Inspection Reports for
Republic Nursing and Rehab
901 State Hwy 174, Republic, MO 65738, MO, 65738
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
9.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
74% occupied
Based on a July 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: Jul 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the physician timely of a resident's change in condition and abnormal lab results, and failure to use appropriate infection control measures during wound care and medication administration.
Complaint Details
The complaint investigation revealed that staff failed to notify the physician timely about a resident's deteriorating condition and abnormal lab results, despite multiple documented changes and abnormal labs. The resident was eventually hospitalized with severe complications. The investigation also found lapses in infection control practices during care of two residents.
Findings
The facility failed to notify the physician in a timely manner about a resident's change in condition and abnormal lab results, resulting in delayed hospital transfer and serious health complications. Additionally, the facility failed to implement proper infection control practices during wound care and blood sugar testing, including improper handling of supplies, inadequate hand hygiene, and improper use of personal protective equipment.
Deficiencies (2)
Failed to notify the physician of a change in resident condition and abnormal laboratory results in a timely manner for one resident.
Failed to use appropriate infection control measures to prevent or reduce the risk of spreading bacteria or other infectious contaminants during wound care and blood sugar checks and insulin administration.
Report Facts
Facility census: 94
Elevated potassium: 5.8
Elevated blood urea nitrogen (BUN): 72
Elevated creatinine: 4.3
Decreased GFR: 10
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Documented resident condition notes and interviewed regarding failure to notify physician |
| LPN C | Licensed Practical Nurse | Documented resident condition notes |
| RN E | Registered Nurse | Documented resident progress notes and nurse practitioner notifications |
| Director of Nursing | Director of Nursing (DON) | Documented resident condition and interviewed about notification procedures |
| LPN A | Licensed Practical Nurse | Interviewed regarding resident condition assessments and notification practices |
| RN H | Registered Nurse | Interviewed regarding reporting changes in resident condition |
| LPN F | Licensed Practical Nurse | Interviewed regarding notification of physician and lab result procedures |
| LPN D | Licensed Practical Nurse | Interviewed regarding change in condition and lab result reporting |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding lab result handling and infection control |
| LPN G | Licensed Practical Nurse | Observed providing blood glucose testing and insulin administration with infection control lapses |
| Administrator | Facility Administrator | Interviewed regarding notification policies and infection control oversight |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 2
Date: Jul 24, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations including notification of changes in resident condition and infection prevention and control.
Findings
The facility failed to notify the physician in a timely manner of a resident's change in condition and abnormal laboratory results. Additionally, the facility did not implement appropriate infection control measures, including failure to use personal protective equipment and proper hand hygiene, putting residents at risk of infection.
Deficiencies (2)
F580 Notification of Changes: The facility failed to notify the physician of a resident's change in condition and abnormal lab results in a timely manner. Staff did not document physician notification for the resident's condition changes.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention program. Staff failed to use appropriate personal protective equipment and hand hygiene during wound care and blood sugar checks for residents.
Report Facts
Facility census: 94
Inspection Report
Routine
Census: 82
Deficiencies: 8
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including accurate resident assessments, comprehensive care planning, safe transfer methods, smoking safety, respiratory care, trauma-informed care, food safety, and environmental cleanliness.
Deficiencies (8)
Failed to ensure accurate nutritional and weight loss information was included in the Minimum Data Set (MDS) for one resident.
Failed to complete a comprehensive and individualized care plan addressing antianxiety medication use and hospice services for two residents.
Failed to obtain a physician's order for hospice and update the resident's care plan to reflect hospice admission for one resident.
Failed to ensure safe transfer methods and obtain therapy assessment for a non-weight bearing resident; failed to limit access to smoking materials to residents assessed as safe.
Failed to provide respiratory care consistent with standards by not having a physician's diagnosis for CPAP use and not addressing CPAP on care plan or MDS for one resident.
Failed to ensure trauma-informed care by not documenting PTSD diagnosis, triggers, or interventions in the medical record or care plan for one resident.
Failed to keep food safe from contamination by stacking wet dishware, not separating dented cans, and not properly sealing dry food containers.
Failed to maintain a sanitary kitchen environment with dirty walls, baseboards, and vents.
