Inspection Reports for
Nhc Healthcare, Maryland Heights
2920 FEE FEE RD, MARYLAND HEIGHTS, MO, 63043-1915
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
9.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
87% occupied
Based on a May 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 191
Deficiencies: 15
Date: May 6, 2024
Visit Reason
Annual survey conducted to assess compliance with federal regulations for nursing home facility NHC Healthcare, Maryland Heights.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring accident prevention and supervision, proper medication labeling and storage, and infection control during food service. Multiple deficiencies were cited related to housekeeping, resident safety, medication management, and staff practices.
Deficiencies (15)
F584 Safe Environment: The facility failed to provide a clean and homelike environment, with stained furniture and inadequate supplies such as toilet paper and hand towels in resident rooms and common areas.
F689 Free of Accident Hazards: The facility failed to ensure staff took appropriate precautions to prevent injury, including trip hazards on floors, improper chemical storage, and inadequate supervision of residents with wandering behavior.
F695 Respiratory/Tracheostomy Care: The facility failed to ensure respiratory services were provided consistent with professional standards, including proper use and cleaning of BiPAP machines for residents.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure medications were properly labeled, stored, and monitored for expiration dates, with expired medications found in medication rooms.
F770 Laboratory Services: The facility failed to obtain timely laboratory services and ensure proper quality and timeliness of lab results for residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure proper hand hygiene during meal service and maintain infection control practices in the dining room.
A3038 Furniture/Equip, Provide Comfort & Safety: The facility failed to maintain furniture and equipment in good condition, with broken and heavily soiled items.
A4062 Medication Labeling: The facility failed to label all prescription and over-the-counter medications in accordance with pharmacy standards and regulations.
A4074 Protective Oversight: The facility failed to provide adequate protective oversight for residents, including supervision and assistance consistent with their needs.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions and nursing practice standards.
A4092 Equip Sanitized/Stored, Prevent Contamination: The facility failed to keep utensils and equipment sanitized, sterilized, or stored to prevent contamination.
A6005 Toxic Material Storage: The facility failed to properly store poisonous or toxic materials in locked cabinets separate from residents' access.
A6007 Use of Toxic Materials: The facility failed to use toxic materials in a manner consistent with manufacturer labeling and safety requirements.
A6041 Toilet Room Requirements: The facility failed to provide toilet rooms that are conveniently located, accessible, and completely enclosed.
A7002 Wash Hands/Arms & Clean Fingernails: The facility failed to ensure employees thoroughly washed hands and kept fingernails clean before and during work.
Report Facts
Sample size: 35
Census: 191
Residents with wandering behavior: 20
Residents sampled for BiPAP machines: 3
Medication rooms checked: 4
Medication carts checked: 7
Inspection Report
Routine
Census: 191
Deficiencies: 6
Date: May 6, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations related to resident environment cleanliness, accident prevention, respiratory care, medication storage, laboratory services, and infection control during meal service.
Findings
The facility was found deficient in maintaining a clean and homelike environment, ensuring accident hazards were minimized, providing proper respiratory care, storing medications correctly, ensuring quality laboratory services, and enforcing hand hygiene during meal service. Specific issues included soiled furniture, missing toilet paper and hand towels, missing toilet tank lids, improper chemical storage, unsafe wheelchair assistance, wet floors without adequate signage, expired or undated medications, improper cleaning of BiPAP equipment, and failure of staff to perform hand hygiene during meal service.
Deficiencies (6)
Failed to provide a clean and homelike environment; furniture in common areas was visibly soiled and stained, and resident rooms lacked adequate toilet paper and hand towels.
Failed to ensure accident hazards were minimized; unsafe wheelchair assistance, trip hazards in shower room, improper chemical storage accessible to residents, and wet floors without adequate signage.
Failed to provide respiratory care consistent with professional standards; no physician orders for cleaning BiPAP machine, mask, and tubing, and staff unaware of cleaning requirements.
Failed to ensure medications were within expiration dates or properly labeled; multiple medication rooms and carts contained undated or expired medications.
Failed to ensure quality laboratory services; blood glucose test strips were not dated upon opening as required.
Failed to ensure staff performed hand hygiene during meal service; multiple observations showed staff handling food, residents, and equipment without washing or sanitizing hands.
