Inspection Reports for
Odessa Health Care Center
609 GOLF ST, ODESSA, MO, 64076-1462
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
287% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
93% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 6
Date: Jun 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding inadequate assistance with activities of daily living (ADL), insufficient staffing, lack of registered nurse coverage, and issues with food temperature and quality at Odessa Health Care Center.
Complaint Details
The investigation was complaint-driven with complaint numbers MO00255324, MO00255403, MO00255632, and MO00255047. Complaints included inadequate bathing and hygiene care, insufficient staffing including lack of RN and DON coverage, cold and unappetizing food, and unlicensed staff performing resident care.
Findings
The facility failed to provide adequate ADL care including bathing and grooming for sampled residents, had insufficient nursing and certified staff coverage including lack of RN and DON presence, and served food that was often cold and unappetizing. Non-certified staff were performing resident care without proper training or certification, and administrative oversight was lacking.
Deficiencies (6)
Failure to carry out activities of daily living (ADL) to maintain grooming and personal hygiene for sampled residents.
Failure to provide sufficient nursing staff 24/7 to meet resident needs and ensure safety.
Failure to have a registered nurse on duty at least 8 consecutive hours per day and designate a full-time Director of Nursing.
Failure to ensure food was served at a safe and appetizing temperature; residents frequently received cold food.
Failure to administer the facility in a manner that enables effective and efficient use of resources, including lack of full-time administrative and nursing oversight.
Failure to employ staff that are licensed, certified, or registered in accordance with state laws; non-certified staff performed resident care without training or certification.
Report Facts
Residents affected: 3
Facility census: 56
Missed showers: 6
Missed showers: 3
Staffing counts: 2
Room trays served: 20
Food temperatures: 102.8
Food temperatures: 99.8
Food temperatures: 99.1
Food temperatures: 101.7
Food temperatures: 67.3
Residents requiring ADL assistance: 45
Residents requiring feeding assistance: 5
Residents requiring toileting assistance: 40
Residents requiring total dependent care: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practice Nurse | Reported facility short staffing, lack of RN coverage, and Administrator covering charge nurse duties. |
| CNA A | Certified Nurse Assistant | Reported residents not getting bathed, long call light wait times, and Administrator working as charge nurse. |
| CNA C | Certified Nurse Assistant | Reported residents going weeks without bathing, short staffing, and unsafe transfer practices. |
| CNA D | Certified Nurse Assistant | Observed residents soiled due to inadequate care and short staffing. |
| CNA E | Certified Nurse Assistant | Reported residents not getting showers due to staffing shortages and informed Administrator. |
| Administrator | Facility Administrator | Frequently covered charge nurse duties, mandated non-certified staff to work floor, acknowledged staffing and RN coverage issues. |
| Dietary Staff A | Dietary Staff | Reported short staffing in dietary, delayed meal delivery, lack of heated tray covers, and cold food complaints. |
| Dietary Staff B | Dietary Staff | Reported staff disciplinary actions and food being prepared hours in advance leading to cold meals. |
| Dietary Staff C | Dietary Staff | Under 18, worked overnight shift, answered call lights, and was mandated to work to meet fire code. |
| Environmental Services Staff A | Environmental Services Staff | Assisted with resident cares without certification or training, felt uncomfortable performing duties. |
| Activities Director | Activities Director | Reported Administrator spent most time in office and facility lacked nursing supervision most days. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Apr 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding insufficient nursing staff coverage, lack of RN and Director of Nursing (DON) presence, and failure to post nurse staffing information as required.
Complaint Details
Complaint # MO 00251633 regarding inadequate staffing, lack of RN and DON coverage, and failure to post staffing information.
Findings
The facility failed to maintain adequate nursing staff on night shifts, did not have RN coverage for eight hours per day, seven days a week, lacked a full-time DON onsite, and failed to post daily nurse staffing information accessible to residents and visitors. Staffing shortages were observed and confirmed through interviews and record reviews.
Deficiencies (3)
Failed to provide enough nursing staff every day to meet resident needs and have a licensed nurse in charge on each shift, including inadequate night shift staffing.
Failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week, and failed to ensure a Director of Nursing (DON) was onsite full-time.
Failed to post nurse staffing information daily in a location easily accessible to residents and visitors, including facility name, daily census, and actual hours worked per shift for nursing staff categories.
Report Facts
Census: 54
Staffing hours: 6.03
Staffing requirement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in staffing deficiency and interview regarding night shift coverage |
| CNA A | Certified Nurse Aide | Named in staffing deficiency and interview regarding night shift coverage |
| Regional Chief Nursing Officer | Regional CNO | Interviewed regarding staffing and RN coverage |
| Interim DON | Director of Nursing | Newly arrived interim DON interviewed about staffing and coverage |
| Regional Director of Operations | Regional Director of Operations | Interviewed regarding staffing scheduling and DON resignation |
| Social Services Designee | Social Services Designee | Interviewed about staffing schedule and assistance with resident care |
| Regional CEO | Regional CEO | Interviewed about DON resignation and staffing arrangements |
| Interim OPS Manager | Interim Operations Manager | Interviewed about absence of DON and RN coverage |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 5
Date: Apr 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to staffing deficiencies and compliance with nursing staff requirements at Odessa Health Care Center.
Complaint Details
Complaint # MO 00251633 triggered the investigation. The complaint concerned insufficient nursing staff coverage and lack of a full-time Director of Nursing. The complaint was substantiated by observations and interviews.
Findings
The facility failed to have sufficient nursing staff on a 24-hour basis to meet resident needs and fire safety requirements. The facility also lacked a full-time Director of Nursing and did not post required nurse staffing information as mandated.
Deficiencies (5)
F725 Sufficient Nursing Staff: The facility failed to have adequate nursing staff on a 24-hour basis to provide care and meet fire safety minimum staffing requirements. The census was 54 residents during the inspection.
F727 RN 8 Hrs/7 days/Wk, Full Time DON: The facility failed to ensure a full-time Director of Nursing or registered nurse coverage for eight hours daily, seven days a week. The census was 54 residents and no RN was present during key shifts.
F732 Posted Nurse Staffing Information: The facility failed to post daily nurse staffing data including resident census and staffing hours in a location accessible to residents and visitors. The census was 54 residents.
A4038 19 CSR 30-85.042(34) DON, Full time: The facility did not employ a full-time Director of Nursing responsible for patient care quality and supervision. This deficiency references F727.
A4040 19 CSR 30-85.042(35)(B) SNF RN-Day Shift, LPN/RN eve/nights: The facility failed to have a registered nurse on duty during day and evening/night shifts as required. This deficiency references F727 and F725.
Report Facts
Resident census: 54
Staffing hours required: 8
Staffing hours worked: 6.03
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of resident property when a Certified Nursing Assistant (CNA) borrowed $150 from a resident to pay court costs.
Complaint Details
The complaint was substantiated as the CNA borrowed $150 from Resident #3 without proper consent. The resident was refunded the money and the CNA was terminated. Police were contacted but could not take action as the money was considered a loan.
Findings
The facility failed to prevent misappropriation of resident property by a CNA who borrowed $150 from a resident. The CNA was terminated, the resident was refunded the money, and the facility took corrective actions including staff reeducation and investigation.
Deficiencies (1)
Failed to protect resident from wrongful use of belongings when CNA borrowed $150 from resident.
Report Facts
Residents present: 53
Amount misappropriated: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in misappropriation finding; terminated for no call no show and involved in borrowing money from resident |
| Administrator A | Administrator | Notified of incident and investigation lead |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Notified of past non-compliance and involved in investigation |
| Director of Nursing | Director of Nursing (DON) | Started investigation immediately upon notification |
| Activities Director | Activities Director | Notified Administrator of resident's concern and provided written statement |
| Social Service Director | Social Service Director | Provided written statement regarding resident interview |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jan 2, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's responsible party after a choking incident and subsequent medical changes for Resident #3.