Report Facts
Facility census: 82
Resident weight loss: 14
Resident weight loss: 5.5
Resident weight loss: 13
CPAP pressure setting: 4
Dented cans: 2
Wet dishware stacks: 6
Open dry food bags: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Interviewed regarding hospice orders, smoking policies, PTSD care plans, and CPAP care |
| MDS Coordinator | Interviewed regarding care plan responsibilities and knowledge of deficiencies in care planning | |
| Administrator | Interviewed regarding facility policies and oversight of care plans, smoking, and kitchen sanitation | |
| CNA A | Certified Nurse Aide | Observed transferring resident #1 using unsafe method |
| COTA C | Certified Occupational Therapy Assistant | Interviewed regarding transfer assessments and recommendations |
| Director of Therapy Services | Interviewed regarding transfer assessments and recommendations | |
| DA O | Dietary Aide | Interviewed regarding food storage and dented cans |
| Dishwasher M | Interviewed regarding dishwashing practices |
Inspection Report
Life Safety
Census: 82
Capacity: 127
Deficiencies: 7
Date: Mar 14, 2024
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 building construction, fire safety, smoke barriers, corridor doors, and electrical systems.
Findings
The facility failed to maintain the integrity of the building construction by allowing unsealed penetrations and openings that compromised fire barriers and smoke compartments. Additionally, corridor doors were obstructed and failed to close properly, and electrical panels were blocked, posing safety risks.
Deficiencies (7)
K-161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and lower areas, allowing smoke to pass and potentially affecting 57 residents, staff, and visitors.
K-363: Corridor doors were obstructed by trash cans and other items, preventing proper closure and smoke resistance, potentially affecting 43 residents, staff, and visitors in two smoke compartments.
K-372: The facility failed to maintain the smoke resistive properties of smoke barrier walls due to drywall tape falling and gaps, allowing smoke passage between compartments and affecting all residents, staff, and visitors in the affected halls.
K-911: Electrical panels were blocked by furniture and storage items, violating clearance requirements and posing a risk to all building occupants in an electrical emergency.
A-2054: Smoke section walls and doors did not meet fire rating and self-closing requirements as per 19 CSR 30-85.022(29).
A-3001: The building was not substantially constructed and maintained in good repair, violating 19 CSR 30-85.032(2).
A-3030: Electrical wiring and equipment were not installed and maintained according to NFPA 70, 1999 edition, risking health and safety.
Report Facts
Facility capacity: 127
Census: 82
Potentially affected residents: 57
Potentially affected residents: 43
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Date: Jul 29, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal and physical abuse of a resident by a Certified Nursing Assistant (CNA A).
Complaint Details
The complaint was substantiated based on interviews with staff and review of the facility investigation. CNA A admitted to raising his/her voice and pushing the resident harder than appropriate. Other staff and administration confirmed that such behavior is considered abuse and should be reported immediately.
Findings
The facility failed to protect one resident's right to be free from verbal and physical abuse when CNA A yelled at the resident and forcefully pushed the resident by the shoulders to sit down. Multiple staff interviews and facility investigation confirmed the abuse allegation.
Deficiencies (1)
Failure to protect a resident from verbal and physical abuse by staff, including yelling and forcefully pushing the resident to sit down.
Report Facts
Facility census: 103
Resident admission date: Dec 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Alleged perpetrator who yelled at and pushed the resident |
| LPN C | Licensed Practical Nurse | Reported the abuse allegation to the Assistant Director of Nursing |
| CNA B | Certified Nursing Assistant | Witness who observed the abuse |
| CNA D | Certified Medication Technician | Interviewed staff member who described abuse reporting procedures |
| CNA E | Certified Medication Technician | Interviewed staff member who described abuse reporting procedures |
| LPN F | Licensed Practical Nurse | Interviewed staff member who described abuse reporting procedures and removal of alleged perpetrator |
| Director of Nursing | Director of Nursing | Confirmed abuse allegation and described facility procedures for abuse allegations |
| Administrator | Administrator | Confirmed abuse allegation and described facility procedures for abuse allegations |
Inspection Report
Plan of Correction
Census: 103
Deficiencies: 2
Date: Jul 29, 2023
Visit Reason
The inspection was conducted due to allegations of verbal and physical abuse by staff towards a resident, requiring a plan of correction to address the deficiencies.
Findings
The facility failed to protect a resident from verbal and physical abuse by staff, including yelling and pushing the resident. Multiple staff interviews and investigations confirmed the abuse allegations.
Deficiencies (2)
F600 Freedom from Abuse and Neglect: The facility failed to protect a resident from verbal and physical abuse by staff, including yelling and pushing the resident forcibly to sit down.
A4074 Protective Oversight, Voluntary Leave: The facility did not provide adequate protective oversight and supervision for residents on voluntary leave, as evidenced by the abuse findings.
Report Facts
Facility census: 103
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 6
Date: Feb 25, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation/exploitation of resident property and medication management issues.