Report Facts
Residents sampled: 35
Facility census: 191
Residents with wandering behavior: 20
Residents on Meadow unit: 27
Falls documented: 9
Wet floor signs: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Named in unsafe wheelchair assistance and hand hygiene observations |
| Housekeeping Supervisor | Named in furniture cleanliness and chemical storage findings | |
| Administrator | Named in furniture cleanliness, accident prevention, and hand hygiene expectations | |
| CNA S | Certified Nurse Aide | Named in observations and interviews regarding toileting and chemical storage |
| LPN J | Licensed Practical Nurse | Named in toileting, chemical storage, and accident prevention findings |
| Director of Nurses | DON | Named in respiratory care and accident prevention findings |
| CNA Q | Certified Nurse Aide | Named in toileting and chemical storage findings |
| LPN G | Licensed Practical Nurse | Named in respiratory care findings |
| RN A | Registered Nurse | Named in respiratory care findings |
| CMT I | Certified Medication Technician | Named in hand hygiene during meal service observations |
| CNA U | Certified Nurse Aide | Named in hand hygiene during meal service observations |
| CNA V | Certified Nurse Aide | Named in hand hygiene during meal service observations |
| CNA E | Certified Nurse Aide | Named in hand hygiene during meal service observations |
| CNA D | Certified Nurse Aide | Named in hand hygiene during meal service observations |
| Dietary Manager | Named in hand hygiene expectations | |
| Administrator | Named in hand hygiene expectations | |
| LPN P | Licensed Practical Nurse | Named in medication storage and laboratory services findings |
Inspection Report
Life Safety
Census: 91
Capacity: 220
Deficiencies: 5
Date: May 1, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code for a healthcare facility.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including door locking mechanisms, emergency lighting, sprinkler system maintenance, smoke barrier integrity, and fire drill documentation. Multiple deficiencies were identified that could affect resident safety.
Deficiencies (5)
K222 Egress Doors: Doors in required means of egress were equipped with locking devices that impeded emergency egress and did not release upon fire alarm activation, trapping occupants inside bathrooms.
K291 Emergency Lighting: The facility failed to test emergency lighting monthly as required, with no documented evidence of testing for February and April 2024.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system properly, including excess ice and lint buildup on sprinkler heads and missing weekly inspections of dry system gauges.
K372 Smoke Barrier: The facility failed to ensure smoke barriers were continuous and properly sealed, with unsealed gaps and penetrations observed in multiple locations.
K712 Fire Drills: The facility failed to conduct fire drills at least quarterly on each shift as required, with missing documentation for the Day Shift fire drill during the fourth quarter of 2023.
Report Facts
Occupied beds: 191
Total licensed beds: 220
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed findings related to locking devices, emergency lighting, sprinkler system, smoke barriers, and fire drills |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2023
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted as a complaint investigation on 05/03/2023.
Complaint Details
This complaint investigation involved a COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey. No deficiencies were cited.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited as a result of this complaint investigation. The facility was also found to be in compliance with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Deficiencies: 0
Date: May 3, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of a nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Census: 190
Deficiencies: 9
Date: Oct 3, 2022
Visit Reason
The document is a plan of correction submitted by NHC Healthcare, Maryland Heights following a deficiency statement dated October 3, 2022.
Findings
The facility was found deficient in multiple areas including failure to perform annual review of advance directives, incomplete personal inventory sheets, incomplete controlled substance inventory sheets, improper storage of drugs and biologicals, and incomplete COVID-19 vaccination compliance among staff.
Deficiencies (9)
F578 Advance Directive Requirements. The facility failed to perform an annual review of code status and advance directives for sampled residents.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to ensure completion of personal inventory sheets for residents and proper investigation of missing items.
F755 Pharmacy Services. The facility failed to complete controlled substance inventory sheets accurately and maintain accountability of controlled substances.
F761 Label/Store Drugs and Biologicals. The facility failed to store narcotic medications in double locked compartments and maintain secure medication storage.
F888 COVID-19 Vaccination of Facility Staff. The facility failed to ensure all staff were fully vaccinated or had approved exemptions against COVID-19.
A4065 Schedule II Meds-Storage. The facility failed to store Schedule II medications under double lock separately from noncontrolled medication.
A4071 Controlled Substance Reconcile/Record. The facility failed to establish a system of records for receipt and disposition of all controlled drugs to enable accurate reconciliation.