Complaint Details
The complaint investigation found that the resident's representative was not notified of the choking incident, x-ray results, or new medications ordered. The resident's representative learned of the incident from the resident's spouse. Staff interviews confirmed responsibility for notification but failure to notify occurred.
Findings
The facility failed to notify the resident's responsible party after staff performed the Heimlich Maneuver on Resident #3 who choked on food, and did not relay physician-ordered medication changes and tests to the responsible party. Staff were educated on notification policies and the deficiency was corrected.
Deficiencies (1)
Failure to notify the resident's responsible party after a choking incident and subsequent medical changes.
Report Facts
Residents Affected: 3
Facility Census: 54
Medication dosage: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding notification responsibilities and in-service training |
| Director of Nursing | Director of Nursing (DON) | Interviewed about notification responsibilities and staff in-service |
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 1
Date: Jan 2, 2025
Visit Reason
The document is a plan of correction submitted by Anew Healthcare Odessa following a deficiency cited related to failure to notify the resident's responsible party after a Heimlich Maneuver incident.
Findings
The facility failed to notify the resident's responsible party after a choking incident requiring the Heimlich Maneuver on one sampled resident. The deficiency was corrected by educating staff and monitoring notifications daily.
Deficiencies (1)
F580 Notification of Changes: The facility did not notify the resident's responsible party after a choking incident requiring the Heimlich Maneuver on a sampled resident. The facility failed to ensure timely notification of changes in condition as required by regulation.
Report Facts
Facility census: 54
Dates of incident and correction: Incident occurred 12/19/24, correction completed 12/31/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding notification responsibilities |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification responsibilities and staff in-service |
Inspection Report
Life Safety
Census: 49
Capacity: 60
Deficiencies: 18
Date: May 28, 2024
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and life safety regulations.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to document procedures for residents with special electrical medical equipment, subsistence needs during emergencies, roles under a waiver declared by the Secretary, and fire safety requirements such as range hood inspections, fire alarm system maintenance, sprinkler system outages, fire extinguisher placement, evacuation plans, and generator alarm annunciator operation.
Deficiencies (18)
E007 Emergency Plan: Facility failed to document procedures for residents with special electrical medical equipment and failed to identify generator power sources and continuity of services during emergencies.
E015 Subsistence Needs: Facility failed to establish and maintain a comprehensive emergency preparedness plan addressing subsistence needs such as water and sheltering in place for staff and residents.
E026 Roles Under a Waiver Declared by Secretary: Facility failed to include policies describing its role and ability to provide care under a waiver during emergencies.
K324 Cooking Facilities: Facility failed to provide timely documentation of annual and semi-annual inspections of the range hood fire suppression system.
K345 Fire Alarm System: Facility failed to provide complete documentation of professional annual and semi-annual inspections of the fire alarm system components.
K354 Sprinkler System: Facility had a sprinkler system out of service for more than 10 hours in a 24-hour period without proper notification and fire watch policy.
K355 Portable Fire Extinguishers: Facility failed to ensure Class K fire extinguisher was properly located, inspected, and marked in the kitchen area.
K711 Evacuation and Relocation Plan: Facility failed to maintain a comprehensive fire plan including evacuation maps, staff designations, and route maps properly posted and oriented.
K916 Electrical Systems: Facility failed to properly educate staff on generator alarm annunciator and emergency shut-off procedures.
K929 Gas Equipment: Facility failed to ensure combustibles were stored properly away from oxygen tanks and educate staff on oxygen storage safety.
A2003 No Fire Hazard: Facility presented a fire hazard as detailed in referenced deficiencies.
A2012 Fire Extinguishers-Minimum per Floor: Facility failed to provide required fire extinguishers per floor travel distance requirements.
A2017 Range Hood Certification: Facility failed to maintain range hood certification and inspections as required.
A2019 Fire Alarm System-Test/Maintain: Facility failed to maintain and test fire alarm system components as required.
A2036 Sprinkler System Out of Service More Than 4hr: Facility failed to notify authorities and implement fire watch during sprinkler system outage exceeding 4 hours.
