Inspection Reports for
Potosi Manor
307 SOUTH HIGHWAY 21, POTOSI, MO, 63664-9317
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
109% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
69% occupied
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Oct 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect of a resident at Potosi Manor.
Complaint Details
Complaint #MO243888 regarding abuse and neglect of Resident #1 was investigated and substantiated based on interviews and observations.
Findings
The facility failed to protect a confused and vulnerable resident from physical abuse during medication administration. Staff forcibly administered medication by holding the resident's head and pinching the nose, causing distress and crying. The facility lacked a policy for handling medication refusals by combative residents.
Deficiencies (1)
F 600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to protect a resident from physical abuse during medication administration, as staff forcibly held the resident's head and pinched the nose. The facility did not provide a policy for handling medication refusals by combative residents.
Report Facts
Facility census: 62
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Oct 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident during medication administration.
Complaint Details
Complaint #MO243888 regarding physical abuse of Resident #1 during medication administration was substantiated. Immediate jeopardy was identified and corrected.
Findings
The facility failed to protect a confused and vulnerable resident from physical abuse when staff forcibly administered medication by holding the resident's hands and pinching the nose, causing distress. The facility investigated, terminated involved staff, and provided staff training on abuse and medication administration.
Deficiencies (1)
Failure to protect a resident from physical abuse during medication administration.
Report Facts
Residents present: 62
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Involved in forcibly administering medication to Resident #1 |
| LPN B | Licensed Practical Nurse | Held resident's wrists during medication administration incident |
| CNA C | Certified Nurse Aide | Witnessed and reported the abuse incident |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 7
Date: Oct 11, 2024
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for the nursing facility Potosi Manor.
Findings
The facility was found deficient in multiple areas including nurse aide training completion, food safety and storage, garbage disposal, quality assurance and performance improvement (QAPI) program implementation, infection control practices, and tuberculosis screening documentation. Several deficiencies had the potential to affect all residents.
Deficiencies (7)
F728 Nurse Aide Training: The facility failed to ensure two nurse aides completed a nurse aide training program within four months of employment. The facility lacked a policy related to the nurse aide training program.
F812 Food Safety: The facility failed to store food under sanitary conditions, increasing the risk of food-borne illness. Multiple food items were found expired, undated, or improperly stored.
F814 Garbage Disposal: The facility failed to ensure dumpsters were closed and maintained to keep pests out. Observations showed lids were not closed and trash bags were overflowing.
F865 QAPI Program: The facility failed to have an effective Quality Assurance and Performance Improvement program with policies, plans, and documentation. The program lacked monitoring, corrective actions, and committee meetings.
F867 QAA Improvement Activities: The facility failed to establish and implement written policies for feedback, data collection, and monitoring of quality improvement activities.
F868 QAA Committee: The facility failed to maintain required committee meetings with appropriate members and failed to provide a QAPI plan or policy.
F880 Infection Control: The facility failed to maintain proper infection control practices during incontinent care for two residents and failed to ensure timely and documented tuberculosis screenings for employees and residents.
Report Facts
Facility census: 62
Deficiencies cited: 7
Inspection Report
Routine
Census: 62
Deficiencies: 7
Date: Oct 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nurse aide training, food storage and sanitation, waste disposal, quality assurance programs, infection control, and tuberculosis screening at the nursing home.
Findings
The facility was found deficient in ensuring nurse aides completed training within four months, maintaining sanitary food storage, properly closing dumpsters, implementing an effective QAPI program, adhering to infection control practices during incontinent care, and conducting timely tuberculosis screenings for residents.
Deficiencies (7)
Failed to ensure two nurse aides completed training within four months of employment.
Failed to store food under sanitary conditions, increasing risk of food-borne illness.
Failed to ensure dumpsters were closed at all times and maintained to keep pests out and garbage contained.
Failed to have a Quality Assurance and Performance Improvement (QAPI) program with policies and protocols.
Failed to ensure the QAA/QAPI committee developed and implemented appropriate corrective plans of action.
Failed to maintain quarterly QAA/QAPI committee meetings with required members including medical director.
Failed to maintain proper infection control practices during incontinent care for two residents and failed to ensure proper tuberculosis screening for three residents.
