Inspection Reports for
New Haven Care Center
9503 HIGHWAY 100, NEW HAVEN, MO, 63068-1300
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
65% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 3
Date: Mar 21, 2025
Visit Reason
The document is a Plan of Correction related to deficiencies identified during a facility inspection conducted on 03/21/2025 at New Haven Care Center.
Findings
The facility failed to meet professional standards in medication administration and safe storage of toxic materials. Deficiencies included failure to properly document insulin dosages, administer medications per physician orders, and store toxic chemicals securely.
Deficiencies (3)
F658: The facility failed to maintain professional standards of care in medication administration, including failure to utilize the electronic medication administration record (eMAR) properly and document insulin dosages for multiple residents.
A4055: The facility did not have a safe and effective medication system as evidenced by the deficiencies cited under F658.
A6005: The facility failed to store toxic chemicals in a manner not accessible to residents, with unlocked cabinets and unattended areas observed.
Report Facts
Facility census: 69
Deficiencies cited: 3
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness regulations at New Haven Care Center.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA). No deficiencies were cited related to emergency preparedness or state licensure.
Inspection Report
Routine
Census: 69
Deficiencies: 3
Date: Mar 21, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to medication administration, including insulin administration, extended release medication handling, and oxygen orders for residents.
Findings
The facility failed to properly utilize the electronic medication administration record (eMAR) for insulin administration and documentation for multiple residents, crushed extended release potassium chloride against pharmacy recommendations, and administered oxygen to a resident without a physician's order.
Deficiencies (3)
Failure to utilize the eMAR and document insulin dosages for multiple residents.
Failure to administer extended release potassium chloride per pharmacy recommendations; crushed medication for a resident unable to swallow pills.
Failure to obtain a physician's order for oxygen for one resident using oxygen.
Report Facts
Residents sampled: 30
Facility census: 69
Insulin doses not documented: 69
Extended release potassium chloride dose: 20
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered insulin without using eMAR and referenced handwritten sliding scale |
| RN B | Registered Nurse | Administered insulin using eMAR but did not document doses |
| LPN C | Licensed Practical Nurse | Crushed extended release potassium chloride against recommendations and unaware of physician/pharmacy consultation |
| Assistant Director of Nursing | ADON | Interviewed regarding medication administration policies and deficiencies |
| Director of Nursing | DON | Interviewed regarding medication administration and oxygen order deficiencies |
| Administrator | Facility Administrator | Interviewed regarding expectations for medication administration and documentation |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 5
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, nutrition, and infection control at New Haven Care Center.
Findings
The facility was found deficient in providing adequate personal hygiene care to residents unable to perform their own activities of daily living, ensuring safe mechanical lift transfers, preventing choking hazards during meal service, maintaining nutritional status to prevent significant weight loss, and implementing proper infection prevention and control procedures including hand hygiene.
Deficiencies (5)
Failure to provide necessary care and assistance for activities of daily living including grooming, nail care, and shaving for residents unable to care for themselves.
Failure to provide safe mechanical lift transfers, including improper use of mechanical lift base and inadequate staff assistance.
Failure to provide appropriate diet and supervision during meal service to prevent choking hazard for a resident with swallowing difficulties.
Failure to ensure resident received necessary services and assistance to maintain nutritional status, resulting in significant weight loss without documented interventions or notifications.
Failure to use appropriate infection control procedures including hand hygiene between glove changes and use of disposable wipes, risking spread of infection.
Report Facts
Facility census: 66
Resident weight loss percentage: 6.33
Number of packages of denture cleaner: 93
Number of disposable razors: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in findings related to mechanical lift transfer and infection control deficiencies |
| CNA F | Certified Nurse Aide | Named in findings related to personal hygiene care and infection control deficiencies |
| CNA B | Certified Nurse Aide | Interviewed regarding supervision of resident during meals |
| LPN I | Licensed Practical Nurse | Interviewed regarding chemical storage and weight monitoring |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies and deficiencies |
| Registered Dietician | Registered Dietician | Interviewed regarding nutritional care and supervision |
| Medical Director | Medical Director | Interviewed regarding resident weight monitoring and notification |
| Social Services Director | Social Services Director | Interviewed regarding monitoring of resident meal intake |
| CNA L | Certified Nurse Aide | Interviewed regarding resident eating behaviors and meal assistance |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 8
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing home care, including resident care, safety, infection control, nutrition, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including activities of daily living care, protective oversight, infection control, nutrition and hydration, and safe resident handling. Several residents were observed to have unmet personal hygiene needs, unsafe mechanical lift transfers, and inadequate supervision during meals.
