Inspection Reports for
Rocky Ridge Manor
3111 HIGHWAY A, MANSFIELD, MO, 65704-8105
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
6.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
74% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Date: Jan 13, 2026
Visit Reason
The inspection was conducted due to a complaint alleging that the facility failed to timely report and properly investigate an allegation of abuse involving one resident (Resident #1) and a staff member (Restorative Nurse Aide E).
Complaint Details
Complaint #2713651 involved an allegation by Resident #1 that Restorative Nurse Aide E asked the resident to suck his/her breast and play with him/her. The facility failed to report this allegation to the state within two hours and did not conduct a full investigation. The accused staff was not suspended and continued to work. The Administrator acknowledged the allegation should have been reported and investigated.
Findings
The facility failed to report allegations of possible abuse immediately to the Administrator and within two hours to the state licensing agency. Additionally, the facility did not complete a full and documented investigation of the abuse allegation, and the accused staff member was not suspended pending investigation.
Deficiencies (2)
Failed to timely report suspected abuse to the Administrator and state licensing agency within two hours.
Failed to complete and document a full investigation of all allegations of abuse with steps taken to protect residents during the investigation.
Report Facts
Facility census: 48
Complaint number: 2713651
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA E | Restorative Nurse Aide | Accused staff member in the abuse allegation |
| CMT F | Certified Medication Technician | Witness present during the resident's accusation and interview |
| DON | Director of Nursing | Documented resident's accusation and conducted limited investigation |
| Administrator | Acknowledged failure to report and investigate abuse allegation |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Apr 30, 2025
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, and misappropriation of resident rights at Rocky Ridge Manor.
Complaint Details
The complaint investigation was substantiated. The facility failed to treat residents with dignity and respect, withheld smoke breaks improperly, failed to report abuse allegations timely, and did not conduct full investigations into abuse allegations involving Resident #1.
Findings
The facility failed to ensure residents were treated with dignity, specifically regarding withholding smoke breaks without proper authorization. The facility also failed to report allegations of abuse in a timely manner and did not conduct a full investigation into abuse allegations involving one resident.
Deficiencies (5)
F550 Resident Rights: The facility failed to ensure all residents were treated in a dignified manner when staff withheld a resident's smoke breaks without proper authorization.
F609 Reporting of Alleged Violations: The facility failed to report allegations of abuse involving one resident to management and the state licensing agency in a timely manner and did not complete a full investigation.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to complete and document a full investigation of all allegations of abuse and failed to protect residents during the investigation.
A8023 Develop/Implement A/N Policies: The facility did not develop and implement policies to prohibit mistreatment, neglect, and abuse of residents as required.
A8030 Dignity/Privacy: The facility failed to treat residents with full recognition of their dignity and individuality, referencing the issues noted in F550.
Report Facts
Facility census: 49
Admission date: 2025
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 3
Date: Apr 30, 2025
Visit Reason
The inspection was conducted due to complaints regarding the treatment of a resident's rights and allegations of abuse involving Resident #1 at Rocky Ridge Manor.
Complaint Details
The complaint involved Resident #1 who was denied smoke breaks by the Social Services Director (SSD) as a form of punishment despite not having a guardian's permission. The resident also alleged abuse by staff, including verbal and physical abuse, which was not reported to the state licensing agency in a timely manner. The facility failed to fully investigate these allegations and did not suspend accused staff pending investigation.
Findings
The facility failed to ensure residents were treated with dignity when a staff member withheld a resident's smoke breaks improperly. Additionally, the facility failed to timely report and fully investigate two allegations of abuse involving the same resident, including failure to notify the state licensing agency and incomplete investigations.
Deficiencies (3)
Failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights by improperly withholding a resident's smoke breaks.
Failed to timely report allegations of abuse to management and the state licensing agency within required timeframes.
Failed to complete and document a full investigation of all allegations of abuse, including steps taken to protect residents during the investigation.
