance committee meetings. Several residents' care plans lacked measurable objectives and interventions, and medication administration errors exceeded the acceptable threshold.
Deficiencies (5)
F656: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for residents' medical, nursing, and psychosocial needs. Four residents were affected and the facility census was 55.
F700: The facility failed to assess residents for risk of entrapment and did not complete side rail assessments for three residents. Bed rails were not used appropriately and no physician orders were found for their use.
F759: The facility failed to maintain a medication error rate of less than 5%, with an 11.54% error rate identified in two residents. Medication administration policies and procedures were not fully followed.
F812: The facility failed to maintain food safety requirements, including proper labeling, dating, temperature logs, and cleaning schedules in the kitchen and food storage areas. The facility census was 55.
F868: The facility failed to maintain a quality assessment and assurance committee with required members and quarterly meetings. The committee did not meet as required and the Medical Director did not attend meetings.
Report Facts
Facility census: 55
Medication error rate: 11.54
Medication error opportunities: 26
Medication errors: 3
Inspection Report
Routine
Census: 55
Deficiencies: 4
Date: Jun 2, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with care planning, medication administration, food safety, and quality assurance requirements at the nursing home.
Findings
The facility failed to develop and implement comprehensive care plans addressing bed rail use and entrapment assessments for several residents, had a medication error rate exceeding 5%, failed to maintain kitchen sanitation and proper food labeling and temperature logging, and did not maintain required quarterly Quality Assessment and Assurance meetings with all required members.
Deficiencies (4)
Failed to develop and implement a complete care plan that meets all resident needs including measurable objectives and timeframes, specifically regarding bed rail assessments and entrapment risk.
Failed to ensure medication error rates were less than 5%, with a medication error rate of 11.54% due to unclear physician orders and improper administration.
Failed to maintain kitchen sanitation, proper food labeling and dating, and accurate temperature logs for refrigerators and freezers, including ice buildup in walk-in freezer.
Failed to maintain quarterly Quality Assessment and Assurance committee meetings with required members, specifically the Medical Director was not invited or present.
Report Facts
Medication error rate: 11.54
Medication errors: 3
Medication administration opportunities: 26
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding bed rail assessments and medication order clarifications |
| Administrator | Facility Administrator | Interviewed regarding bed rail policies, kitchen sanitation, and QAPI meetings |
| Registered Nurse A | Registered Nurse | Observed administering medications with noted errors |
| Licensed Practical Nurse A | Licensed Practical Nurse | Observed administering medications with noted errors |
| Dietary [NAME] A | Dietary Staff | Interviewed regarding kitchen sanitation and food labeling |
| Dietary [NAME] B | Dietary Staff | Interviewed regarding food labeling and temperature logs |
| Maintenance Coordinator | Maintenance Coordinator | Interviewed regarding ice buildup in walk-in freezer and maintenance procedures |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 8, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC regulations and recommendations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 18, 2021
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted on 08/17/2021 and 08/18/2021 to assess compliance with federal COVID-19 regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on December 22 and 23, 2020 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
Routine
Census: 46
Deficiencies: 3
Date: Dec 3, 2020
Visit Reason
The inspection was conducted to assess compliance with safety, food service, and infection control standards in the nursing home.
Findings
The facility was found deficient in proper use of gait belts and mechanical lifts during resident transfers, food storage practices including undated spices and improperly stored icing, and infection prevention practices such as failure to change gloves and wash hands between clean and dirty tasks.
Deficiencies (3)
Failure to use proper techniques to reduce accidents during gait belt transfers and mechanical lift operation.
Failure to store food in accordance with professional standards, including undated spices, open pancake mix not closed or dated, and icing left at room temperature.
Failure to provide infection prevention by not changing gloves and washing hands between dirty and clean tasks affecting three residents.
Report Facts
Residents affected: 12
Facility census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings related to improper gait belt use and infection control |
| CNA D | Certified Nurse Aide | Named in findings related to improper mechanical lift use and infection control |
| Director of Nurses | Director of Nursing | Provided statements on expected staff practices regarding gait belt and infection control |
| LPN A | Licensed Practical Nurse | Named in infection control deficiency related to peri care and glove use |
| Dietary Manager | Dietary Manager | Provided statements on food storage and dating practices |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 5
Date: Dec 3, 2020
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident safety, food safety, and infection control at Morningside Center.