Deficiencies (8)
F677 Activities of Daily Living care was deficient as staff failed to ensure five residents received necessary grooming, bathing, and assistance with eating. Observations showed residents with debris under fingernails, long hair, and facial hair not trimmed as per care plans.
F689 Protective Oversight was deficient as staff failed to provide safe mechanical lift transfers for one resident and failed to ensure the environment was free of accident hazards, including improperly stored sharps and toxic chemicals. The facility census was 66.
F692 Nutrition and Hydration was deficient as staff failed to ensure one resident received necessary services to maintain nutritional status, resulting in significant weight loss. Documentation and monitoring of weight loss were inadequate.
F880 Infection Prevention and Control was deficient as staff failed to use appropriate hand hygiene between glove changes during care for two residents, increasing risk of infection spread. The facility census was 66.
A4074 Protective Oversight, Voluntary Leave regulation was not met as the facility lacked adequate procedures for oversight and supervision of residents on voluntary leave.
A4077 Residents Groomed/Dressed Appropriately regulation was not met as residents were not consistently well-groomed or dressed appropriately, referencing F677.
A4086 Infection Control/Communicable Disease regulation was not met as the facility failed to maintain infection control policies and procedures, referencing F880.
A5001 Nutritional Needs Met, Assess Residents, Inform Doctor regulation was not met as residents' nutritional needs were not adequately assessed or addressed, referencing F692.
Report Facts
Facility census: 66
Deficiency counts: 8
Inspection Report
Life Safety
Census: 66
Capacity: 90
Deficiencies: 5
Date: Dec 15, 2023
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire alarm, sprinkler, and electrical system safety requirements.
Findings
The facility was found deficient in maintaining and testing the fire alarm system, fire watch policy, sprinkler system, corridor doors, and essential electrical systems. Several policies were outdated or incomplete, and documentation of inspections and testing was lacking.
Deficiencies (5)
K345 Fire Alarm System - Testing and Maintenance: The facility failed to inspect, test, and maintain the fire alarm system including the kitchen hood connection, and lacked documentation for these activities.
K346 Fire Alarm System - Out of Service: The facility lacked a complete policy for procedures when the fire alarm system is out of service for more than four hours, and the fire watch policy was incomplete.
K354 Sprinkler System - Out of Service: The facility failed to ensure a complete policy was in place for sprinkler system outages exceeding four hours, and lacked proper fire watch procedures.
K363 Corridor Doors: Doors protecting corridor openings did not have proper clearance and fire rating labels were missing or incomplete, risking smoke passage and fire containment.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to provide complete and verifiable documentation of annual inspections and testing of essential electrical systems and emergency power.
Report Facts
Facility census: 66
Total capacity: 90
Inspection date: Dec 15, 2023
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 7
Date: Nov 4, 2022
Visit Reason
The inspection was conducted based on complaints and observations regarding failure to maintain resident dignity, safe and homelike environment, proper notification of transfers and discharges, comprehensive care planning, assistance with activities of daily living, wheelchair safety, and food safety practices.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to maintain resident dignity, safe environment, proper notification of transfers, comprehensive care planning, assistance with ADLs, wheelchair safety, and food safety.
Findings
The facility was found deficient in multiple areas including failure to maintain dignity by not changing soiled catheter privacy bags, failure to maintain a safe and homelike environment with chipped paint and odors, failure to provide written discharge/transfer notices and bed hold policy information, incomplete and missing care plans for residents' medical and nursing needs, inadequate assistance with personal hygiene and grooming, improper wheelchair propulsion risking resident safety, and poor food safety practices including inadequate hand hygiene and improper cleaning of food preparation equipment.
Deficiencies (7)
Failure to maintain dignity by not changing wet and stained urinary catheter privacy bags for residents.
Failure to provide a safe, clean, comfortable and homelike environment due to chipped paint, gouged walls, black marks, dirty privacy curtains, and lingering odors in resident rooms.
Failure to provide written notice of discharge/transfer and bed hold policy to residents and/or representatives for hospital transfers.
Failure to develop and implement complete care plans addressing splint use, code status, oxygen use, facial hair and nail care preferences, blood sugar monitoring, and surgical wound care.
Failure to provide necessary care and assistance with activities of daily living including hair care and nail care for residents.
Failure to properly propel residents in wheelchairs with feet on foot pedals, risking injury.
Failure of dietary staff to perform hand hygiene consistently and failure to wash, rinse, and sanitize food processor and food preparation sink between uses, risking cross-contamination.