Report Facts
Facility census: 62
Number of nurse aides not completing training within 4 months: 2
QAPI meetings held: 3
Number of residents with improper TB screening: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Named in nurse aide training deficiency and infection control observation |
| NA E | Nurse Aide | Named in nurse aide training deficiency |
| CNA C | Certified Nurse Assistant | Named in infection control deficiency observation |
| CNA D | Certified Nurse Assistant | Named in infection control deficiency observation |
| CNA B | Certified Nurse Assistant | Named in infection control deficiency observation |
| Administrator | Interviewed regarding multiple deficiencies and expectations | |
| Dietary Manager | Interviewed regarding food storage policies | |
| Quality Assurance Nurse | Interviewed regarding tuberculosis screening and QAPI program |
Inspection Report
Life Safety
Census: 62
Deficiencies: 6
Date: Oct 10, 2024
Visit Reason
Life Safety Code facility room inspection conducted to evaluate compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to ensure all doors to hazardous areas were self-closing and latched appropriately, the range hood was free of grease and debris, the sprinkler system was maintained and free of corrosion, portable fire extinguishers were inspected and maintained, combustible decorations were restricted, and oxygen cylinders were properly separated and marked. These deficiencies had the potential to affect all occupants of the building.
Deficiencies (6)
K223 Doors with Self-Closing Devices: The facility failed to ensure all doors to hazardous areas with self-closing devices were installed closed and latched appropriately when released. The door to the oxygen storage room did not shut completely or latch as appropriate.
K324 Cooking Facilities: The facility failed to ensure the range hood was free of accumulation of grease and debris, showing heavy buildup of yellow grease, drips, runs, and dark colored fuzzy debris.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system in accordance with NFPA 25, with four sprinkler heads loaded with grease and dust in the kitchen.
K355 Portable Fire Extinguishers: The facility failed to ensure portable fire extinguishers were inspected and maintained per NFPA 10, with extinguishers at the front door and maintenance office not inspected since August 2024 and the kitchen's ANSUL pull station not inspected since April 2024.
K753 Combustible Decorations: The facility failed to restrict the use of combustible decorations, with candles with wicks present in the bookkeeping office and main dining area.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure oxygen cylinders in two separate storage rooms were adequately separated to prevent confusion, with empty and full tanks mixed together and lacking proper signage.
Report Facts
Facility census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding self-closing devices, range hood cleaning, sprinkler head cleaning, fire extinguisher inspections, and oxygen cylinder storage |
Inspection Report
Routine
Census: 56
Deficiencies: 9
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, care, assessment, safety, staffing, and sanitation in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure dignity in catheter care, inadequate posting of Ombudsman information, failure to issue Medicare notices, untimely and inaccurate Minimum Data Set (MDS) assessments, inadequate pressure ulcer care documentation, failure to post nurse staffing data properly, unsanitary kitchen conditions, and unsafe environmental conditions such as items on light fixtures, use of wax warmers, and broken skylight windows.
Deficiencies (9)
Failed to ensure dignity of residents by not properly covering urinary catheter bags.
Failed to provide accessible information on the location of the State Long-Term Care Ombudsman program.
Failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) when Medicare covered services had ended.
Failed to complete comprehensive Minimum Data Set (MDS) assessments in a timely manner.
Failed to accurately code the Minimum Data Set (MDS) for anticoagulant medication.
Failed to document weekly skin assessments and status of pressure ulcers for residents with wounds.
Failed to post nurse staffing data with all required components in a clear and readable format daily.
Failed to maintain sanitary kitchen conditions including buildup of grime and lack of cleaning schedules.
Failed to provide a safe environment by allowing items on light fixtures, use of wax warmers, and presence of broken skylight windows.