A2059 Fire Drills - Plan Requirements: Facility failed to maintain a fire drill plan including phased response and staff assignments.
A3030 Electrical Wiring & Equipment Maintained: Facility failed to maintain electrical wiring and equipment in accordance with NFPA standards.
A4013 Policies/Procedures-Operational: Facility failed to develop policies and procedures addressing residents' health, safety, and rights including emergency preparedness.
Report Facts
Facility census: 49
Total licensed capacity: 60
Fuel tank capacity: 480
Fuel tank capacity: 500
Water supply: 64
Fire alarm inspections: 2
Range hood inspections: 2
Fire extinguisher travel distance: 75
Evacuation route map hallway length: 60
Fire watch duration: 4
Inspection Report
Annual Inspection
Census: 49
Capacity: 60
Deficiencies: 19
Date: May 28, 2024
Visit Reason
The annual inspection was conducted to assess compliance with state and federal regulations including resident care, medication management, infection control, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to conduct proper background checks, incomplete resident assessments, inadequate care planning, medication errors, infection control lapses, staffing shortages, and financial management issues. Several residents' care plans and medication regimens were not properly managed, and infection prevention protocols were not fully implemented.
Deficiencies (19)
Failed to check the Nurses' Aide Registry for new employees prior to hire and did not complete checks for four sampled employees.
Failed to accurately complete the Minimum Data Set (MDS) for two sampled residents.
Failed to ensure completion, submission, and retention of a Level I Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition (PASRR) for one resident.
Failed to provide baseline care plans to two sampled residents and/or their responsible parties within 48 hours of admission.
Failed to develop a comprehensive, person-centered care plan for one sampled resident.
Failed to hold medications according to physician's orders and failed to obtain physician's orders for colostomy care for two sampled residents.
Failed to ensure necessary information was communicated to the resident and receiving health care provider at discharge for one sampled resident.
Failed to ensure a Registered Nurse was on duty eight hours per day, seven days per week.
Failed to provide addiction recovery program or psychological services for one resident needing such services for liver transplant eligibility.
Failed to respond to pharmacist's monthly medication regimen review and failed to follow physician's order for medication management for three sampled residents.
Failed to implement gradual dose reductions and appropriate monitoring for antipsychotic and psychotropic medications for one sampled resident.
Failed to hold insulin per physician's orders for one sampled resident.
Failed to observe resident self-administering medications and failed to keep medication carts locked when not in use.
Failed to procure and maintain adequate supplies and services, including laundry chemical pumps, cleaning supplies, and laboratory services due to unpaid bills.
Failed to maintain infection prevention and control program including Legionella risk management, tuberculosis screening, hand hygiene, enhanced barrier precautions, and wound care practices.
Failed to ensure staff washed hands during medication administration and failed to follow enhanced barrier precautions during wound care and IV medication administration.
Failed to ensure wound VAC was not placed on the floor and that wound care supplies were handled with proper infection control.
Failed to ensure tuberculin skin tests (TST) were administered and read timely for residents and employees.
Failed to ensure oxygen equipment was maintained in a sanitary condition including dated tubing and humidifiers for three sampled residents.
Report Facts
Facility census: 49
Total capacity: 60
Past due invoice amount: 46480.77
Past due invoice amount: 6373.48
Medication administration errors: 1
Medication carts unlocked observations: 2
TB tests late: 8
Missing TST read dates: 5
Medication regimen review responses missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to medication administration and wound care |
| LPN A | Licensed Practical Nurse | Named in findings related to medication administration and wound care |
| Administrator | Facility Administrator | Named in interviews regarding facility operations and vendor payments |
| DON | Director of Nursing | Named in findings related to medication management, staffing, infection control |
| ADON | Assistant Director of Nursing | Named in findings related to medication management, infection control, TB screening |
| SSD | Social Service Designee | Named in findings related to PASRR screening and addiction recovery services |
| Floor Technician A | Maintenance Staff | Named in findings related to supply ordering and laundry chemical issues |
| Laundry Supervisor | Laundry Supervisor | Named in findings related to laundry chemical usage |
| Medical Director | Medical Director | Named in interview regarding lab services |
| CMT A | Certified Medication Technician | Named in findings related to medication cart security and infection control |
Inspection Report
Life Safety
Census: 27
Capacity: 60
Deficiencies: 8
Date: Sep 15, 2022
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements related to subsistence needs for staff and patients, evacuation communication plans, and life safety code provisions including storage of combustibles, sprinkler system maintenance, and smoking regulations. Multiple deficiencies were cited affecting all residents and staff.
