Inspection Reports for
Riverways Manor
403 WATERCRESS RD, VAN BUREN, MO, 63965-9100
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
78% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 7
Date: Sep 27, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing care, infection control, resident rights, and other regulatory requirements at Riverways Manor.
Findings
The facility was found noncompliant with several federal regulations including resident rights, Medicaid/Medicare coverage notices, accuracy of assessments, professional standards for services provided, free of accident hazards, bowel/bladder incontinence care, and infection prevention and control. Multiple residents' records and observations showed failures in privacy, notification, medication administration, assessment accuracy, and infection control practices.
Deficiencies (7)
F550 Resident Rights: The facility failed to ensure staff treated residents with dignity and respect by leaving one resident's genitalia exposed to the public during multiple observations.
F582 Medicaid/Medicare Coverage: The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to residents and/or their representatives at least two days before discharge from skilled services.
F641 Accuracy of Assessments: The facility failed to document accurate Minimum Data Set (MDS) assessments reflecting residents' status, including coding and care plans for side rails, medications, and restraints.
F658 Services Provided Meet Professional Standards: The facility failed to ensure medications were available and administered timely to residents according to physician orders and professional standards.
F689 Free of Accident Hazards: The facility failed to assess, care plan, and monitor for efficacy the use of a wheelchair seatbelt for one resident and others.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to maintain urinary indwelling catheter drainage bags off the floor and ensure proper catheter care.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices during disinfection of a glucometer and catheter care, and failed to ensure staff completed required competencies timely.
Report Facts
Facility census: 47
Residents affected: 1
Residents affected: 2
Residents sampled: 12
Residents sampled: 9
Residents sampled: 1
Residents sampled: 2
Residents sampled: 3
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 27, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey 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 was found to be in substantial compliance with the applicable provisions of the Life Safety Code. No deficiencies or licensure deficiencies were cited during this inspection.
Inspection Report
Routine
Census: 47
Deficiencies: 7
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication administration, resident assessments, catheter care, infection control, and safety measures in a nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, inaccurate resident assessments, medication administration delays and omissions, improper catheter care, inadequate infection control practices, and lack of proper assessment and care planning for wheelchair seatbelt use.
Deficiencies (7)
Failure to ensure staff treated residents with dignity and respect by leaving one resident exposed to the public.
Failure to issue Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to residents prior to discharge from skilled services.
Failure to document accurate Minimum Data Set (MDS) assessments for residents.
Failure to follow physician's orders and ensure timely medication administration for multiple residents.
Failure to assess, care plan, and monitor efficacy for the use of a wheelchair seatbelt for one resident.
Failure to ensure urinary indwelling catheter drainage bags were kept off the floor for two residents.
Failure to maintain infection control practices during disinfection of glucometer and catheter care.
Report Facts
Residents affected: 47
Missed medication doses: 13
Missed g-tube feedings: 3
Missed residual checks: 4
Missed g-tube flushes: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nursing Assistant | Named in dignity and catheter care findings |
| CNA F | Certified Nursing Assistant | Named in dignity and wheelchair seatbelt findings |
| Director of Nursing | Director of Nursing (DON) | Named in dignity, MDS accuracy, medication administration, catheter care, and seatbelt assessment findings |
| LPN C | Licensed Practical Nurse | Named in medication administration, glucometer disinfection, and catheter care findings |
| RN A | Registered Nurse | Named in medication administration and glucometer disinfection findings |
| Administrator | Facility Administrator | Named in dignity, SNF ABN, MDS accuracy, medication administration, catheter care, and seatbelt assessment findings |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Date: Jun 28, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide an appropriate facility-initiated discharge notice, discharge plan, and reassessment of a resident's status after hospital discharge, as well as refusal to allow the resident to return to the facility.
Complaint Details
Complaint investigation involved Resident #1 who was discharged from the facility to an acute care hospital due to suicidal behavior. The facility sent an emergency discharge notice but did not have documentation supporting the discharge or reassessment. The resident was not allowed to return to the facility after hospital discharge and remained in the ER for over five days awaiting placement. The resident's legal guardian and hospital staff confirmed the facility's refusal to readmit the resident.
Findings
The facility failed to provide an appropriate discharge notice and plan prior to discharging Resident #1, did not reassess the resident after hospital discharge, and refused to allow the resident to return to the facility. Documentation from the physician regarding the discharge and resident safety was lacking. The resident remained in the hospital ER for over five days due to the facility's refusal to readmit him/her.