Complaint Details
Complaint #MO00196147 regarding misappropriation of medications and resident property was substantiated as evidenced by missing narcotics and failure to secure medication carts.
Findings
The facility failed to protect residents from misappropriation of property related to missing doses of controlled medications. The facility also failed to document checking the Nurse Aide Registry prior to employment and failed to ensure a safe environment and proper care related to falls and bedrails.
Deficiencies (6)
F602: The facility failed to protect residents from misappropriation of property when staff discovered missing doses of controlled medications for two residents. Medication cart security and narcotic counts were not properly maintained.
F607: The facility failed to document checking the Nurse Aide Registry prior to the start date of one staff member, violating abuse/neglect policies.
F689: The facility failed to ensure a safe environment by not completing fall risk assessments, not locking courtyard doors, and not ensuring proper fit of wheelchairs for residents at risk of falls.
F700: The facility failed to properly assess and monitor bed rails for risk of entrapment and failed to obtain physician orders for side rail use for several residents.
F744: The facility failed to routinely assess and document the effectiveness of interventions for residents with dementia and failed to provide appropriate care plans for dementia behaviors.
F921: The facility failed to maintain a safe, functional, and sanitary environment by not ensuring the kitchen floor under the ice machine was clean and free of debris.
Report Facts
Facility census: 91
Missing oxycodone tablets: 12
Missing oxycodone tablets: 13
Missing Percocet tablets: 3
SCU census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in narcotic count discrepancies and medication cart security issues. |
| LPN D | Licensed Practical Nurse | Involved in narcotic counts and medication cart security. |
| CMT B | Certified Medication Technician | Involved in narcotic counts and medication cart security. |
| CMT E | Certified Medication Technician | Signed for medication receipt and involved in medication administration issues. |
| Housekeeper A | Housekeeper | Mentioned in relation to employee screening and background checks. |
| CNA F | Certified Nurse Aide | Witnessed medication cart issues and reported missing medication cart. |
| CNA G | Certified Nurse Aide | Assisted resident and involved in behavioral observations. |
| LPN I | Licensed Practical Nurse | Completed side rail assessments and involved in resident care. |
| CNA H | Certified Nurse Aide | Reported resident behaviors and assisted with resident care. |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 6
Date: Feb 25, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of controlled medications and other care concerns at Republic Nursing & Rehab.
Complaint Details
The complaint investigation was triggered by allegations of misappropriation of controlled medications for two residents, Resident #60 and Resident #79, with findings of missing narcotics and failure to follow medication cart security protocols.
Findings
The facility failed to protect residents from misappropriation of controlled medications, failed to complete nurse aide registry checks prior to employment, failed to complete routine fall risk assessments and care planning, failed to properly maintain bed rails and document their use, failed to assess and document effectiveness of behavioral interventions for residents with dementia, and failed to maintain cleanliness under the kitchen ice machine.
Deficiencies (6)
Failed to protect residents from misappropriation of controlled medications when staff discovered missing doses for two residents.
Failed to document checking the Nurse Aide Registry prior to the start date of one staff member.
Failed to complete routine fall risk assessments, update care plans after falls, lock wheelchair wheels, and ensure proper wheelchair fit for one resident; also failed to secure courtyard door.
Failed to assess, monitor, and document bed rail use, including obtaining physician orders and care planning for residents using bed rails.
Failed to routinely assess effectiveness of behavioral interventions and complete person-centered care plans for residents with dementia/behaviors.
Failed to ensure the floor under the kitchen ice machine was clean and free from debris.
Report Facts
Missing Percocet tablets: 3
Missing oxycodone tablets: 12
Facility census: 91
Medication counts: 13
Medication counts: 20
Medication counts: 30
Medication counts: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medication Technician | Named in medication misappropriation and narcotic count discrepancy. |
| RN C | Registered Nurse | Involved in narcotic count and investigation of missing medications. |
| LPN D | Licensed Practical Nurse | Involved in narcotic count and investigation of missing medications. |
| Housekeeper A | Named in failure to complete Nurse Aide Registry check prior to employment. | |
| Director of Nursing | DON | Involved in narcotic investigation and care plan oversight. |
| Administrator | Provided statements regarding facility policies and observations. | |
| Dietary Aide K | Provided statements regarding kitchen floor cleaning. | |
| Dietary Manager | Provided statements regarding kitchen floor cleaning. |
Inspection Report
Life Safety
Census: 91
Capacity: 127
Deficiencies: 5
Date: Feb 25, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code, including fire safety systems, means of egress, and smoke barriers.
