Inspection Reports for
Nixa Nursing &Amp; Rehab
1104 NORTH MAIN ST, NIXA, MO, 65714-9316
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
79% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Date: Jul 23, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report and investigate an allegation of misappropriation of property involving a resident's embroidery scissors.
Complaint Details
The complaint involved Resident #122 reporting that an aide took his/her embroidery scissors. The facility failed to report this allegation to the state within 24 hours and did not document a timely investigation. Interviews with staff including the Social Service Director, Administrator, and Director of Nursing confirmed these failures.
Findings
The facility failed to report an allegation of misappropriation to the State Survey Agency within the required 24-hour timeframe and failed to complete a timely and thorough investigation of the allegation. Staff interviews confirmed lack of reporting and investigation documentation. The facility census was 65.
Deficiencies (2)
Failed to timely report allegations of possible misappropriation to the State Survey Agency within the required 24-hour timeframe.
Failed to complete investigations of all allegations of misappropriation, specifically failing to investigate one resident's allegation of misappropriation.
Report Facts
Facility census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director (SSD) | Interviewed regarding reporting and investigation of misappropriation allegation |
| Administrator | Administrator | Interviewed regarding reporting and investigation of misappropriation allegation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding reporting and investigation of misappropriation allegation |
| Certified Nurse Aide A | Certified Nurse Aide (CNA) | Interviewed about reporting procedures for misappropriation |
| Certified Medical Technician B | Certified Medical Technician (CMT) | Interviewed about reporting procedures for misappropriation |
Inspection Report
Plan of Correction
Census: 65
Deficiencies: 3
Date: Jul 23, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or misappropriation involving a resident's missing embroidery scissors and the facility's failure to report and investigate these allegations properly.
Complaint Details
The investigation was triggered by a complaint regarding missing embroidery scissors belonging to Resident #122. The complaint was substantiated as the facility failed to report and investigate the allegation properly.
Findings
The facility failed to report allegations of misappropriation within the required timeframes and did not complete thorough investigations of all allegations. Additionally, the facility failed to ensure residents' choices regarding cardiopulmonary resuscitation (CPR) were consistently and clearly documented.
Deficiencies (3)
F609: The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or misappropriation were reported immediately or within required timeframes, including failure to report missing resident property within 24 hours.
F610: The facility failed to complete thorough investigations of all allegations of misappropriation and did not report investigation results to appropriate officials within required timeframes.
F678: The facility failed to ensure each resident's choice regarding cardiopulmonary resuscitation (CPR) was consistently and clearly documented in the medical record.
Report Facts
Facility census: 65
Residents sampled for CPR documentation: 16
Residents with inconsistent CPR documentation: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator R. Hutcheson | Administrator | Named in findings related to failure to report and investigate allegations |
| Director of Nursing (DON) | Involved in investigation and reporting of allegations | |
| Social Service Director (SSD) | Involved in investigation and reporting of allegations | |
| Certified Nurse Aide (CNA) A | Certified Nurse Aide | Reported responsibility for investigating allegations of misappropriation |
| Certified Medical Technician (CMT) B | Certified Medical Technician | Reported procedures for reporting abuse, neglect, or misappropriation |
| Certified Medication Tech (CMT) C | Certified Medication Technician | Reported involvement in investigation of allegations |
| Housekeeping Supervisor | Reported staff notification about missing scissors | |
| Activities Director | Reported resident activities and staff notifications | |
| Licensed Practical Nurse (LPN) E | Licensed Practical Nurse | Reported on residents' advanced health care directives and code status |
Inspection Report
Annual Inspection
Census: 65
Capacity: 82
Deficiencies: 14
Date: Jul 23, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including medical documentation, life safety, fire safety, and facility maintenance.
Findings
The facility was found deficient in maintaining a system for medical documentation backup during emergencies, maintaining fire safety features such as sprinkler systems, smoke barriers, and range hood cleanliness, and proper storage and separation of oxygen cylinders. Deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (14)
E023 Policies and procedures. The facility failed to maintain a system of medical documentation backup during electronic health record downtime, risking access to resident physician orders for all 65 residents.
K161 Building Construction Type and Height. The facility failed to maintain the one-hour fire rating of ceilings with unsealed penetrations between the attic and areas below, risking smoke passage affecting all residents and staff.