Deficiencies (3)
Failed to provide an appropriate facility-initiated discharge notice and discharge plan prior to discharge.
Failed to reassess resident's status after hospital discharge.
Refused to allow resident to return to the facility after hospital discharge without proper documentation or reassessment.
Report Facts
Facility census: 39
Days resident boarded in ER: 5
Appeal timeframe: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #1's discharge and status |
| Administrator | Administrator | Interviewed regarding emergency discharge and refusal to readmit Resident #1 |
| Manager for Care Coordination | Manager for Care Coordination | Hospital staff interviewed regarding Resident #1's status and placement |
| Public Administrator/Guardian | Resident's Public Administrator/Guardian | Interviewed regarding lack of discharge paperwork and placement issues |
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 2
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to transfer and discharge requirements at Riverways Manor, including compliance with facility-initiated discharge notices and documentation.
Findings
The facility failed to provide appropriate discharge notices, discharge plans, and reassess residents' status after hospital discharge. Documentation from physicians regarding residents' safety risks and specific needs was missing, and the facility did not meet regulatory requirements for transfer and discharge procedures.
Deficiencies (2)
F622 Transfer and Discharge Requirements. The facility failed to provide an appropriate discharge notice, discharge plan, and reassess residents' status after hospital discharge. Documentation from physicians regarding safety risks and specific needs was not obtained.
A8018 Emergency Discharges. The facility did not submit a written notice of discharge to the resident or legally authorized representative as required in emergency discharge situations.
Report Facts
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident discharge status |
| Administrator | Administrator | Interviewed regarding resident discharge and emergency discharge notice |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 12
Date: Apr 6, 2023
Visit Reason
The inspection was conducted to identify deficiencies in compliance with federal regulations and to require a plan of correction from Riverways Manor.
Findings
The facility was found deficient in multiple areas including documentation of advance directives, Medicaid/Medicare coverage notices, safe and homelike environment, discharge planning, resident assessments, enteral nutrition care, food safety, and maintenance of handrails. The facility census was 46 at the time of inspection.
Deficiencies (12)
F578: The facility failed to ensure consistent documentation of residents' code status in medical records, including advance directives and DNR orders.
F582: The facility failed to provide timely Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices to residents prior to service changes.
F584: The facility failed to provide a safe, clean, comfortable, and homelike environment, including maintenance issues such as missing baseboards, broken shower drain cover, cracked floor tiles, and buildup of grime.
F623: The facility failed to provide proper notice requirements before resident transfer or discharge, including sending notices to the State Long-Term Care Ombudsman.
F637: The facility failed to complete a significant change Minimum Data Set (MDS) assessment within required timeframes for residents with hospice care.
F638: The facility failed to complete quarterly Minimum Data Set assessments within required timeframes for one resident.
F640: The facility failed to complete and transmit Minimum Data Set assessments timely for multiple residents.
F660: The facility failed to develop and implement an effective discharge planning process consistent with regulatory requirements.
F661: The facility failed to complete a comprehensive discharge summary and plan for one resident prior to discharge.
F693: The facility failed to ensure proper care of enteral feeding, including labeling and documentation of feeding bags and formula.
F812: The facility failed to maintain food safety standards, including proper cleaning and sanitization of kitchen equipment and food storage areas.
F924: The facility failed to maintain handrails on corridors, with several sections coming loose or detached, posing a safety risk to residents.
Report Facts
Facility census: 46
Deficiencies cited: 11
Inspection Report
Routine
Census: 46
Deficiencies: 12
Date: Apr 6, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Riverways Manor nursing home to assess compliance with federal regulations regarding resident rights, care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of residents' code status, failure to provide timely Medicare non-coverage notices, unsafe and unclean environment conditions, incomplete resident assessments and Minimum Data Set (MDS) submissions, inadequate discharge planning and summaries, improper care and labeling of enteral feeding tubes, unsanitary kitchen conditions, and unsecured handrails in hallways.
Deficiencies (12)
Failed to ensure consistent documentation of code status for residents #30 and #48.
Failed to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice timely for residents #1 and #38.
Failed to provide a safe, clean, comfortable and homelike environment; multiple maintenance and cleanliness issues observed.
Failed to send timely notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for residents #13, #30, #35, and #37.
Failed to complete a significant change Minimum Data Set (MDS) assessment for resident #48 after hospice election.
Failed to complete a quarterly MDS assessment within required timeframe for resident #12.
Failed to complete and transmit MDS tracking records timely for residents #4, #18, #19, and #46.