Report Facts
Residents affected: 3
Facility census: 56
Days late: 150
Days late: 156
Wound measurements: 6.5
Wound measurements: 5
Wound measurements: 3.5
Wound measurements: 3
Wound measurements: 2.1
Wound measurements: 5
Wound area: 20
Wound volume: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Interviewed regarding dignity bag use for catheter care and wound care documentation |
| CNA C | Certified Nurse Aide | Interviewed regarding dignity bag use for catheter care |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter bag dignity bags, Ombudsman postings, MDS assessments, wound care, and staffing postings |
| Activity Director | Activity Director (AD) | Interviewed regarding Ombudsman information discussion |
| Bookkeeper | Interviewed regarding SNFABN form knowledge | |
| MDS Coordinator | Interviewed regarding MDS assessments and coding | |
| LPN A | Licensed Practical Nurse | Documented wound care and interviewed about wound measurements |
| RN D | Registered Nurse | Documented wound care |
| Dietary Manager | Interviewed regarding kitchen cleaning and sanitation | |
| Administrator | Interviewed regarding Ombudsman postings, SNFABN, MDS, wound care, staffing postings, kitchen sanitation, and environmental safety | |
| CNA F | Certified Nurse Assistant | Interviewed regarding safety concerns about decorations on light fixtures |
| Housekeeper G | Interviewed regarding removal of unsafe items and reporting broken glass | |
| Maintenance Supervisor | Interviewed regarding broken skylight windows and maintenance reporting |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 10
Date: Jul 27, 2023
Visit Reason
Annual inspection survey conducted at Potosi Manor to assess compliance with federal and state regulations for nursing care facilities.
Findings
The facility was found deficient in multiple areas including resident rights, required notices, comprehensive assessments, skin integrity, nurse staffing information, food safety, and environmental conditions. Several residents were found with uncovered urinary catheter bags and pressure ulcers, and the facility failed to provide timely Minimum Data Set (MDS) assessments and required notices.
Deficiencies (10)
F550 Resident Rights: The facility failed to ensure the dignity of three residents with uncovered urinary catheter bags during observations and interviews.
F574 Required Notices: The facility failed to provide accessible information on the State Long-Term Care Ombudsman program to residents as required.
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to two residents when Medicare covered services ended.
F636 Comprehensive Assessments & Timing: The facility failed to complete timely comprehensive Minimum Data Set (MDS) assessments for multiple residents and did not have an MDS policy.
F638 Quarterly Assessment: The facility failed to complete a quarterly MDS for one resident within the required timeframe and lacked an MDS policy.
F641 Accuracy of Assessments: The facility failed to accurately code the MDS for one resident, miscoding anticoagulant medications.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: The facility failed to document weekly skin assessments and the status of pressure ulcers for two residents and did not provide adequate wound care documentation.
F732 Posted Nurse Staffing Information: The facility failed to post nurse staffing data in a clear and accessible format and did not maintain a nurse staffing policy.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: The facility failed to maintain sanitary conditions in the kitchen, including buildup of grime on cooking equipment and missing cleaning schedules.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to provide a safe environment by not removing wax warmers and broken glass from resident areas and having broken skylights.
Report Facts
Facility census: 56
Residents sampled: 14
Residents with uncovered catheter bags: 3
Residents with pressure ulcers assessed weekly: 2
Residents with missing SNFABN notices: 2
Residents with late MDS assessments: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Smith | Laboratory Director/Provider/Supplier Representative | Signed the Statement of Deficiencies and Plan of Correction |
| LPN B | Licensed Practical Nurse | Interviewed regarding dignity bag use and wound care documentation |
| CNA C | Certified Nurse Aide | Interviewed regarding dignity bag use |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter bag dignity bags, MDS assessments, wound care, and nurse staffing postings |
| Administrator | Facility Administrator | Interviewed regarding MDS assessments, wound care, nurse staffing postings, and environmental safety |
| Bookkeeper | Interviewed regarding SNFABN form knowledge | |
| MDS Coordinator | Interviewed regarding MDS assessment submissions and timeliness | |
| Dietary Manager | Interviewed regarding kitchen cleaning and food safety | |
| LPN A | Licensed Practical Nurse | Documented wound care and interviewed about wound assessments |
| Registered Nurse D | Registered Nurse | Documented wound care and interviewed about wound assessments |
| Certified Nurse Assistant F | Certified Nurse Assistant | Interviewed regarding resident decorations and safety |
| Housekeeper G | Interviewed regarding safety concerns about light fixtures and wax warmers | |
| Maintenance Supervisor | Interviewed regarding broken skylights and maintenance reports |
Inspection Report
Life Safety
Census: 56
Deficiencies: 6
Date: Jul 27, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain proper exit illumination, maintain the building sprinkler system, and restrict the use of temporary wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K281 Illumination of Means of Egress: The facility failed to maintain continuous exit illumination around the building, including the 200 hall exterior exit pathway and exit across from dining leading to the public way.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the building's sprinkler system, including having a different sprinkler head in the laundry room entry than the rest of the room.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict the use of temporary wiring, with multiple power strips in use in patient care and office areas.