Deficiencies (8)
E015: The facility failed to include the location and type of thermometers used to monitor temperatures during a climate control outage, potentially affecting all residents and staff.
E020: The facility failed to state their choice of an alternate communication system in the emergency plan, affecting all residents and staff.
K300: The facility failed to prevent storage of combustibles within three feet of hot water heaters, potentially affecting an unknown number of residents.
K324: The facility failed to maintain the metal duct from the range hood in good repair, potentially affecting residents using two smoke zones.
K353: The facility failed to ensure two sprinkler heads in the kitchen area were free from corrosion, potentially affecting residents in one smoke zone.
K362: The facility failed to seal penetrations in the wall of the soiled linen room, potentially allowing smoke passage and affecting residents in one smoke zone.
K363: The facility failed to ensure corridor doors and hazardous area doors resist smoke passage and have proper hardware, potentially affecting residents in two smoke zones.
K741: The facility failed to ensure self-closing ashtrays and proper signage in smoking areas, affecting one resident and multiple outdoor areas.
Report Facts
Facility census: 27
Licensed capacity: 60
Inspection Report
Routine
Census: 27
Deficiencies: 21
Date: Sep 15, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, safety, infection control, and administrative procedures.
Findings
The facility was found deficient in multiple areas including failure to conduct resident council meetings, improper management of resident funds, incomplete employee background checks, untimely and incomplete Minimum Data Set (MDS) assessments, inadequate care planning, insufficient activities programming, failure to coordinate hospice care, inadequate wound care and pressure ulcer management, unsafe use of equipment, improper handling of oxygen and respiratory supplies, failure to post nurse staffing information, poor infection control practices, and lack of an effective antibiotic stewardship program.
Deficiencies (21)
Failed to ensure monthly resident council meetings were held to allow residents and families to voice concerns.
Failed to print and distribute quarterly statements for residents' personal funds managed by the facility.
Failed to complete required criminal background checks, employee disqualification listings, and nurse aide registry screenings for several employees.
Failed to complete and submit comprehensive and significant change Minimum Data Set (MDS) assessments timely for multiple residents.
Failed to ensure a baseline care plan was developed within 24 hours of admission for residents.
Failed to develop and implement comprehensive care plans reflecting residents' current conditions including hospice care.
Failed to provide an ongoing activities program that met residents' physical, mental, and psychosocial needs.
Failed to coordinate hospice care including communication, documentation of visits, and care planning.
Failed to provide timely wound care assessments, treatment orders, wound measurements, and documentation for residents with pressure sores.
Failed to lock wheels on mechanical lift and wheelchair during resident transfers.
Failed to change PICC line dressing weekly and to create a baseline care plan for PICC line management.
Failed to properly store oxygen tubing, nasal cannulas, and breathing treatment masks when not in use.
Failed to obtain physician orders, conduct safety assessments, update care plans, and monitor safety for use of bed side rails.
Failed to ensure food was palatable and to provide a mechanism for residents to voice concerns about food quality.
Failed to ensure food was prepared in a form consistent with residents' diet orders, including soft/mechanical soft diet requirements.
Failed to maintain clean food storage and preparation areas including buildup of dust, food debris, and expired food items.
Failed to keep trash containers covered in the kitchen during meal service.
Failed to implement an effective infection prevention and control program including hand hygiene, wound care infection control, infection tracking, TB screening, and blood sugar check infection control.
Failed to designate a qualified and certified Infection Preventionist to oversee the infection prevention and control program.