Findings
The facility failed to ensure proper signage on exit doors, maintain a fully functional fire alarm system in the interior courtyard, maintain the integrity of fire-rated ceilings, and maintain smoke barrier walls. Deficiencies were noted in fire alarm testing, sprinkler system maintenance, and evacuation plans.
Deficiencies (5)
K200 Means of Egress Requirements - The facility failed to post 'no exit' signs on doors leading to a small interior courtyard, which could confuse residents and staff during evacuation.
K345 Fire Alarm System - The facility failed to maintain a fully functional fire alarm system in the large interior courtyard, with alarms and strobes not activating during tests.
K353 Sprinkler System - The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations around sprinkler heads, risking smoke passage during a fire.
K372 Smoke Barrier Construction - The facility failed to maintain the smoke resistive properties of smoke barrier walls, with holes and gaps observed allowing smoke passage.
K711 Evacuation and Relocation Plan - The facility failed to maintain an accurate evacuation route map, with incorrect emergency exit indications and lack of staff awareness.
Report Facts
Facility capacity: 127
Resident census: 91
Number of fire alarm notifiers tested: 12
Number of fire alarm notifiers tested: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
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
Complaint Investigation
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
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 on this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 3, 2021
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.
Complaint Details
No deficiencies were cited on this complaint investigation.
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. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 27, 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: Oct 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 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: Jul 6, 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
Complaint Investigation
Deficiencies: 0
Date: Jun 4, 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.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2020
Visit Reason
The visit was a COVID-19 Focused Emergency Preparedness and Infection Control Survey conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
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. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Census: 91
Deficiencies: 6
Date: Jul 12, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident notice of Medicare/Medicaid coverage, employee screening, resident assessments, discharge procedures, restorative nursing services, and dialysis care.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare Part A discharge notices to a resident, failure to check employee disqualification list for a new hire, incomplete and late Minimum Data Set assessments for several residents, incomplete discharge summaries, failure to provide restorative nursing services as ordered or recommended, and inadequate communication with the dialysis center for a resident receiving dialysis.
Deficiencies (6)
Failed to provide Medicare Part A discharge notices (SNFABN and NOMNC) to one resident.
Failed to check employee disqualification list prior to contact with residents for one employee.
Failed to complete quarterly and annual Minimum Data Set assessments within required timeframes for four residents.
Failed to complete a comprehensive discharge summary for one resident discharged to the community.
Failed to provide restorative nursing services as directed by therapy for two residents.
Failed to provide ongoing communication with the dialysis center for one resident receiving dialysis.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Facility census: 91
Deficiency count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Designee | Responsible for providing Medicare Part A discharge forms; noted failure in providing forms to Resident #38 | |
| Administrator | Responsible for oversight of employee disqualification list process | |
| Director of Nursing (DON) | Oversaw restorative program and commented on discharge summary process | |
| Assistant Director of Nursing (ADON) | Provided information on restorative program and dialysis communication | |
| Licensed Practical Nurse (LPN) B | Discussed restorative program process and discharge summary completion | |
| CNA G | Previous restorative aide; provided information on restorative program | |
| CNA H | Provided information on resident decline and restorative services | |
| Occupational Therapist | Described restorative program referral and order process | |
| Licensed Practical Nurse (LPN) A | Reported lack of dialysis communication paperwork | |
| Social Service Director | Not involved with dialysis appointments or communication |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 6
Date: Jul 12, 2019
Visit Reason
Annual inspection of Republic Nursing & Rehab to assess compliance with Medicare and Medicaid regulations, including review of resident care, policies, and documentation.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicaid/Medicare notices, incomplete employee disqualification checks, incomplete quarterly and annual assessments, inadequate discharge summaries, failure to provide restorative nursing services, and insufficient dialysis communication and documentation.
Deficiencies (6)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide required Medicare Part A discharge notices to one resident and did not inform residents or representatives timely about Medicare non-coverage and potential liabilities.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to check the employee disqualification list prior to contact with residents for one employee out of 12 recently hired.
F638 Qrtly Assessment at Least Every 3 Months: The facility failed to ensure timely completion of quarterly and annual Minimum Data Set (MDS) assessments for four residents out of 20 sampled.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for one resident discharged to the community.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide restorative nursing services to maintain or improve functional status for two residents out of 20 sampled.
F698 Dialysis: The facility failed to provide ongoing communication with the dialysis center for one resident and did not maintain required documentation of dialysis treatments and communication.