Findings
The facility was found deficient in ensuring free of accident hazards and proper use of gait belts and mechanical lifts, food safety practices including proper dating and storage of food items, and infection prevention and control procedures including hand hygiene and use of gloves.
Deficiencies (5)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff used proper techniques during gait belt transfers and mechanical lift operations for sampled residents, causing resident discomfort and potential injury.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store food in accordance with professional standards, including undated spices and opened food items left at room temperature.
F880 Infection Prevention & Control: The facility failed to provide care to prevent infection, including improper glove use and hand hygiene, affecting multiple residents.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current nursing practice. Deficiency referenced to F689.
A4085 Infection Control/Communicable Disease: Residents shall be cared for using acceptable infection control procedures. Deficiency referenced to F880.
Report Facts
Facility census: 46
Sampled residents: 12
Deficiencies cited: 5
Plan of correction completion date: Completion date for corrective actions is 2021-01-18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan Sweats | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Director of Nurses | Director of Nursing | Interviewed regarding gait belt and mechanical lift procedures |
| Dietary Cook | Interviewed regarding food storage and safety practices | |
| Dietary Manager | Interviewed regarding food safety and labeling | |
| Certified Nurse Aides A, B, C, D, E | Certified Nurse Aides | Observed transferring residents and providing care |
| Licensed Practical Nurse A | Licensed Practical Nurse | Observed assisting resident with mechanical lift and hand hygiene |
Inspection Report
Life Safety
Census: 46
Capacity: 60
Deficiencies: 12
Date: Dec 3, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the NFPA Life Safety Code and related fire safety regulations at Morningside Center.
Findings
The facility failed to meet several Life Safety Code requirements including building construction type and height, means of egress signage, fire alarm system testing and maintenance, smoke barrier doors, and electrical receptacle inspections. Deficiencies were noted in documentation, signage, door locking devices, and fire alarm sensitivity testing.
Deficiencies (12)
K161 Building Construction Type: The facility failed to maintain the Type V (111) protected wood-frame construction standard, with holes and penetrations in ceilings opening into attic space affecting two smoke compartments.
K211 Means of Egress: The facility failed to clearly mark means of egress for two exit routes, including lack of NO EXIT signage and signage directing staff away from locked doors with keypad locks.
K345 Fire Alarm System - Testing and Maintenance: The facility did not provide complete and accurate documentation or 100% testing of the fire alarm system semi-annually as required, including sensitivity testing of smoke detectors.
K374 Smoke Barrier Doors: The facility failed to ensure smoke barrier doors closed with fire alarm activation and lacked approvals for magnetic locking devices on certain doors.
K912 Electrical Systems - Receptacles: The facility failed to maintain annual electrical outlet inspections in patient care areas, with incomplete documentation of receptacle testing and assessments.
A2019 Fire Alarm System-Test/Maintain: The facility failed to maintain complete fire alarm system testing and maintenance in accordance with NFPA 72, 1999 edition.
A2030 Smoke/Heat Detectors-Correct Faults: The facility failed to equip all resident rooms and sleeping areas with battery-powered smoke alarms and interconnected heat detectors as required.
A2047 Exit Sign Requirements: The facility failed to place required exit signs bearing the word EXIT in plain, legible letters at all required exits except doors directly from rooms.
A2048 Exit Sign Placement/Letter Size: The facility failed to place additional exit signs in corridors and passageways with letters at least six inches high and three-fourths inch wide as required.
A2054 Smoke Section Walls/Doors: The facility failed to separate smoke sections by one-hour fire-rated walls and doors that close automatically upon fire alarm activation.
A3001 Substantially Constructed/Maintained: The facility failed to maintain the building in good repair and comply with construction standards, referencing K161 and K374.
A3030 Electrical Wiring & Equipment Maintained: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, 1999 edition, referencing K912.
Report Facts
Facility capacity: 60
Resident census: 46
Deficiencies cited: 11
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on May 21 and May 22, 2020 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
Plan of Correction
Census: 54
Deficiencies: 2
Date: Nov 7, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to quality of care, specifically regarding a resident fall and subsequent treatment and notification procedures.
Findings
The facility failed to notify the resident's physician and family in a timely manner after a resident fell and sustained a fractured left hip. The investigation revealed gaps in fall risk assessment, monitoring, and communication protocols.