Failed to post nurse staffing information visibly daily for residents and visitors.
Failed to ensure a licensed pharmacist performed monthly drug regimen reviews and that recommendations were obtained and followed up.
Report Facts
Facility census: 27
Deficiency count: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in hand hygiene and infection control deficiencies during incontinence care |
| LPN A | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| LPN B | Licensed Practical Nurse | Named in wound care, PICC line dressing, and infection control deficiencies |
| CMT A | Certified Medication Technician | Named in infection control and activities program deficiencies |
| CMT B | Certified Medication Technician | Named in infection control and activities program deficiencies |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies and expectations |
| Administrator | Facility Administrator | Named in interviews regarding resident council and food palatability |
| DM | Dietary Manager | Named in food palatability and kitchen cleanliness deficiencies |
| BOM | Business Office Manager | Named in resident funds management and activities program deficiencies |
| MDS Coordinator | Minimum Data Set Coordinator | Named in MDS, care planning, infection control, and wound care deficiencies |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 28, 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 practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 9, 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
Abbreviated Survey
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with related CMS and CDC requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparation and infection control.
Inspection Report
Annual Inspection
Census: 29
Capacity: 60
Deficiencies: 4
Date: Jan 7, 2020
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal regulations regarding resident care, medication management, staffing, and food safety.
Findings
The facility was found deficient in accurately documenting significant changes in resident status on the Minimum Data Set (MDS), reconciling medications upon resident discharge, posting nurse staffing hours, and maintaining sanitary food preparation equipment and proper staff hygiene. Deficiencies were noted in care planning, medication disposition documentation, staffing information posting, and kitchen cleanliness.
Deficiencies (4)
Failure to ensure significant changes in resident status were accurately documented on the MDS for three sampled residents.
Failure to reconcile resident's medication upon discharge, including lack of documentation of quantity of pills remaining.
Failure to post hours worked by licensed and unlicensed nursing staff per shift at the nurses' station.
Failure to maintain safe, sanitary, and easily cleanable food preparation equipment and serving utensils, and failure to ensure hairnets fully covered kitchen staff hair.
Report Facts
Facility census: 29
Licensed capacity: 60
Weight decrease percentage: 14.2
Number of sampled residents with MDS deficiencies: 3
Number of sampled closed record residents with medication reconciliation deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided interviews regarding MDS documentation, medication reconciliation, and staffing postings | |
| MDS Coordinator | Provided interviews regarding MDS documentation and corrections | |
| Licensed Practical Nurse (LPN) A | Provided interview regarding medication disposition sheet completion | |
| Dietary Manager | Provided interview regarding kitchen sanitation and staff hygiene |
Inspection Report
Plan of Correction
Census: 29
Capacity: 60
Deficiencies: 4
Date: Jan 7, 2020
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, medication management, nurse staffing, and food safety at New Haven Living Center.
Findings
The facility was found deficient in documenting significant changes in resident status, reconciling medications upon discharge, posting nurse staffing data, and maintaining food safety standards. Several deficiencies were cited related to care planning, medication records, nurse staffing postings, and kitchen sanitation.
Deficiencies (4)
F637: The facility failed to ensure accurate documentation of significant changes in residents' status, including Minimum Data Set (MDS) assessments for sampled residents. The facility census was 29 residents.
F661: The facility failed to reconcile medications for one sampled discharged resident, including incomplete medication disposition documentation and lack of instructions for medication quantities upon discharge.
F732: The facility failed to post nurse staffing data daily, including hours worked by licensed and unlicensed nursing staff, and did not have a policy regarding posting staffing hours.
F812: The facility failed to maintain safe, sanitary, and clean food preparation equipment and utensils, including dirty kitchen equipment and uncovered hairnets. The skilled nursing facility census was 29 with a licensed capacity of 60 beds.
Report Facts
Facility census: 29
Licensed capacity: 60
Inspection Report
Life Safety
Census: 29
Capacity: 60
Deficiencies: 10
Date: Jan 7, 2020
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and fire safety regulations.