K324 Cooking Facilities. The facility failed to maintain the range hood, which had excess grease and dust accumulation, increasing the risk of grease fire affecting all residents and staff.
K351 Sprinkler System - Installation. The facility failed to maintain the sprinkler system air compressors properly, risking sprinkler system failure in a fire event.
K372 Subdivision of Building Spaces - Smoke Barrier Construction. The facility had unsealed penetrations in smoke barrier walls, risking smoke passage affecting 46 residents in smoke sections.
K521 HVAC. The facility failed to ensure bathroom ventilation was properly vented outside and lacked fire dampers in fan ducts, risking fire and smoke spread.
K923 Gas Equipment - Cylinder and Container Storage. The facility failed to separate full and empty oxygen cylinders properly, risking oxygen storage hazards affecting all residents and staff.
A1102 Ventilation Requirements. Ventilation requirements were not met as referenced in K521.
A2010 Oxygen Storage. Oxygen storage requirements were not met as referenced in K923.
A2017 Range Hood Certification. The facility failed to maintain the range hood and extinguishing system as referenced in K324.
A2034 Sprinkler System-Test/Maintain. The facility failed to maintain the sprinkler system as referenced in K351.
A2054 Smoke Section Walls/Doors. Smoke section walls and doors requirements were not met as referenced in K372.
A2058 Fire Drill/Emergency Preparedness - Plans. The facility failed to document required annual fire department consultation, risking inadequate fire and evacuation preparedness.
A3001 Substantially Constructed/Maintained. The facility failed to maintain the physical plant in accordance with construction standards as referenced in K161.
Report Facts
Facility census: 65
Facility total capacity: 82
Inspection date: Jul 23, 2024
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 4
Date: Sep 16, 2022
Visit Reason
The inspection was conducted to evaluate compliance with nurse staffing information posting requirements and medication error rates, including insulin administration practices, at Nixa Nursing & Rehab.
Findings
The facility failed to post daily nurse staffing information in a clear, readable, and accessible manner for residents and visitors. The facility also failed to maintain medication error rates below 5%, with documented insulin administration errors for three residents.
Deficiencies (4)
F732 Nurse Staffing Information. The facility failed to post daily nurse staffing information in a clear and readable format in a prominent place accessible to residents and visitors.
F759 Medication Errors. The facility failed to ensure medication error rates were less than 5%, with three errors out of 26 opportunities related to insulin pen priming and administration for three residents.
F760 Residents Free of Significant Medication Errors. The facility failed to ensure residents were free of significant medication errors during insulin administration for three residents during medication pass observations.
A4055 Safe/Effective Medication System. The facility failed to maintain a safe and effective medication system as evidenced by deficiencies F759 and F760.
Report Facts
Facility census: 62
Medication error rate: 11.53
Medication opportunities: 26
Medication errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding nurse staffing posting and insulin administration procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding nurse staffing schedule and insulin administration instructions |
| Administrator | Administrator | Interviewed regarding nurse staffing posting during remodeling and insulin administration procedures |
| Licensed Practical Nurse B | Licensed Practical Nurse | Observed preparing and administering insulin during medication pass |
| Licensed Practical Nurse A | Licensed Practical Nurse | Observed administering insulin during medication pass |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding insulin administration procedures |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed regarding insulin pen priming and dosing procedures |
Inspection Report
Routine
Census: 62
Deficiencies: 3
Date: Sep 16, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including posting of nurse staffing information and medication administration practices.
Findings
The facility failed to post daily nurse staffing information in a publicly accessible manner and had medication administration errors related to insulin pen use, including failure to prime pens and failure to ensure meals were provided within 30 minutes of insulin administration for three residents.
Deficiencies (3)
Failure to post daily nurse staffing information in a clear and readable format accessible to residents and visitors.
Medication error rate exceeded 5% due to failure to prime insulin pens and failure to ensure full dose administration and timely meal intake for three residents.
Failure to ensure residents were free from significant medication errors related to insulin pen administration.