Report Facts
Facility census: 49
Admission date: Jan 21, 2025
MDS assessment date: Feb 3, 2025
Care plan revision date: Apr 1, 2025
Progress note date: Apr 16, 2025
Progress note date: Mar 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director (SSD) | Social Services Director | Named in findings related to withholding smoke breaks and handling abuse allegations |
| Certified Nurse's Aide (CNA) A | Certified Nurse's Aide | Interviewed regarding resident rights and abuse reporting |
| Certified Nurse's Aide (CNA) B | Certified Nurse's Aide | Interviewed regarding resident rights and abuse reporting |
| Certified Medication Technician (CMT) D | Certified Medication Technician | Interviewed regarding resident rights and abuse reporting |
| Registered Nurse (RN) E | Registered Nurse | Interviewed regarding abuse reporting procedures |
| Business Office Manager (BOM) | Business Office Manager | Interviewed regarding abuse reporting and facility policies |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding abuse reporting and resident rights |
| Administrator | Administrator | Interviewed regarding abuse investigations and facility policies |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Jan 15, 2025
Visit Reason
The inspection was conducted in response to allegations of sexual abuse and neglect involving residents at Rocky Ridge Manor.
Complaint Details
The complaint investigation substantiated multiple incidents of sexual abuse by Resident #1 towards other residents. The facility failed to report all allegations timely and did not implement adequate interventions or care plans to prevent further abuse.
Findings
The facility failed to protect residents from sexual abuse by other residents and did not adequately investigate or intervene in reported incidents. Staff did not implement appropriate care plans or interventions to prevent further abuse.
Deficiencies (5)
F600 Freedom from Abuse and Neglect: The facility failed to protect residents from sexual abuse by other residents and did not implement effective interventions to prevent further incidents.
F609 Reporting of Alleged Violations: The facility failed to report all allegations of resident-to-resident abuse to the State Survey Agency within the required two-hour timeframe.
A4074 Protective Oversight, Voluntary Leave: The facility did not provide adequate protective oversight and supervision for residents on voluntary leave.
A8023 Develop/Implement Abuse/Neglect Policies: The facility failed to develop and implement policies prohibiting abuse, neglect, and misappropriation of resident property.
A8025 Report Abuse/Neglect to DHSS/DMH When Needed: The facility did not ensure timely reporting of suspected abuse or neglect to the Department of Health and Senior Services.
Report Facts
Facility census: 49
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Director of Nursing | Documented sexual inappropriate behaviors and involved in care planning |
| Jane Doe | Registered Nurse | Reported sexual abuse incidents and educated resident |
| Mary Johnson | Licensed Practical Nurse | Reported resident behaviors and involved in care interventions |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Jan 15, 2025
Visit Reason
The inspection was conducted due to allegations of sexual abuse by one resident towards other residents, focusing on the facility's failure to protect residents from abuse and to report allegations to the State Survey Agency within the required timeframe.
Complaint Details
The complaint investigation focused on Resident #1's sexually abusive behaviors towards Residents #2, #3, and #4. The facility failed to implement new care plans or interventions to prevent further abuse and failed to report multiple abuse allegations to the State Survey Agency within the required two-hour timeframe.
Findings
The facility failed to protect residents from sexual abuse by Resident #1, who exhibited sexually inappropriate behaviors towards multiple residents. Staff failed to implement new interventions or care plans to prevent further abuse. Additionally, the facility failed to timely report multiple allegations of abuse to the State Survey Agency as required.
Deficiencies (2)
Failed to protect residents from sexual abuse by Resident #1 exhibiting sexually inappropriate behaviors towards other residents.
Failed to timely report allegations of resident-to-resident sexual abuse to the State Survey Agency within the required two hours.