Report Facts
Facility census: 60
Residents affected: 2
Residents affected: 3
Residents affected: 6
Residents affected: 5
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA H | Certified Nursing Assistant | Named in wheelchair propulsion deficiency |
| RN E | Registered Nurse | Named in catheter care and dignity deficiency |
| CNA F | Certified Nursing Assistant | Named in catheter care and dignity deficiency |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including catheter care, environment, care plans, and wheelchair safety |
| Administrator | Interviewed regarding multiple deficiencies including environment, transfer notices, care plans, and wheelchair safety | |
| SSD | Social Services Designee | Interviewed regarding transfer notices and baseline care plans |
| DM | Dietary Manager | Named in food safety and hand hygiene deficiencies |
| CNA/CMT A | Certified Nurse Aide/Certified Medical Technician | Named in hair and nail care and wheelchair propulsion deficiencies |
| LPN B | Licensed Practical Nurse | Interviewed regarding care plans and hair/nail care |
| Shower Aide D | Interviewed regarding hair and nail care | |
| RN I | Registered Nurse | Interviewed regarding nail care |
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 8
Date: Nov 4, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for New Haven Care Center following a survey conducted on 11/04/2022.
Findings
The facility was found deficient in multiple areas including resident rights, safe and homelike environment, notice requirements before transfer/discharge, comprehensive care planning, ADL care, accident prevention, food safety, and hygiene practices. Several residents' care plans and documentation were incomplete or not properly followed.
Deficiencies (8)
F550 Resident Rights: Facility failed to maintain dignity of two residents by not changing wet and stained catheter dignity bags. Facility census was 60.
F584 Safe/Clean Environment: Facility failed to provide a comfortable and homelike environment on the 300 Hall with chipped paint, gouged walls, black marks, and odor. Facility census was 60.
F623 Notice Requirements Before Transfer/Discharge: Facility failed to provide written notice of discharge/transfer to residents or representatives for three residents. Facility census was 60.
F625 Notice of Bed Hold Policy: Facility failed to provide written bed hold policy information to residents or representatives at time of transfer for three residents. Facility census was 60.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to develop comprehensive care plans including measurable objectives and timeframes for six residents. Facility census was 60.
F677 ADL Care Provided for Dependent Residents: Facility failed to provide necessary ADL care for five residents. Facility census was 60.
F689 Free of Accident Hazards: Facility failed to ensure residents' environment was free of accident hazards and failed to properly supervise three residents in wheelchairs. Facility census was 60.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to maintain sanitary conditions in food preparation and service areas, including hand hygiene and cleaning of equipment. Facility census was 60.
Report Facts
Facility census: 60
Deficiencies cited: 8
Inspection Report
Life Safety
Census: 60
Capacity: 90
Deficiencies: 15
Date: Nov 4, 2022
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at New Haven Care Center.
Findings
The facility failed to meet several life safety code requirements including emergency lighting testing documentation, sprinkler system maintenance, smoke barrier integrity, smoking area safety, electrical receptacle testing, and oxygen storage safety. Deficiencies had the potential to affect all facility occupants.
Deficiencies (15)
K291 Emergency Lighting: Facility staff failed to maintain complete and verifiable documentation of 30-second monthly testing of all emergency lighting fixtures. An emergency light in the 400 hallway did not work when tested.
K353 Sprinkler System: Facility staff failed to maintain sprinklers free of corrosion, foreign materials, paint, and obstruction. Twelve escutcheon plates were not tight fitting to the ceiling or had unsealed gaps.
K372 Smoke Barrier: Facility staff failed to maintain one out of six smoke barrier walls free of openings to provide at least a half hour fire resistance rating. Five penetrations were identified and unsealed.
K741 Smoking Regulations: Facility staff failed to maintain the designated smoking area free from fire hazards and ensure proper disposal of cigarette waste. Accumulation of cigarette waste was observed near the smoking waste disposal container.
K914 Electrical Systems: Facility staff failed to assess electrical receptacles in resident care rooms annually for physical integrity, grounding circuit continuity, polarity, and retention force. Documentation of receptacle inspection was incomplete.
K918 Electrical Systems - Essential Electric System: Facility staff failed to provide documentation of annual diesel fuel testing and periodic maintenance of emergency generators. Remote manual stop buttons were missing or not properly installed.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to secure oxygen storage location against unauthorized entry and ensure combustible materials were not stored within five feet of oxygen cylinders.
A1132 Night-lights-Required Locations: Facility staff failed to provide night-lights in six common toilet rooms accessible to residents.