Report Facts
Facility census: 62
Medication error rate: 11.53
Medication errors: 3
Insulin doses: 1
Insulin doses: 8
Insulin doses: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Observed administering insulin without priming pen |
| Licensed Practical Nurse B | Licensed Practical Nurse | Described insulin pen administration process |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed about nurse staffing posting and insulin pen administration |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed about insulin pen administration |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed about insulin pen priming importance |
| Director of Nursing | Director of Nursing | Provided instructions on insulin pen administration and nurse staffing posting |
| Administrator | Administrator | Agreed with DON instructions and explained nurse staffing posting status |
Inspection Report
Life Safety
Census: 62
Capacity: 82
Deficiencies: 6
Date: Sep 16, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related regulations, focusing on emergency preparedness, egress doors, corridor doors, smoke barriers, electrical systems, and other safety features.
Findings
The facility failed to meet several Life Safety Code requirements including proper signage on delayed-egress doors, maintenance of smoke resistive properties of corridor doors and smoke barrier walls, and ensuring electrical outlets near water sources had ground fault circuit interrupters. Deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (6)
K222 Egress Doors: The facility failed to ensure three egress doors with 15-second delayed-egress locking had appropriate signage adjacent to the release device in the direction of egress.
K363 Corridor Doors: The facility failed to maintain the smoke resistive properties of corridor doors by allowing gaps at the top of doors, potentially allowing smoke passage during a fire.
K372 Smoke Barrier Walls: The facility failed to maintain smoke resistive properties of smoke barrier walls due to unsealed penetrations, risking smoke passage between compartments.
K912 Electrical Systems - Receptacles: The facility failed to ensure all electrical outlets near water sources had ground fault circuit interrupters (GFCI), risking electrocution hazards.
K918 Electrical Systems - Essential Electric System: The facility failed to complete a required four-hour load test of the emergency generator within the past three years, risking generator failure during power outages.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain proper use of power strips and extension cords, risking fire or electrical injury.
Report Facts
Facility capacity: 82
Resident census: 62
Delayed-egress door signage deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Responsible for ensuring egress doors have appropriate signage and checking corridor doors and smoke barrier walls | |
| Administrator | Responsible for ensuring appropriate signage on doors and maintenance of smoke barrier walls | |
| Maintenance Supervisor | Responsible for checking doors monthly and maintaining smoke barrier walls |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 5, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Report Facts
Regulatory compliance references: 42
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation to assess compliance with relevant CMS and CDC guidelines.
Complaint Details
This was a complaint investigation related to COVID-19 preparedness and infection control. No deficiencies were cited, indicating the complaint was not substantiated.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted 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 practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted 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 practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's 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 infection control practices for COVID-19.
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 3
Date: Sep 26, 2019
Visit Reason
The document is a Plan of Correction submitted by Nixa Nursing & Rehab following a survey conducted on 09/26/2019. The plan addresses deficiencies cited during the inspection related to resident transfer/discharge notices, bed hold policies, and infection prevention and control.
Findings
The facility failed to notify residents and their representatives in writing of transfers or discharges, failed to provide bed hold policy information at transfer, and did not properly disinfect glucometers used for diabetic residents. The facility census was 47 at the time of the survey.
Deficiencies (3)
F623: The facility failed to notify residents and their representatives in writing of transfers or discharges, including providing required notices to the ombudsman. Two residents were affected.
F625: The facility failed to inform residents and families of the bed hold policy at the time of transfer to the hospital for two residents. The facility census was 47.
F880: The facility failed to properly disinfect glucometers used for residents with diabetes, risking transmission of infection among residents.
Report Facts
Facility census: 47
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lydia Witt | Administrator | Signed the Plan of Correction and is named as responsible for monitoring compliance |
| LPN A | Licensed Practical Nurse | Observed performing blood glucose tests and improperly disinfecting glucometers |
| LPN B | Licensed Practical Nurse | Interviewed regarding glucometer cleaning procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding discharge and transfer paperwork procedures |
| Social Services Director | Social Services Director | Interviewed regarding transfer notice procedures and documentation |
Inspection Report
Routine
Census: 47
Deficiencies: 3
Date: Sep 26, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident transfer notifications, bed hold policies, and infection control practices related to glucometer disinfection.
Findings
The facility failed to notify residents and their representatives in writing about hospital transfers and failed to notify the ombudsman for two residents. The facility also failed to inform residents and families about bed hold policies at the time of hospital transfer. Additionally, the facility did not properly disinfect glucometers between uses, risking infection transmission.
Deficiencies (3)
Failed to notify resident, representative, and ombudsman in writing of hospital transfer for two residents.
Failed to inform residents and representatives in writing about bed hold policies at time of hospital transfer for two residents.