A2034 Sprinkler System-Test/Maintain: The facility did not meet requirements for inspection, maintenance, and testing of the sprinkler system as required by regulations.
A2050 Emergency Lighting: The facility failed to provide emergency lighting of sufficient intensity for safety of residents and others using exits, stairways, and corridors.
A3037 Extension Cords/Duplex Receptacles: The facility used extension cords that were not UL-approved or compliant, placed under rugs or in locations subject to physical damage.
Report Facts
Facility census: 56
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 3
Date: Feb 26, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, including medication monitoring, incontinent care, and drug regimen review at Potosi Manor.
Findings
The facility failed to obtain timely lab orders for Coumadin monitoring for one resident, failed to provide adequate incontinent care for two residents, and failed to ensure the pharmacy consultant identified and reported the absence of lab work related to Coumadin use. All deficiencies were noted to cause minimal harm or potential for actual harm affecting few residents.
Deficiencies (3)
Failed to obtain orders for labs related to Coumadin monitoring for one resident (Resident #17).
Failed to provide adequate incontinent care for one resident (Resident #9) and one resident (Resident #21), including improper cleaning techniques.
Failed to ensure the pharmacy consultant identified and reported the absence of lab work related to Coumadin use for one resident (Resident #17).
Report Facts
Facility census: 37
PT lab value: 15.5
INR lab value: 1.4
Coumadin dose: 4
Coumadin dose: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding PT/INR monitoring and contacting physician for new STAT order |
| CNA E | Certified Nursing Assistant | Interviewed regarding incontinent care procedures |
| Licensed Practical Nurse C | Licensed Practical Nurse | Observed providing incontinent care |
| CNA B | Certified Nursing Assistant | Observed and interviewed regarding incontinent care |
| CNA A | Certified Nursing Assistant | Observed and interviewed regarding incontinent care |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for PT/INR monitoring and incontinent care |
| Administrator | Administrator | Interviewed regarding expectations for lab orders and incontinent care |
| Pharmacist Consultant | Pharmacist Consultant | Interviewed regarding drug regimen review and failure to report lack of lab testing |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 3
Date: Feb 26, 2021
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, ADL care, and drug regimen review requirements at Potosi Manor, Inc.
Findings
The facility failed to provide adequate monitoring of PT/INR labs for residents on Coumadin, did not provide adequate incontinence care for dependent residents, and failed to ensure the pharmacy consultant identified and reported absence of lab work related to Coumadin use.
Deficiencies (3)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) The facility failed to provide care in accordance with standards when staff did not obtain orders for labs related to Coumadin monitoring for one resident. The facility lacked a policy addressing Coumadin use or PT/INR monitoring.
F677 ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2) The facility failed to provide adequate incontinence care for one resident out of two sampled residents, including failure to wash residents' buttocks, hips, thighs, or peri area properly.
F756 Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5) The facility failed to ensure the pharmacy consultant identified and reported the absence of lab work related to Coumadin use for one resident out of 12 sampled residents.
Report Facts
Facility census: 37
Sampled residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pharmacist Consultant | Confirmed no note had been written regarding lack of lab testing on Resident #17's Coumadin use | |
| Director of Nursing | DON | Interviewed regarding PT/INR lab monitoring and incontinence care |
| Licensed Practical Nurse | LPN | Interviewed regarding PT/INR monitoring |
| Certified Nursing Assistant | CNA | Observed providing inadequate incontinence care |
Inspection Report
Life Safety
Census: 37
Deficiencies: 2
Date: Feb 26, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to ensure power strips were not used beyond temporary installation or as a substitute for adequate wiring, which could affect all occupants. The Emergency Preparedness portion of the survey did not result in deficiencies.
Deficiencies (2)
K920 Electrical Equipment - Power Strips: The facility failed to ensure power strips were not used beyond temporary installation or as a substitute for adequate wiring, violating NFPA 70 requirements.