A8010 Advance Directive Requirements. The facility failed to inform residents or their representatives about advance directives and failed to review directives annually.
A8037 Personal Clothing/Possessions. The facility failed to maintain a record of personal items accompanying residents upon admission or during their stay.
Report Facts
Census: 190
Sample size: 35
Staff members: 285
Vaccination rate: 98.9
Missing narcotic count sheets: 3
Inspection Report
Life Safety
Census: 190
Capacity: 220
Deficiencies: 3
Date: Oct 3, 2022
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 reference documents.
Findings
The facility failed to maintain exits free of obstruction due to locked gates without proper staff training on emergency opening. Additionally, the facility did not maintain smoke barrier walls with the required fire resistance rating and failed to ensure annual testing of non-hospital grade electrical receptacles in patient sleeping areas.
Deficiencies (3)
K211 Means of Egress - The facility failed to maintain exits free of obstruction when gates were locked without training staff on emergency opening. This posed a risk to residents, staff, and visitors during emergencies.
K372 Subdivision of Building Spaces - The facility failed to maintain smoke barrier walls with the required 1/2-hour fire resistance rating in multiple locations. This deficiency affected residents in 10 of 13 smoke compartments.
K914 Electrical Systems - The facility failed to ensure annual testing of non-hospital grade electrical receptacles in patient sleeping areas. This deficiency had the potential to affect all residents.
Report Facts
Facility capacity: 220
Resident census: 190
Inspection Report
Annual Inspection
Census: 190
Deficiencies: 5
Date: Oct 3, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident rights, medication management, personal belongings inventory, and staff vaccination status.
Findings
The facility was found deficient in multiple areas including failure to perform annual reviews of residents' advanced directives, incomplete personal inventory sheets for residents' belongings, improper controlled substance inventory and storage, and incomplete staff COVID-19 vaccination compliance.
Deficiencies (5)
Failed to perform an annual review of code status and advanced directives for eight of 35 sampled residents.
Failed to ensure personal inventory sheets were completed or updated for five residents to track personal belongings.
Failed to complete controlled substance inventory sheets appropriately, with multiple blanks and missing signatures on narcotic count sheets.
Failed to store narcotic medications in double locked compartments and pre-pulled medications were stored unlabeled in medication carts.
Failed to ensure all staff were fully vaccinated against COVID-19 or had approved exemptions; three staff members were not fully vaccinated.
Report Facts
Residents sampled: 35
Facility census: 190
Staff members: 285
Staff not fully vaccinated: 3
Blank opportunities on controlled substance sheets: 85
Opportunities with only one staff initial: 62
Opportunities with two staff initials but no count: 4
Narcotic counts with no initials: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker S | Social Worker | Interviewed regarding advanced directives process and resident code status |
| Social Worker T | Social Worker | Interviewed regarding missing resident belongings and inventory process |
| Social Services Manager I | Social Services Manager | Interviewed regarding personal inventory sheets and missing items |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding controlled substance inventory and staff vaccination policy |
| Administrator | Administrator | Interviewed regarding code status review and staff vaccination policy |
| Staff AA | Staff member not fully vaccinated against COVID-19 | |
| Staff BB | Staff member not fully vaccinated against COVID-19 | |
| Staff CC | Staff member not fully vaccinated against COVID-19 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 22, 2021
Visit Reason
The inspection was conducted as a COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey from 04/20/2021 through 04/22/2021.
Complaint Details
This was a complaint investigation related to COVID-19 infection control and emergency preparedness. No deficiencies were cited.
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. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey from 01/22/2021 through 02/09/2021 to assess compliance with CMS and CDC recommended practices and emergency preparedness regulations.
Complaint Details
This was a complaint investigation related to COVID-19 infection control and emergency preparedness. No deficiencies were cited.
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. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 01/05/2021 through 01/06/2021 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
Routine
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with CMS 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: Nov 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted from 11/12/2020 through 11/17/2020 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 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 26, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with the relevant COVID-19 emergency preparedness and infection control regulations.
Inspection Report
Abbreviated Survey
Census: 151
Deficiencies: 6
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from 08/03/2020 through 08/05/2020 to assess compliance with infection prevention and control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness but failed to maintain an infection control program during the COVID-19 pandemic. Deficiencies were noted in hand hygiene, cleaning and disinfecting procedures, use of personal protective equipment (PPE), and infection control practices during dressing changes and blood pressure monitoring.