Failed to ensure discharge planning process addressed resident goals and needs for resident #50.
Failed to complete a comprehensive discharge summary for resident #50.
Failed to ensure proper care and labeling of enteral feeding tubes for resident #8.
Failed to store and distribute food under sanitary conditions; multiple sanitation and labeling issues in kitchen and food storage areas.
Failed to ensure handrails on Red, Blue and Therapy Halls were properly maintained and securely attached.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 46
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 46
Residents affected: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Named in enteral feeding labeling and care deficiency |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including code status, discharge planning, and enteral feeding care |
| Administrator | Administrator | Named in multiple findings including code status, Medicare notices, discharge planning, and kitchen sanitation |
| Maintenance Supervisor (MS) | Maintenance Supervisor | Named in maintenance and repair reporting deficiencies |
| Licensed Practical Nurse (LPN) G | Licensed Practical Nurse | Interviewed regarding code status documentation |
| Housekeeper A | Housekeeper | Interviewed regarding maintenance reporting |
| Certified Nursing Assistant (CNA) B | Certified Nursing Assistant | Interviewed regarding maintenance reporting |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation |
| Dish Aide E | Dish Aide | Interviewed regarding kitchen sanitation |
| Kitchen Aide F | Kitchen Aide | Interviewed regarding kitchen sanitation |
| MDS Coordinator | MDS Coordinator | Named in MDS assessment and tracking deficiencies |
Inspection Report
Life Safety
Census: 46
Deficiencies: 6
Date: Apr 6, 2023
Visit Reason
The inspection was conducted as an Emergency Preparedness and Life Safety Code survey to assess compliance with fire safety and emergency lighting regulations.
Findings
The facility failed to maintain required self-closing doors in hazardous areas, functional exit egress lighting, and sprinkler system coverage. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K223 Doors with Self-Closing Devices: The facility failed to ensure doors originally designed to have self-closures were not altered in hazardous areas including the mop closet, main housekeeping room, and oxygen storage room.
K281 Illumination of Means of Egress: The facility failed to maintain required functional exit egress lighting; exterior lighting from the 100 hall and service hall exit did not function when tested.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain required sprinkler protection; the clean side laundry room had no sprinkler coverage.
A2034 Sprinkler System-Test/Maintain: The facility did not meet inspection and maintenance requirements for the sprinkler system installed prior to August 28, 2007.
A2050 Emergency Lighting: The facility did not meet emergency lighting requirements for safety of residents and others using exits, stairways, and corridors.
A2055 Door Devices: The facility failed to have attached self-closing devices on all doors providing separation between floors; doors held open lacked electromagnetic hold-open devices interconnected with fire alarm or suppression systems.
Report Facts
Facility census: 46
Inspection Report
Routine
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: May 14, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify responsible parties of changes in resident condition and issues with drug labeling and storage.
Complaint Details
Complaint #MO00178298 was investigated and substantiated based on failure to notify responsible parties and improper drug storage and labeling.
Findings
The facility failed to notify the responsible party of a resident's change in condition and did not maintain proper policies for notification. The facility also failed to properly label and store drugs and biologics, including controlled substances, and maintain accurate narcotic counts.
Deficiencies (2)
F580 Notification of Changes. The facility failed to notify the responsible party of a change in condition for one resident and did not provide a policy on notification of responsible parties when a change occurs.
F761 Label/Store Drugs and Biologicals. The facility failed to maintain accurate documentation and accountability of controlled narcotics, including failure to discard liquid lorazepam 90 days after opening for one resident.
Report Facts
Facility census: 40
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding narcotic counts and medication accountability |
| Pharmacy Technician B | Pharmacy Technician | Interviewed regarding liquid lorazepam discard policy |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding notification policies and narcotic counts |
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 5
Date: Sep 25, 2020
Visit Reason
The inspection was conducted to identify deficiencies in the facility's compliance with regulatory requirements and to document plans of correction for those deficiencies.
Findings
The facility was found deficient in preparation for safe and orderly transfer or discharge, accuracy of assessments, comprehensive care plan timing and revision, and nurse staffing information. The facility failed to document proper transfer preparation, accurate Minimum Data Set assessments, updated care plans, and posting of nurse staffing data.
Deficiencies (5)
F624 Preparation for Safe/Orderly Transfer/Discharge: The facility failed to document preparation and orientation for transfer to the hospital for one resident and others as required.