A1125 Electrical System Complies With Code: The facility did not meet the electrical system compliance requirements as evidenced by the K920 deficiency.
Report Facts
Facility census: 37
Inspection Report
Routine
Deficiencies: 0
Date: Sep 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with related 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: May 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted to assess compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 4
Date: Apr 26, 2019
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident care, including accuracy of assessments, continence care, dialysis services, and drug regimen management.
Findings
The facility was found deficient in accurately coding dialysis services, providing appropriate treatment for residents with indwelling catheters, coordinating dialysis care, and ensuring drug regimens were free from unnecessary drugs. Multiple residents were identified as being at risk due to these deficiencies.
Deficiencies (4)
F641 Accuracy of Assessments. The facility failed to accurately code dialysis services for Resident #28 on the Minimum Data Set (MDS).
F690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide appropriate treatment and services for care of an indwelling catheter for four residents, resulting in catheter tubing dragging on the floor.
F698 Dialysis. The facility failed to ensure coordination of care between the facility and the contracted dialysis center for two residents, lacking documentation of daily communication.
F757 Drug Regimen is Free from Unnecessary Drugs. The facility failed to ensure drug regimens were free from unnecessary drugs for two residents, including lack of adequate monitoring and documentation for dose reduction or discontinuation.
Report Facts
Facility census: 60
Residents with catheter issues: 4
Residents with dialysis coordination issues: 2
Residents with unnecessary drug issues: 2
Inspection Report
Life Safety
Census: 60
Deficiencies: 3
Date: Apr 26, 2019
Visit Reason
The inspection was conducted to assess compliance with fire safety regulations, specifically focusing on the maintenance and inspection of fire safety equipment in the kitchen area.
Findings
The facility failed to maintain monthly inspections on fire safety equipment in the kitchen, including the ANSUL charge indicator and the pull station for the fire suppression hood. The emergency preparedness portion of the survey did not result in any deficiencies.
Deficiencies (3)
K324 The facility failed to maintain monthly inspections on fire safety equipment in the kitchen, including the ANSUL charge indicator and the pull station for the fire suppression hood. This potentially affected all residents and staff.
A2016 Fire extinguishers were not maintained in accordance with NFPA 10, 1998 edition, including documentation and dating of monthly pressure checks.
A2017 The range hood and its extinguishing system were not certified at least twice annually as required by NFPA 96, 1998 edition.
Report Facts
Facility census: 60
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 22, 2018
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements.
Findings
No deficiencies or state licensure deficiencies were cited as a result of this annual recertification survey and inspection.
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 7
Date: Jun 22, 2018
Visit Reason
The inspection was an annual recertification survey conducted to assess compliance with applicable regulations including life safety codes and fire protection standards.
Findings
The facility was found to have multiple deficiencies related to fire safety, including delayed egress door locking, improper sprinkler system maintenance, missing fire extinguisher components, and combustible decorations. No deficiencies were cited in the initial recertification survey summary, but detailed findings showed noncompliance with NFPA standards.
Deficiencies (7)
K222: The delayed egress exit door did not open within the posted time, potentially endangering the facility. The door took 30 seconds to open when pushed to initiate.
K353: The facility did not maintain proper sprinkler clearance; sprinkler heads were blocked by food and covered in dust and debris. Observations showed violations in multiple locations including the freezer, refrigerator, and dry storage room.
K355: The facility failed to maintain all portable fire extinguishers to NFPA standards; a fire extinguisher cabinet handle was missing in a high hazard area. Maintenance was planned to correct this.
K753: The facility allowed combustible decorations including candles with wicks, creating a fire hazard. The dietary manager's office had 14 candles on display, which was not prohibited as required.
A2016: Fire extinguishers did not bear required labels or documentation for monthly pressure checks, violating NFPA 10 standards. This was classified as a Class III deficiency.
A2034: The sprinkler system was not properly inspected, maintained, or tested as required by NFPA 25. This was classified as a Class II deficiency.
A2041: Door locks did not meet NFPA requirements for emergency release; only one lock was permitted per door. This was classified as a Class II deficiency.
Report Facts
Facility census: 56
Candles counted: 14
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