Report Facts
Facility census: 91
Sample size for MDS assessments: 20
Recently hired employees sampled: 12
Residents reviewed for restorative nursing: 20
Residents reviewed for dialysis: 20
Inspection Report
Annual Inspection
Census: 91
Capacity: 127
Deficiencies: 2
Date: Jul 12, 2019
Visit Reason
Annual recertification survey to assess compliance with the Life Safety Code and other regulatory requirements.
Findings
The facility failed to ensure corridor doors fit tightly within the doorframe to resist the passage of smoke, with gaps greater than a quarter inch observed on multiple doors. No emergency preparedness deficiencies were cited.
Deficiencies (2)
K363 Corridor doors did not fit tightly within the doorframe, allowing gaps greater than a quarter inch that could permit smoke passage. Multiple corridor doors were observed with these gaps during the survey.
A2054 Smoke section walls/doors did not meet the requirement for one-hour fire-rated walls and doors that close automatically upon fire alarm activation. This deficiency references K363.
Report Facts
Facility capacity: 127
Resident census: 91
Inspection Report
Plan of Correction
Census: 89
Deficiencies: 1
Date: Nov 21, 2018
Visit Reason
The inspection was conducted to address a deficiency related to failure to provide basic life support including CPR to a resident requiring emergency care, as documented in a statement of deficiencies and plan of correction.
Findings
The facility failed to provide CPR to a resident whose heartbeat and breathing had stopped, resulting in a violation of emergency care procedures. The staff member responsible was suspended and later terminated, and the facility implemented corrective actions including staff in-service training on CPR.
Deficiencies (1)
F 678 Cardio-Pulmonary Resuscitation (CPR): Personnel failed to provide basic life support including CPR to a resident requiring emergency care prior to arrival of emergency medical personnel. The facility census was 89 at the time of the incident.
Report Facts
Facility census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in the finding related to failure to initiate CPR and delayed emergency response |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding CPR procedures and staff actions during the incident |
| Administrator | Administrator | Notified of the immediate jeopardy and involved in corrective actions |
| Physician A | Physician | Interviewed regarding the resident's code status and CPR procedures |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 127
Deficiencies: 5
Date: Aug 13, 2018
Visit Reason
The inspection was conducted to investigate complaints related to residents' rights, restorative nursing services, accident prevention, medication administration, and call system functionality at Republic Nursing & Rehab.
Complaint Details
The complaint investigation substantiated multiple deficiencies related to residents' rights, restorative nursing, accident prevention, medication administration, and call system requirements.
Findings
The facility was found noncompliant in multiple areas including failure to ensure residents' choice of code status was accessible and consistent, inadequate restorative nursing services, failure to prevent accidents for a visually impaired resident, medication errors exceeding acceptable rates, and deficiencies in the resident call system.
Deficiencies (5)
F578: The facility failed to ensure a resident's choice of code status was accessible to staff and consistent across medical records, including conflicting Do Not Resuscitate (DNR) and full code orders.
F688: The facility failed to consistently provide restorative nursing services as prescribed by the physician for one resident, resulting in missed therapy sessions and decline in resident abilities.
F689: The facility failed to prevent potential accidents by not assuring a call light was within reach at all times for a visually impaired resident with a history of falls.
F759: The facility failed to maintain a medication error rate of less than five percent, with staff failing to properly administer insulin and perform blood glucose tests for multiple residents.
F919: The facility failed to provide an adequately equipped call system allowing residents to call for staff assistance, with call light activation switches missing in two toilet rooms.
Report Facts
Facility census: 90
Total licensed capacity: 127
Residents sampled for restorative nursing review: 18
Medication error rate threshold: 5
Fall risk score: 19
Inspection Report
Annual Inspection
Census: 90
Capacity: 127
Deficiencies: 5
Date: Aug 13, 2018
Visit Reason
Annual recertification survey to assess compliance with life safety code and other regulatory requirements.
Findings
The facility failed to maintain delayed egress locking devices, proper smoke compartment door operation, kitchen hood operation, emergency generator fuel quality testing, and electrical equipment safety. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (5)
K222 Delayed egress locking arrangements were not maintained, allowing front and Special Care Unit doors to remain individually operational, potentially compromising emergency egress.
K223 The door between the kitchen and dining room remained open upon fire alarm activation, allowing smoke passage and risking resident and staff safety.
K324 The kitchen hood had gaps between filters, compromising fire safety by allowing grease-laden vapors to accumulate.
K918 The facility failed to conduct an annual fuel quality test on the emergency generator's diesel supply, risking generator failure during power outages.
K919 Electrical outlets in resident rooms were obstructed by furniture, creating pressure on cords and increasing fire risk.
Report Facts
Facility capacity: 127
Resident census: 90
Report
Mar 14, 2024
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