Report Facts
Facility census: 49
15-minute checks: 1
Dates of documented incidents: Multiple dates including 11/18/24, 11/20/24, 12/01/24, 12/09/24, 12/17/24, and 01/06/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Reported Resident #1's sexual abuse behaviors to DON and considered the behaviors sexual abuse |
| LPN C | Licensed Practical Nurse | Updated care plans, reported sexual abuse behaviors to physician, DON, and Administrator, stated abuse should have been reported to DHSS |
| SSD | Social Services Director | Had conversations with Resident #1 about inappropriate behaviors, aware of reporting requirements, stated Administrator responsible for reporting abuse |
| DON | Director of Nursing | Notified of Resident #1's behaviors, responsible for oversight of care and reporting |
| Administrator | Facility Administrator | Acknowledged Resident #1's behaviors and reporting failures, responsible for reporting to DHSS |
| CNA H | Certified Nurse Aide | Witnessed sexual abuse behaviors and reported to charge nurse and DON |
| CNA F | Certified Nurse Aide | Reported Resident #1 on 15-minute checks due to sexual behaviors |
| CNA E | Certified Nurse Aide | Reported Resident #1's inappropriate sexual behaviors to charge nurse |
| CMT D | Certified Medication Tech | Reported witnessing sexual abuse and stated reporting responsibilities |
| Nurse Practitioner | Nurse Practitioner | Aware of Resident #1's behaviors and monitoring, involved in care |
| Physician | Physician | Notified of Resident #1's behaviors, stated behaviors beyond facility capability |
Inspection Report
Life Safety
Census: 39
Capacity: 65
Deficiencies: 6
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents, focusing on building construction type, sprinkler system maintenance, and smoke barrier integrity.
Findings
The facility failed to maintain the integrity of the building construction by allowing unsealed penetrations in ceilings and sprinkler heads, and failed to maintain the smoke resistive properties of smoke barrier walls. These deficiencies had the potential to affect all residents, staff, and visitors in the event of a fire.
Deficiencies (6)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and areas below, allowing smoke passage. Eight resident rooms had bathroom vents terminating in the attic, and vents above the kitchen were unsealed.
K353: The facility failed to maintain the sprinkler system by allowing unsealed penetrations around sprinkler heads, including holes and missing escutcheons in ceilings. No policy was provided for checking sprinklers.
K372: The facility failed to maintain the smoke resistive properties of smoke barrier walls due to unsealed gaps at the roof deck, allowing smoke passage between compartments. No policy was provided for checking smoke barriers.
A2034: Facilities with sprinkler systems installed prior to August 28, 2007, must inspect, maintain, and test these systems per regulations. This requirement was not met.
A2054: Smoke sections must be separated by one-hour fire-rated walls with self-closing doors. This requirement was not met.
A3001: The building must be substantially constructed and maintained in good repair per construction standards. This requirement was not met.
Report Facts
Facility capacity: 65
Census: 39
Inspection Report
Routine
Census: 39
Deficiencies: 10
Date: Sep 12, 2024
Visit Reason
Routine inspection of Rocky Ridge Manor nursing home to assess compliance with regulatory standards including resident care, infection control, activities, and staff competency.
Findings
The facility had multiple deficiencies including failure to accommodate resident needs for call light placement, incomplete PASARR screening, failure to update care plans for hospice services, inadequate assistance with activities of daily living, insufficient meaningful activities programming, improper catheter and wound care infection control practices, delayed pain management, lack of trauma-informed care for a resident with PTSD, incomplete nurse aide competency evaluations, and failure to maintain a clean and safe environment.
Deficiencies (10)
Failed to provide reasonable accommodation for a resident by not placing the call light within reach.
Failed to complete required PASARR screening prior to or upon admission for one resident.
Failed to update care plans to include hospice services for two residents.
Failed to assist a resident with peri-care following incontinence and toileting.
Failed to provide an ongoing program of meaningful activities based on residents' interests and abilities.
Failed to provide appropriate care and infection control during wound care and catheter care, including failure to perform hand hygiene and improper use of PPE.
Failed to provide timely and effective pain management for a resident with frequent severe pain.
Failed to provide trauma-informed care by not addressing PTSD diagnosis, triggers, and interventions in the care plan and not informing staff.
Failed to complete annual competency evaluations and performance reviews for two certified nurse aides.
Failed to maintain a sanitary and comfortable environment including unclean ice machine exterior, dirty light fixtures, vents, and ceiling areas.