F641 Accuracy of Assessments: The facility failed to document a complete and accurate Minimum Data Set for one resident and did not provide a policy for MDS completion.
F657 Care Plan Timing and Revision: The facility failed to revise and update the comprehensive care plan with specific interventions for one resident.
F732 Posted Nurse Staffing Information: The facility failed to post updated and accurate nurse staffing data daily, with multiple days missing or incomplete staffing sheets.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies in F624, F641, and F657.
Report Facts
Facility census: 42
Deficiencies cited: 5
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 2
Date: Sep 25, 2020
Visit Reason
The document is a plan of correction submitted following a survey related to electrical equipment and extension cords compliance.
Findings
The facility failed to maintain the facility free of surge protectors in patient care areas, which potentially affected all residents and staff. The plan of correction includes removal of surge protectors and ongoing monitoring by the Maintenance Supervisor and Administrator.
Deficiencies (2)
K 920: The facility failed to maintain the facility free of surge protectors in patient care areas, which is not compliant with NFPA 70 standards. Observation showed a power strip with multiple devices plugged in, and the maintenance director stated surge protectors should not be used and would be removed.
A3037: Extension cords and duplex receptacles were not compliant with 19 CSR 30-85.032(37) as extension cords were not Underwriters Laboratories (UL)-approved or sized properly, and were placed in locations subject to physical damage.
Report Facts
Census: 42
Inspection Report
Routine
Census: 42
Deficiencies: 4
Date: Sep 25, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, assessments, care planning, and nurse staffing documentation at Riverways Manor nursing home.
Findings
The facility was found deficient in documenting resident preparation for hospital transfers, completing accurate Minimum Data Set assessments, updating comprehensive care plans with specific interventions, and posting accurate daily nurse staffing information accessible to residents and visitors.
Deficiencies (4)
Failed to document preparation and orientation for transfer to the hospital for one resident.
Failed to document a complete and accurate Minimum Data Set (MDS) and accurately identify the type of assessment for one resident.
Failed to revise and update the comprehensive care plan with specific interventions for one resident.
Failed to post nurse updated and accurate staffing data accessible to residents and visitors on a daily basis.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 42
Census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding transfer documentation and care plan deficiencies | |
| Administrator | Interviewed regarding MDS assessment and nurse staffing posting deficiencies |
Inspection Report
Routine
Deficiencies: 0
Date: May 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/20/20 to assess compliance with CMS and CDC recommended practices and related federal 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
Complaint Investigation
Census: 34
Deficiencies: 10
Date: Mar 29, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify residents and their representatives in writing about facility-initiated transfers and failure to provide written notification of bed-hold policy at the time of transfers.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify residents and representatives of transfers and bed-hold policies, as well as multiple care and treatment deficiencies.
Findings
The facility failed to notify residents and their representatives in writing of transfers to the hospital for five of seven sampled residents. The facility also failed to provide written notification regarding their bed-hold policy at the time of transfers for five residents. Additional deficiencies were cited related to comprehensive care plans, wound care, pressure ulcer prevention, drug regimen review, psychotropic drug use, infection control, and antibiotic stewardship.
Deficiencies (10)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and their representatives in writing of facility-initiated transfers for five of seven sampled residents. The facility census was 34.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notification regarding their bed-hold policy at the time of transfers for five residents. The facility census was 34.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement a person-centered care plan with specific interventions for one resident out of a sample of 12. The facility census was 34.
F658 Services Provided Meet Professional Standards: The facility failed to obtain a wound care consult order for one resident out of 12 sampled. The facility census was 34.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to promote prevention and healing of a Stage 3 pressure ulcer and failed to prevent additional pressure injuries for one resident. The facility census was 34.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide restorative services for two residents out of two sampled. The facility census was 34.
F756 Drug Regimen Review, Report Irregular, Act On: The facility failed to ensure a pharmacist reviewed the drug regimen monthly for one resident out of five sampled. The facility census was 34.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure appropriate diagnosis and documentation for antipsychotic medication use for one resident out of five sampled. The facility census was 34.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program that met regulatory requirements. The facility census was 34.
F881 Antibiotic Stewardship Program: The facility failed to establish an antibiotic stewardship program that included protocols and monitoring. The facility census was 34.