Findings
The facility failed to establish and maintain a comprehensive emergency preparedness program meeting regulatory standards. Deficiencies were also found in fire alarm notification devices, sprinkler system signage, fire extinguisher installation and signage, and electrical system documentation.
Deficiencies (10)
E001: The facility failed to establish and maintain a comprehensive emergency preparedness program that meets all regulatory standards, including training, monitoring, and communication methods.
K343: The facility failed to ensure all components of the fire alarm system, including audio and visual notification devices, were properly installed and functional in multiple areas.
K351: The facility failed to install a posted identification sign for the Fire Department Connection (FDC) that was clearly visible from the front parking lot.
K355: The kitchen's Class K portable fire extinguisher was not installed with correct, clear, and concise instructional signage as required by NFPA standards.
K918: The facility failed to provide complete annual documentation on electrical main and feeder circuit breaker inspections and testing, including itemized lists and Pass/Fail status.
A2016: Fire extinguishers were not maintained in accordance with NFPA 10, including monthly pressure checks and labeling requirements.
A2018: The facility lacked a complete fire alarm system that automatically transmits alarms to the fire department or monitoring agency as required.
A2034: The sprinkler system was not properly inspected, maintained, and tested as required by regulations.
A3030: Electrical wiring and equipment were not maintained in accordance with NFPA 70 standards, posing potential safety risks.
A4013: The facility failed to develop and implement policies and procedures covering personnel practices, infection control, and resident rights as required.
Report Facts
Facility census: 29
Licensed capacity: 60
Inspection Report
Plan of Correction
Census: 28
Deficiencies: 3
Date: Mar 8, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to discharge summaries and antibiotic stewardship program compliance at New Haven Living Center.
Findings
The facility failed to complete a proper discharge summary for discharged residents and did not have an effective antibiotic stewardship program in place. The facility census was 28 residents at the time of the survey.
Deficiencies (3)
F 661 Discharge Summary: The facility failed to complete a recapitulation of the resident's stay in the discharge summary for a closed record sampled resident. Nurses did not complete a discharge summary note that included a recapitulation of the resident's stay.
F 881 Antibiotic Stewardship Program: The facility failed to establish and implement an antibiotic stewardship program that included protocols to optimize antibiotic use and monitor antibiotic usage. The facility census was 28 residents.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection and to report communicable diseases within seven days as required.
Report Facts
Facility census: 28
Date of survey: Mar 8, 2019
Plan of Correction completion date: Apr 19, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Omwolar | Administrator | Signed the plan of correction and is mentioned in the report |
Inspection Report
Life Safety
Census: 28
Capacity: 60
Deficiencies: 7
Date: Mar 8, 2019
Visit Reason
The inspection was conducted as a Life Safety Code Survey to evaluate compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found non-compliant with several fire safety requirements including incomplete documentation and testing of the fire alarm system, inadequate smoke detection in certain areas, and improper storage and fire resistance of oxygen cylinders. The facility was found compliant with emergency preparedness requirements.
Deficiencies (7)
K345 Fire Alarm System - The facility did not maintain complete documentation of the annual fire alarm system testing and maintenance, and the HVAC system was improperly tied into the fire alarm system, potentially affecting 28 residents.
K347 Smoke Detection - The facility failed to ensure smoke detection in two open corridor areas, potentially affecting 22 residents in the dining room and west residential hallway.
K923 Gas Equipment - The facility failed to properly maintain fire resistive qualities in the oxygen storage area, compromising fire resistance and potentially affecting 19 residents.
A1038 Oxygen Storage Room - The oxygen storage room was not surrounded by one-hour rated construction with proper ventilation as required.
A2018 Complete Fire Alarm System Requirements - The facility did not have a complete fire alarm system installed in accordance with NFPA 101 standards.
A2019 System-Test/Maintain - The facility failed to properly test and maintain the complete fire alarm system as required by NFPA 72 standards.
A2020 Fire Alarm System-Inspections/Certifications - The facility did not have annual inspections and certifications of the fire alarm system completed by an approved qualified service representative.
