Inspection Reports for
Rock Point Nursing Center
8477 NORTH STREET, BIRCH TREE, MO, 65438-8887
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
81% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 70
Deficiencies: 4
Date: Jan 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication management, infection control, and psychotropic medication dose reductions at Rock Point Nursing Center.
Findings
The facility was found deficient in maintaining a safe and homelike environment, failed to implement gradual dose reductions for psychotropic medications for three residents, had a medication error rate exceeding 5% due to improper insulin pen administration, and failed to implement Enhanced Barrier Precautions during tube feeding and incontinent care for one resident.
Deficiencies (4)
Failed to maintain a safe, clean, comfortable and homelike environment, including a deep crack in the dining room floor and exposed sheetrock in the hallway.
Failed to attempt gradual dose reductions (GDR) for psychotropic medications for three residents without documented contraindications.
Medication error rate exceeded 5% due to failure to prime insulin pens before administration for two residents.
Failed to implement Enhanced Barrier Precautions (EBP) during tube feeding and incontinent care for one resident.
Report Facts
Facility census: 70
Medication error rate: 7.14
Medication administration opportunities: 28
Medication errors: 2
Length of crack in dining room floor: 15
Depth of crack in dining room floor: 1
Length of missing baseboard trim: 20
Size of exposed sheetrock: 400
Number of residents sampled for GDR review: 5
Number of residents with failed GDR attempts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medical Technician | Named in medication error finding for failing to prime insulin pens before administration |
| LPN C | Licensed Practical Nurse | Named in infection control finding for not wearing gown during tube feeding |
| CNA E | Certified Nursing Assistant | Named in infection control finding for not wearing gown during incontinent care |
| NA D | Nursing Assistant | Named in infection control finding for not wearing gown during incontinent care |
| Pharmacist A | Pharmacist | Interviewed regarding medication review and GDR practices |
| Administrator | Interviewed regarding awareness of deficiencies and expectations for staff compliance | |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for insulin pen priming and infection control practices |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding facility maintenance issues including dining room floor crack |
Inspection Report
Routine
Census: 69
Deficiencies: 7
Date: Sep 29, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident care, environment, safety, and facility operations at Rock Point Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care during meals, inadequate maintenance of a safe and clean environment, failure to follow physician orders, inadequate assistance with activities of daily living such as showering, insufficient supervision during smoking, and ineffective pest control measures.
Deficiencies (7)
Failed to provide care in a manner that enhanced the resident's dignity while eating for one resident.
Failed to maintain a safe, clean, comfortable, and homelike environment with multiple maintenance issues and strong urine odors.
Failed to obtain physician's order and complete safety evaluation for use of trapeze for two residents.
Failed to provide showers at least weekly for five residents and twice weekly for one resident.
Failed to follow physician's orders for oxygen therapy and application of tubigrips for two residents.
Failed to provide adequate supervision of residents during smoking on the secured behavioral unit.
Failed to maintain an effective pest control program to control fly and gnat populations in the facility.
Report Facts
Facility census: 69
Deficiencies cited: 7
Missed showers: 2
Missed showers: 2
Missed showers: 1
Missed showers: 2
Missed showers: 3
Missed showers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Mentioned in relation to supervision during meals and wound care without applying tubigrips |
| SNA A | Student Nurse Assistant | Mentioned in relation to supervision of residents during smoking |
| PTA E | Physical Therapy Assistant | Mentioned in relation to trapeze use and therapy plans |
| Administrator | Provided statements regarding facility policies and expectations for care and supervision | |
| ADON | Assistant Director of Nursing | Provided statements regarding care standards and physician orders |
| Housekeeping Supervisor | Discussed pest control reporting and procedures | |
| Maintenance Director | Discussed pest control and maintenance requests |
Inspection Report
Routine
Census: 54
Deficiencies: 7
Date: Sep 3, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, dialysis care, pharmaceutical services, and vaccination policies at Rock Point Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to protect resident confidentiality, incomplete and inaccurate care plans, inadequate assessment and documentation of dialysis AV fistula and pommel cushion use, improper narcotic count documentation, failure of the pharmacist to ensure appropriate diagnoses for antipsychotic medication use, and failure to provide pneumococcal vaccine education and documentation.
Deficiencies (7)
Failed to ensure resident's confidential medical information was not posted in a manner the general public could observe.
Failed to ensure residents had complete, accurate and individualized care plans addressing specific needs.
Failed to assess and document the assessment of Resident #34's pommel cushion.
Failed to assess and document the assessment of Resident #13's dialysis AV fistula.
Failed to ensure staff properly documented narcotic counts for controlled substances on medication cart.
Pharmacist failed to identify the need and ensure physician documented reason for decline of gradual dose reduction and appropriate diagnosis for antipsychotic medication use.
Failed to provide information and education to resident or representative regarding pneumococcal vaccines and failed to document vaccination history and consent/refusal.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Narcotic count log missed signatures: 53
Narcotic count log total opportunities: 205
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Described use and placement of DNR bracelets on residents |
| Licensed Practical Nurse A | Licensed Practical Nurse | Discussed use of pommel cushion for Resident #34 |
| Licensed Practical Nurse B | Licensed Practical Nurse | Discussed assessment and documentation of dialysis AV fistula and narcotic count log signing |
| Director of Nursing | Director of Nursing | Provided expectations for care planning, narcotic count documentation, pharmacist medication review, and vaccination documentation |
| Pharmacy Consultant | Consultant Pharmacist | Failed to request appropriate diagnoses for antipsychotic medications and was unaware of documentation requirements |
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