A1133 Electrical System-Test/Certify per Code: Facility failed to have a qualified electrician test and certify the entire electrical system in compliance with the National Electrical Code.
A2010 Oxygen Storage: Facility failed to comply with NFPA 99 requirements for oxygen storage including securing cylinders and maintaining storage areas free of combustible materials.
A2034 Sprinkler System-Test/Maintain: Facility failed to inspect, maintain, and test sprinkler systems in accordance with applicable requirements.
A2050 Emergency Lighting: Facility failed to conduct monthly and annual testing of emergency lighting as required by code.
A2054 Smoke Section Walls/Doors: Facility failed to maintain smoke section walls and doors with required fire ratings and separations.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Facility failed to provide ashtrays of noncombustible material and safe design in designated smoking areas.
A3030 Electrical Wiring & Equipment Maintained: Facility failed to maintain electrical wiring and equipment in compliance with NFPA 70 and NFPA 101 standards.
Report Facts
Census: 60
Total Capacity: 90
Number of nightlights missing: 6
Number of escutcheon plates not tight: 12
Number of smoke barrier penetrations: 5
Number of LED night lights replaced: 11
Inspection Report
Plan of Correction
Census: 4
Deficiencies: 1
Date: Nov 4, 2022
Visit Reason
The inspection was conducted to assess compliance with food preparation and sanitary conditions at New Haven Care Center, focusing on hand hygiene and food safety practices.
Findings
The facility failed to perform hand hygiene and change gloves as necessary during food preparation, risking cross-contamination. The food processor and preparation sink were not properly washed, rinsed, or sanitized between uses, potentially affecting all residents.
Deficiencies (1)
19 CSR 30-86.052(1) Food Prep & Services: Facility staff failed to perform hand hygiene and change gloves as necessary to prevent cross-contamination during food preparation. The food processor and food preparation sink were not properly washed, rinsed, or sanitized between uses.
Report Facts
Census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook K | Observed failing to change gloves and perform hand hygiene during food preparation | |
| Dietary Manager | DM | Observed failing to perform hand hygiene and interviewed regarding policies |
| Cook L | Observed failing to perform hand hygiene after glove removal and during food preparation | |
| Cook J | Observed failing to wash, rinse, or sanitize food preparation sink after use | |
| Administrator | Interviewed regarding staff hand hygiene policies and dishwashing expectations |
Inspection Report
Routine
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant 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: Oct 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant 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 practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
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
Annual Inspection
Census: 77
Deficiencies: 5
Date: Oct 3, 2019
Visit Reason
Annual inspection survey conducted at New Haven Care Center to assess compliance with federal regulations regarding resident safety, medication administration, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including accident hazards related to wheelchair safety, bed rail entrapment assessments, medication error rates exceeding 5%, improper medication storage and labeling, and infection prevention and control practices. Several residents' records lacked required assessments and consents, and staff failed to follow proper procedures in medication administration and infection control.
Deficiencies (5)
F689: Facility staff failed to properly propel three residents in wheelchairs and did not have a policy directing staff on wheelchair safety.
F700: Facility staff failed to complete entrapment assessments and obtain informed consent for use of bed rails for six residents, and did not follow manufacturer recommendations for bed rail installation and maintenance.
F759: Medication error rate exceeded 5%, with four errors out of 29 opportunities observed, and staff failed to ensure medication administration policies were followed.
F761: Facility failed to ensure medications were stored safely and effectively, with expired medications not removed and improper labeling of medications observed.
F880: Facility failed to establish and maintain an effective infection prevention and control program, including failure to follow isolation procedures and conduct annual program review.
Report Facts
Facility census: 77
Medication error opportunities observed: 29
Medication errors observed: 4
Medication error rate: 13.79
Residents reviewed for bed rail entrapment: 6
Residents reviewed for infection control: 18
Residents with deficient infection control care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse F | Registered Nurse | Named in interviews regarding wheelchair safety and medication administration |
| Certified Nursing Assistant K | Certified Nursing Assistant | Observed propelling residents in wheelchairs without footrests |
| Nursing Assistant G | Nursing Assistant | Observed propelling resident in wheelchair without foot pedals |
| Administrator | Administrator | Interviewed regarding wheelchair safety and medication administration policies |
| Director of Nursing | Director of Nursing | Interviewed regarding wheelchair safety and medication administration policies |
| Certified Medication Technician D | Certified Medication Technician | Observed administering medications and interviewed about medication expiration checks |
| Licensed Practical Nurse LPN I | Licensed Practical Nurse | Interviewed about medication expiration checks |
Inspection Report
Life Safety
Census: 77
Capacity: 90
Deficiencies: 4
Date: Oct 3, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and related provisions.