Failed to properly disinfect glucometers between uses, risking infection transmission among residents with diabetes.
Report Facts
Residents affected: 2
Residents affected: 3
Facility census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in glucometer disinfection deficiency observations |
| LPN B | Licensed Practical Nurse | Interviewed regarding glucometer cleaning procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding transfer paperwork and glucometer cleaning expectations |
| Social Services Director | Social Services Director | Interviewed regarding transfer notice procedures and record keeping |
Inspection Report
Life Safety
Census: 47
Capacity: 82
Deficiencies: 4
Date: Sep 24, 2019
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, focusing on building construction type, sprinkler system maintenance, and fire safety.
Findings
The facility failed to maintain the integrity of the building construction by not maintaining the one-hour fire rating of the ceilings and had unsealed penetrations that could allow smoke passage. The sprinkler system heads were obstructed by fuzzy buildup, paint spatter, and plastic clips, which could impair their function in a fire.
Deficiencies (4)
K161: The facility failed to maintain the one-hour fire rating of the ceilings due to unsealed penetrations between the attic and areas below, potentially allowing smoke to pass and affecting residents, staff, and visitors.
K353: The facility failed to keep sprinkler heads free from obstruction by fuzzy buildup, paint spatter, and plastic clips, which could delay fire response and affect safety.
A2034: Facilities with sprinkler systems installed prior to August 28, 2007, must inspect, maintain, and test these systems per regulations; this requirement was not met as referenced in K353.
A3001: The building was not substantially constructed and maintained in good repair according to construction standards, as referenced in K161.
Report Facts
Facility capacity: 82
Resident census: 47
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 7
Date: Aug 13, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, and mistreatment involving multiple residents, as well as failure to report incidents and injuries in a timely manner.
Complaint Details
Complaint # MO00145841 involved allegations of abuse, neglect, and mistreatment of residents. The complaint was substantiated as the facility failed to report and investigate incidents timely and adequately. The facility was required to take corrective action and submit evidence of compliance.
Findings
The facility failed to provide reasonable accommodations for a resident's wheelchair needs, failed to report injuries and allegations of abuse within required timeframes, and failed to properly investigate and document incidents of abuse and resident injuries. Additionally, the facility did not timely assess and treat a resident's pressure ulcers.
Deficiencies (7)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to assess, identify, and provide an appropriate fitting wheelchair with proper footrest for a resident, causing discomfort and injury.
F609 Reporting of Alleged Violations: The facility failed to report injuries of unknown origin and allegations of abuse within required timeframes and failed to investigate incidents properly.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate allegations of abuse and mistreatment and did not report findings appropriately.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to timely assess and treat a resident's Stage II pressure ulcers and provide consistent skin care.
A4077 Reposition Every 2 hr/Maintain Body Alignment: Residents did not have their positions changed at least every two hours to maintain good body alignment.
A4082 Pressure Sore Prevention/Treatment: The facility failed to provide adequate treatment for pressure sores as required.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents.
Report Facts
Facility census: 62
Sample size: 17
Deficiencies cited: 7
Inspection Report
Annual Inspection
Census: 62
Capacity: 82
Deficiencies: 4
Date: Aug 13, 2018
Visit Reason
Annual recertification survey to assess compliance with the Life Safety Code and other regulatory requirements.
Findings
The facility failed to meet provisions of the 2012 Life Safety Code related to cooking facilities and smoke barrier doors. Deficiencies included gaps in the kitchen exhaust hood filters and smoke barrier doors with visible gaps exceeding allowed limits, posing fire and smoke safety risks.
Deficiencies (4)
K324 Cooking Facilities: The facility failed to maintain the grease laden vapor trapping properties of the kitchen exhaust hood by allowing gaps to remain between the filters and for a filter to remain broken, creating a fire hazard.
K374 Smoke Barrier Doors: The facility failed to maintain the smoke resistive properties of the smoke barrier doors, which had visible gaps greater than 1/8 inch between meeting edges, risking smoke passage during a fire.
A2017 Range Hood Certification: The facility did not provide a range hood extinguishing system certified at least twice annually as required by NFPA 96.
A2054 Smoke Section Walls/Doors: The facility did not meet requirements for smoke section separation by one-hour fire-rated walls and self-closing doors as required by regulation.
Report Facts
Facility capacity: 82
Census: 62
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