Report Facts
Facility census: 28
Licensed capacity: 60
Date of survey: Mar 8, 2019
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 10
Date: May 7, 2018
Visit Reason
The inspection was an annual survey of New Haven Living Center to assess compliance with federal regulations regarding resident rights, bed-hold policies, pain management, medication storage, infection control, and other care standards.
Findings
The facility was found deficient in maintaining resident dignity during meals, notifying residents of bed-hold policies, documenting pain assessments and medication effectiveness, proper medication storage and labeling, and infection control practices. Several residents' records and observations revealed failures in staff communication, documentation, and adherence to policies.
Deficiencies (10)
F550 Resident Rights: The facility failed to ensure dignity was maintained during meals for one sampled resident, including lack of communication and engagement by staff during feeding.
F625 Notice of Bed Hold Policy: The facility failed to notify residents or their representatives of the bed-hold policy before transferring or discharging residents to the hospital for five sampled residents and one closed record.
F697 Pain Management: The facility failed to ensure pain assessments were completed and documented before and after giving PRN pain medication and failed to document reasons for administering pain medication for one sampled resident.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure medication refrigerator temperatures were maintained within acceptable ranges and failed to properly store beverages and supplements separately from medications.
F880 Infection Prevention & Control: The facility failed to ensure infection control practices were followed to prevent cross-contamination during blood glucose monitoring for three sampled residents.
A4063 Medication Storage: The facility failed to store medications, including refrigerated and controlled drugs, in a safe and orderly manner with proper labeling and separation from food.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4085 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection and failed to report communicable diseases as required.
A8008 Informed Services/Charges - Alzheimer’s Disclosure: The facility failed to fully inform residents or their representatives of services and charges related to Alzheimer’s special care services.
A8030 Dignity/Privacy: The facility failed to treat residents with full consideration, respect, and dignity, including privacy in treatment and care.
Report Facts
Census: 33
Sampled residents: 14
Completion date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in findings related to feeding and interaction with resident #20 |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in findings related to pain medication documentation and blood glucose monitoring |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff expectations for resident interaction and medication refrigerator management |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding PRN medication effectiveness documentation |
| Administrator | Administrator | Interviewed regarding bed-hold policy notification and plan of correction |
| RN A | Registered Nurse | Observed during blood glucose monitoring and infection control procedures |
| CNA A | Certified Nursing Assistant | Observed during infection control procedures and resident care |
| CNA C | Certified Nursing Assistant | Observed during infection control procedures and resident care |
Inspection Report
Life Safety
Census: 33
Capacity: 60
Deficiencies: 7
Date: May 7, 2018
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related emergency preparedness requirements.
Findings
The facility failed to meet several Life Safety Code requirements including exit discharge design, electrical equipment testing and maintenance, emergency preparedness program establishment, ventilation, and exit requirements. Deficiencies were noted that potentially affected residents' safety and emergency readiness.
Deficiencies (7)
K271 Exit discharge area from the west hall was obstructed and not designed to allow an unobstructed exit for residents. The facility census was 33 residents with a licensed capacity of 60.
K921 Electrical equipment testing and maintenance documentation was not produced. Multiple surge protectors lacked assessment for integrity and UL listing, posing potential electrical injury and fire hazards.
E001 Emergency preparedness training was incomplete; the chief responsible for emergencies was not clearly identified, and fire extinguisher locations were not mapped.
A1102 Ventilation requirements were not met due to absence of a negative air flow device in the soiled linen room, potentially affecting 10 residents.
A2037 Exit requirements were not met; the lobby lacked a one-hour fire-rated separation from the remainder of the exiting floor.
A3030 Electrical wiring and equipment were not maintained according to NFPA 70 standards, constituting a Class III deficiency.
A4013 Policies and procedures for resident health, safety, and emergency preparedness were incomplete, constituting a Class III deficiency.
Report Facts
Facility census: 33
Licensed capacity: 60
Residents potentially affected: 21
Residents potentially affected: 10
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