Deficiencies (6)
F880 Infection Prevention & Control: The facility failed to ensure hand hygiene was performed appropriately, failed to clean multi-use dressing equipment and supplies properly, failed to remove PPE prior to leaving resident rooms, and failed to wear appropriate PPE while preparing silverware for resident use. The census was 151.
F880 Infection Prevention & Control: A Registered Nurse failed to clean scissors after cutting dressings, did not wash hands between glove changes, and used the same scissors on clean and soiled supplies during a dressing change for Resident #3.
F880 Infection Prevention & Control: A Registered Nurse failed to clean the blood pressure machine and cuff after use before recording resident data and plugging in the machine.
F880 Infection Prevention & Control: A Certified Nurse Aide disposed of isolation gown items improperly and did not know the location for disposal of PPE.
F880 Infection Prevention & Control: Staff failed to wear facemasks consistently; a Dietary Aide was observed not wearing a mask until prompted, and the Administrator stated staff should wear masks while in the building and rolling silverware.
A4085 Infection Control/Communicable Disease: The facility failed to meet infection control regulations requiring reporting communicable diseases to the state within seven days.
Report Facts
Census: 151
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in findings related to improper dressing change and blood pressure machine cleaning |
| CNA C | Certified Nurse Aide | Named in findings related to improper PPE disposal and hand hygiene |
| Administrator | Administrator | Provided statements regarding mask wearing and infection control policies |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control practices |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding infection control practices |
| DA A | Dietary Aide | Observed not wearing a facemask until prompted |
| Dietary Manager | Dietary Manager | Provided statements regarding mask wearing |
Inspection Report
Routine
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 06/11/2020 through 06/16/2020 to assess compliance with CMS and CDC recommended practices for COVID-19.
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
Complaint Investigation
Census: 189
Deficiencies: 6
Date: Apr 22, 2019
Visit Reason
The inspection was conducted due to complaints regarding failure to report and investigate resident-to-resident abuse, failure to investigate bruises of unknown origin, inadequate pressure ulcer care, medication errors, and failure to manage resident pain appropriately.
Complaint Details
The complaint investigation focused on allegations of failure to report and investigate resident-to-resident abuse, failure to investigate bruises of unknown origin, inadequate pressure ulcer care, medication errors, and failure to manage resident pain appropriately. The investigation substantiated multiple deficiencies in these areas.
Findings
The facility failed to timely report a resident-to-resident altercation to the Department of Health and Senior Services, failed to thoroughly investigate incidents of abuse and bruises of unknown source, failed to document and manage pressure ulcers properly, failed to administer IV antibiotics correctly, and failed to address a resident's complaints of pain related to shingles.
Deficiencies (6)
Failure to timely report a resident-to-resident altercation to the Department of Health and Senior Services.
Failure to thoroughly investigate incidents of resident-to-resident abuse and bruises of unknown source.
Failure to notify physician timely and document thoroughly regarding a resident's red/inflamed skin and pressure ulcer care.
Failure to document and assess pressure ulcers thoroughly and obtain physician orders timely.
Failure to address resident's complaints of pain related to shingles and failure to provide appropriate pain management.
Failure to ensure correct dose and infusion rate of intravenous antibiotic for a resident.
Report Facts
Census: 189
Deficiencies cited: 6
Pressure ulcer size: 2.5
Pressure ulcer size: 2
Pressure ulcer size: 1
Pressure ulcer size: 1
IV antibiotic dose: 2
IV antibiotic infusion rate: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Registered Nurse | Involved in IV antibiotic medication error for Resident #476 |
| Nurse G | Registered Nurse | Completed skin assessment on Resident #129 but failed to document wound description and measurements |
| CNA L | Certified Nurse Aide | Witnessed resident-to-resident altercation and provided statement |
| Nurse M | Registered Nurse | Failed to report resident-to-resident altercation to administrator and Director of Nurses |
| DON | Director of Nurses | Interviewed regarding failures in reporting, investigation, wound care, and medication administration |
Inspection Report
Complaint Investigation
Census: 189
Deficiencies: 6
Date: Apr 22, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving resident-to-resident altercations and injuries at NHC Healthcare, Maryland Heights.
Complaint Details
The investigation was triggered by allegations of abuse involving resident-to-resident altercations, including slapping and hitting. The complaint was substantiated as the facility failed to report and investigate these incidents properly.