Deficiencies (2)
F684 Quality of care: The facility failed to notify the resident's physician and family promptly after a resident fell and sustained a fractured left hip, causing a delay in treatment.
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 the quality of care deficiency.
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan Duarte | Administrator | Signed the inspection report and plan of correction |
| Director of Nursing | Interviewed regarding notification procedures following resident fall | |
| Licensed Practical Nurse | Interviewed regarding notification of resident's physician and family |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Mar 21, 2019
Visit Reason
The inspection was conducted as a licensure inspection to determine compliance with state and federal regulations for the facility.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 51
Capacity: 60
Deficiencies: 2
Date: Mar 21, 2019
Visit Reason
The inspection was conducted to evaluate the fire alarm system testing and maintenance compliance at Morningside Center as part of a life safety code survey.
Findings
The facility failed to perform the semi-annual inspection of the automatic fire alarm system, which is required to ensure operation in the event of a fire emergency. This deficiency was cited under NFPA 70, National Electric Code, and NFPA 72 standards.
Deficiencies (2)
K345 Fire Alarm System - Testing and Maintenance. The facility failed to perform the semi-annual inspection of the automatic fire alarm system to ensure its operation during a fire emergency.
A2019 Fire Alarm System-Test/Maintain. The facility did not maintain the complete fire alarm system in accordance with NFPA 72, 1989 edition, Class II.
Report Facts
Facility capacity: 60
Resident census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan Swetts | Administrator | Signed the inspection report and plan of correction. |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 7
Date: May 11, 2018
Visit Reason
Annual survey conducted to assess compliance with professional standards of care, medication administration, and facility policies at Morningside Center.
Findings
The facility failed to meet professional standards in medication administration, including improper application of eye drops, failure to instruct residents on inhaler use, and medication error rates exceeding 5%. Deficiencies were noted in medication regimen review, storage of controlled substances, and documentation of pharmacist recommendations.
Deficiencies (7)
F658: Facility failed to ensure staff applied lacrimal pressure when administering eye drops and did not instruct residents to rinse mouth after steroid inhaler use. Medication administration was not timely or properly disinfected.
F756: Facility failed to ensure medication regimen reviews included pharmacist reports of irregularities and physician responses. Policies and procedures for medication regimen review were inadequate.
F759: Medication error rate exceeded 5%, with errors in administration of medications to multiple residents. Facility failed to ensure staff administered medications as ordered and followed policy.
F761: Facility failed to properly store and label drugs and biologics, including controlled substances. Staff did not discard expired medications and failed to monitor narcotic counts adequately.
A4054: Facility failed to maintain a safe and effective medication system, including medication distribution, administration, control, and use.
A4070: Facility failed to establish a system for controlled substance record reconciliation to ensure accurate accounting and monitoring.
A4074: Facility failed to provide personal attention and nursing care consistent with residents' conditions and accepted nursing practice.
Report Facts
Facility census: 53
Medication error rate: 11.11
Medication error rate: 15.6
Medication error rate requirement: 5
Inspection Report
Plan of Correction
Census: 53
Capacity: 60
Deficiencies: 4
Date: May 11, 2018
Visit Reason
The inspection was conducted to assess the facility's compliance with emergency preparedness requirements and life safety code provisions, including fire safety and smoke barrier door inspections.
Findings
The facility failed to meet the Emergency Preparedness requirements and the Life Safety Code provisions related to smoke barrier doors. The emergency preparedness manual was incomplete, and the smoke barrier door between the Assisted Living Facility and skilled nursing unit had not been inspected by a qualified contractor.
Deficiencies (4)
E001 Emergency Preparedness program was incomplete and did not meet federal, state, and local requirements. The manual lacked components such as fire response and other disaster plans.
K374 The facility failed to assure all fire doors were inspected per NFPA 80. One door separating the Assisted Living Facility from the skilled nursing unit had not been inspected by a qualified outside contractor.
A2058 Fire Drills and Emergency Preparedness plan was not up to date and did not meet regulatory requirements. The facility failed to provide an up-to-date copy of the entire plan to the local emergency management director.
A3001 The building was not substantially constructed or maintained in good repair per 19 CSR 30-85.032(2). The facility did not meet physical plant requirements for licensed health care occupancies.
Report Facts
Bed capacity: 60
Census: 53
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