Findings
The facility failed to provide self-closing metal containers free of trash in designated smoking areas and did not conduct the required simulated resident evacuation with local fire or emergency services during the 12-month review period. Additionally, water temperatures in resident rooms exceeded the required range.
Deficiencies (4)
K741 Smoking Regulations: The facility failed to provide a self-closing metal container free of trash and debris in one of three designated smoking areas. The facility census was 77 with a capacity of 90.
A1104 Hot Water 105-120 Degrees F: Facility staff failed to maintain water temperatures between 105-120 degrees Fahrenheit in resident rooms. Observed temperatures exceeded 120°F.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Designated smoking areas lacked proper disposal of ashtrays as required by regulation. See K741 for details.
A2061 Fire Drill Requirements, Evacuation: Facility staff failed to conduct a simulated resident evacuation with local fire or emergency services during the 12-month review period. The census was 77 with a capacity of 90.
Report Facts
Facility census: 77
Facility capacity: 90
Water temperature degrees Fahrenheit: 123.5
Water temperature degrees Fahrenheit: 121.2
Water temperature degrees Fahrenheit: 123
Fire drills required annually: 12
Fire drills required quarterly: 1
Unannounced fire drills required: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharpe Administrator | Administrator | Signed report and plan of correction |
| Maintenance Director | Maintenance Director | Interviewed regarding smoking area and water temperature issues |
| Environmental Aide A | Interviewed regarding housekeeping of smoking area containers |
Inspection Report
Life Safety
Census: 74
Capacity: 90
Deficiencies: 5
Date: Nov 1, 2018
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness requirements and the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) including gas equipment qualifications and training, door alarm systems, fire drill/emergency preparedness plans, and employee orientation/continuing education.
Findings
The facility failed to establish a complete and comprehensive emergency preparedness program and did not provide continuing education regarding safety guidelines for medical gases and cylinders. The facility also lacked a complete, electrically-operated door alarm system audible at the nurses' station and did not meet fire drill and emergency preparedness plan requirements.
Deficiencies (5)
E001: The facility failed to establish a complete and comprehensive emergency preparedness program including policies for emergency medical and pharmaceutical supplies, waste and sewage disposal, staff and resident tracking, and use of volunteers during emergencies.
K926: Facility staff failed to provide continuing education on safety guidelines and usage requirements for medical gases and cylinders, posing a risk of fire and injury to residents and staff.
A1134: Facility failed to provide a complete, electrically-operated door alarm system audible at the nurses' station for all resident-accessible exterior doors, compromising resident protection against elopement and intruders.
A2058: Facility did not have a written fire drill and emergency preparedness plan meeting regulatory requirements and failed to provide an up-to-date copy to the local jurisdiction's emergency management director.
A4022: Facility failed to develop and offer an in-service orientation and continuing education program covering infection control, emergency protocols, and job responsibilities for all personnel.
Report Facts
Facility census: 74
Total capacity: 90
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 6
Date: Nov 1, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding comprehensive resident assessments, quarterly assessments, infection control, and other regulatory requirements.
Findings
The facility failed to complete comprehensive resident assessments timely and accurately for multiple sampled residents, failed to conduct quarterly assessments within required timeframes, and did not properly perform hand hygiene and infection control practices during medication passes. Several deficiencies were cited related to assessment completion, data transmission, and infection prevention.
Deficiencies (6)
F636 Comprehensive Assessments & Timing: The facility failed to complete periodic comprehensive assessments for four of ten sampled residents within required timeframes.
F638 Quarterly Assessment at Least Every 3 Months: The facility failed to ensure quarterly assessments were completed for three of ten sampled residents within 92 days.
F640 Encoding/Transmitting Resident Assessments: The facility failed to transmit required Minimum Data Set assessments for nine residents within required timeframes.
F880 Infection Prevention & Control: The facility failed to perform hand hygiene and/or wash hands to prevent infection during medication passes for ten residents.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection.
A4107 Clinical Records - assessment/interventions: The facility failed to ensure clinical records contained sufficient information reflecting initial and ongoing assessments and interventions.
Report Facts
Facility census: 80
Number of sampled residents with assessment deficiencies: 4
Number of sampled residents with quarterly assessment deficiencies: 3
Number of residents with data transmission deficiencies: 9
Number of residents with hand hygiene deficiencies: 10
Viewing
Loading inspection reports...