Report Facts
Facility census: 34
Residents sampled: 7
Residents sampled: 12
Residents sampled: 5
Residents sampled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Young | Administrator | Signed plan of correction and mentioned in interviews |
| Director of Nursing (DON) | Interviewed regarding transfer notifications, bed hold policy, care plans, wound care, infection control, and medication reviews | |
| Licensed Practical Nurse (LPN) | Interviewed regarding transfer notifications and bed hold policy | |
| Certified Nursing Assistant (CNA) | Interviewed regarding resident care and restorative nursing | |
| Wound Care Consultant F | Interviewed regarding wound care consultations | |
| Nurse Consultant | Involved in antibiotic stewardship program |
Inspection Report
Life Safety
Census: 34
Deficiencies: 4
Date: Mar 29, 2019
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 regulations.
Findings
The facility failed to maintain adequate emergency exit illumination and failed to maintain the facility free of surge protectors. These deficiencies potentially affected all residents and staff.
Deficiencies (4)
K281: The facility failed to maintain adequate emergency exit illumination as required by NFPA 101. The exit leading from the service hall had no emergency illumination.
K920: The facility failed to maintain the facility free of surge protectors, as evidenced by an industrial hair dryer plugged into a surge protector in the Beauty Shop.
A2050: Facilities shall have emergency lighting of sufficient intensity for safety, supplied by an emergency service or battery system. This regulation was not met as evidenced by K281.
A3037: Extension cords must be UL-approved and not used as a substitute for fixed wiring. This regulation was not met as evidenced by K920.
Report Facts
Facility census: 34
Inspection Report
Plan of Correction
Census: 30
Deficiencies: 8
Date: Apr 26, 2018
Visit Reason
The document is a Plan of Correction submitted by Riverways Manor following a survey conducted on 04/26/2018. It addresses deficiencies cited during the inspection related to resident transfers, bed-hold policies, significant change assessments, discharge summaries, infection control, hospice services, and other regulatory requirements.
Findings
The facility failed to notify residents and their representatives in writing about transfers to hospitals and failed to notify the Ombudsman. The facility also failed to provide written notification of bed-hold policies, complete significant change assessments, discharge summaries, and ensure proper infection control and hospice service coordination. Bedtime snacks were not consistently offered to residents.
Deficiencies (8)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents, their representatives, and the Ombudsman in writing about transfers to hospitals for sampled residents. The facility census was 30.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notification regarding their bed-hold policy to two residents. The facility census was 30.
F637 Comprehensive Assessment After Significant Change: The facility failed to recognize and complete assessments for significant changes in status for three residents. The facility census was 30.
F644 Coordination of PASARR and Assessments: The facility failed to notify the appropriate state authority for a Level II PASARR evaluation and determination for one resident. The facility census was 30.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for one resident out of two sampled discharged residents. The facility census was 30.
F809 Frequency of Meals/Snacks at Bedtime: The facility failed to ensure bedtime snacks were offered to all residents, potentially affecting all residents. The facility census was 30.
F849 Hospice Services: The facility failed to coordinate hospice care and ensure proper agreements and communication with hospice providers for one resident out of 15 sampled residents. The facility census was 30.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including proper techniques for ice pass, wound care, and glucometer disinfection for sampled residents. The facility census was 30.
Report Facts
Facility census: 30
Sampled residents: 15
Sampled discharged residents: 2
Residents with significant change: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas King | Administrator | Signed the Plan of Correction and is referenced in interviews regarding notification failures. |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding notification failures, bed-hold policy, discharge summaries, infection control, and hospice services. |
| Licensed Practical Nurse (LPN) D | Licensed Practical Nurse | Observed during wound care and infection control procedures. |
| Licensed Practical Nurse (LPN) E | Licensed Practical Nurse | Observed performing blood sugar screens and glucometer cleaning. |
Inspection Report
Life Safety
Census: 30
Deficiencies: 5
Date: Apr 25, 2018
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 discharge pathways, emergency lighting, exit signage, fire sprinkler system maintenance, and smoke barrier doors. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (5)
K271 Discharge from exits: The facility failed to maintain exit pathways to a public way, including uneven surfaces and obstructions in the exit path.
K291 Emergency lighting: The facility failed to maintain emergency task lighting on the generator, affecting medication preparation during power outages.
K293 Exit signage: The facility failed to maintain and test exit signage for evacuation, including lack of functional testing and test features.
K353 Sprinkler system maintenance: The facility failed to maintain the fire sprinkler system, with loaded sprinkler heads covered in dust, debris, paint, and tape.
K374 Smoke barrier doors: The facility failed to maintain smoke barrier doors, including painted-over fire resistance rating tags and missing tags.
Report Facts
Facility census: 30
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