Findings
The facility failed to follow its policy for reporting and investigating alleged violations of abuse and neglect. There were multiple incidents of resident-to-resident altercations resulting in injuries, and the facility did not thoroughly investigate or report these incidents as required. Additionally, deficiencies were found related to quality of care, skin integrity, pain management, and medication errors.
Deficiencies (6)
F609: The facility failed to report alleged violations of abuse and neglect immediately and did not thoroughly investigate resident-to-resident altercations and injuries.
F610: The facility failed to have evidence that all alleged violations were thoroughly investigated and to prevent further potential abuse during investigations.
F684: The facility failed to ensure residents received treatment and care to prevent pressure ulcers and did not maintain timely documentation and notification to physicians.
F686: The facility failed to document a thorough description and assessment of pressure ulcers and to ensure staff updated wound care documentation and treatment plans.
F697: The facility failed to adequately manage residents' pain and address complaints of pain in a timely and effective manner.
F760: The facility failed to ensure residents were free of significant medication errors, including incorrect antibiotic infusion rates and medication administration errors.
Report Facts
Census: 189
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse M | Mentioned in relation to failure to report incident to administrator or Director of Nurses. | |
| Nurse K | Mentioned as being at the medication cart during the incident and not witnessing it. | |
| Nurse L | Certified Nurse Aide who intervened during resident altercation and was involved in incident documentation. | |
| Director of Nurses (DON) | Director of Nurses | Mentioned regarding expectations for reporting resident altercations and investigations. |
| Nurse G | Completed skin assessment and documented wound care. | |
| Nurse D | Provided incontinence care and wound care documentation. | |
| Nurse A | Reviewed for medication administration and orientation. |
Inspection Report
Life Safety
Census: 189
Capacity: 220
Deficiencies: 2
Date: Apr 22, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically focusing on the sprinkler system maintenance and testing.
Findings
The facility failed to maintain the fire sprinkler system according to NFPA code, with observations of sprinkler heads showing paint, dust, and debris accumulation. The deficiency had the potential to affect all residents and staff in two of 13 smoke compartments.
Deficiencies (2)
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the fire sprinkler system to NFPA code, including sprinkler heads with paint and accumulation of dust and debris.
A2034 Sprinkler System-Test/Maintain: Facilities with sprinkler systems installed prior to August 28, 2007, must inspect, maintain, and test these systems as required. This regulation was not met as evidenced by the deficiency at K353.
Report Facts
Facility capacity: 220
Census: 189
Number of sprinkler heads observed: 5
Inspection Report
Plan of Correction
Census: 189
Deficiencies: 2
Date: Jun 4, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to professional standards of care, specifically regarding comprehensive care plans and medication management.
Findings
The facility failed to document appropriate neurological assessments after a resident's head injury and did not ensure staff checked emergency medication stock or notified physicians when medications were missed. Deficiencies were noted in care planning, documentation, and medication administration.
Deficiencies (2)
F658: The facility failed to document timely neurological checks after a resident's head injury and did not ensure staff checked emergency stock of Heparin or notified the physician when doses were missed or refused.
A4074: Nursing care did not meet acceptable standards consistent with resident condition, as evidenced by the deficiency cited at F658.
Report Facts
Resident census: 189
Heparin dose: 5000
Fall reviews: 6
Inspection Report
Life Safety
Census: 189
Capacity: 220
Deficiencies: 4
Date: Jun 4, 2018
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 maintain two dining room exit passageways free of obstructions and did not maintain posted evacuation maps with current information on four wings. The facility also had door locks that did not meet regulatory requirements and evacuation diagrams that were not accessible or posted as required.
Deficiencies (4)
K211 Means of Egress - General: The facility failed to maintain two dining room exit passageways readily accessible for exiting in case of emergency, potentially delaying evacuation of residents.
K711 Evacuation and Relocation Plan: The facility failed to maintain posted evacuation maps on four wings with current information regarding exits, impacting evacuation safety.
A2041 Door Locks: Door locks did not meet requirements to be opened from inside by turning a knob or operating a simple device, violating NFPA 101 standards.
A2060 Plan Accessible/Evacuation Diagram Posted: The written evacuation plan and evacuation diagrams were not accessible or posted on each floor as required by regulation.
Report Facts
Facility capacity: 220
Resident census: 189
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