Report Facts
Facility census: 39
Deficiencies cited: 10
Resident count in activity sign-in sheets: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN L | Registered Nurse | Observed providing wound and catheter care with infection control deficiencies |
| CNA C | Certified Nurse Aide | Mentioned in relation to pain reporting and peri-care deficiencies |
| CNA D | Certified Nurse Aide | Mentioned in relation to call light placement and peri-care |
| CNA F | Certified Nurse Aide | Mentioned in relation to hospice care knowledge and pain reporting |
| CNA G | Certified Nurse Aide | Mentioned in relation to hospice care and trauma-informed care knowledge |
| CNA J | Certified Nurse Aide | Mentioned in relation to peri-care procedures |
| CNA P | Certified Nurse Aide | Mentioned in relation to resident agitation and PTSD knowledge |
| RN H | Registered Nurse | Mentioned in relation to call light placement, pain management, and wound care |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care plan expectations, pain management, and staff competencies |
| Activities Director | Activities Director | Mentioned in relation to activity programming deficiencies and resident engagement |
| Administrator | Administrator | Provided interviews regarding facility expectations and deficiencies |
| Corporate QA RN | Quality Assurance Registered Nurse | Provided interviews regarding policies and staff competencies |
| Dietary Aide A | Dietary Aide | Mentioned in relation to ice machine cleaning |
| Dietary Aide B | Dietary Aide | Mentioned in relation to ice machine cleaning |
| Dietary Manager | Dietary Manager | Mentioned in relation to cleaning schedules and responsibilities |
| Maintenance Director | Maintenance Director | Mentioned in relation to cleaning responsibilities for lights and vents |
| Licensed Practical Nurse K | Licensed Practical Nurse | Mentioned in relation to knowledge of activities and trauma-informed care |
| Certified Medication Technician E | Certified Medication Technician | Mentioned in relation to pain medication administration |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Date: Dec 18, 2023
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, and mistreatment involving a resident at Rocky Ridge Manor.
Complaint Details
The complaint investigation was substantiated. The facility failed to timely report and investigate an allegation of abuse involving Resident #1 and a Certified Nurse Assistant (CNA J). The investigation showed delays in reporting to administration and state authorities, and failure to protect residents during the investigation.
Findings
The facility failed to report alleged abuse in a timely manner and did not immediately investigate the allegation. Multiple staff interviews and record reviews showed delays in reporting and investigating abuse involving Resident #1 and a staff member.
Deficiencies (3)
F609: The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately as required by regulation.
F610: The facility failed to immediately investigate an allegation of abuse involving Resident #1 and a staff member, and failed to take immediate steps to protect residents during the investigation.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property, and failed to require timely reporting to the department.
Report Facts
Facility census: 32
Admission date: Feb 1, 2023
MDS assessment date: Nov 16, 2023
Abuse and Neglect Hotline report date: Dec 10, 2023
Follow-up investigation report date: Dec 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager I | Received text message about alleged abuse and reported to Administrator | |
| Director of Nursing | DON | Called by Administrator to report alleged abuse and conducted investigation |
| Certified Nurse Assistant | CNA J | Alleged perpetrator of abuse against Resident #1 |
| Dietary Aide | DA G | Witnessed CNA J restraining and yelling at Resident #1 and reported to supervisor |
| Administrator | Received reports of abuse and initiated investigation |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Dec 18, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and appropriately respond to an allegation of employee-to-resident abuse involving one resident (Resident #1).
Complaint Details
The complaint involved an allegation that CNA J restrained and was rough with Resident #1 on 12/08/23. The allegation was reported late by Dietary Aide G on 12/09/23. The facility delayed reporting to the state survey agency until 12/09/23 evening. The investigation included interviews with multiple staff and confirmed delayed reporting and failure to immediately protect residents during the investigation.
Findings
The facility failed to report an allegation of abuse immediately to administration and within two hours to the state survey agency. The investigation revealed that staff delayed reporting the abuse, and the alleged perpetrator was suspended pending investigation. The facility policies require immediate reporting and suspension of employees alleged to commit abuse.
Deficiencies (2)
Failed to timely report suspected abuse involving one resident to administration and state survey agency within two hours.
Failed to immediately investigate and respond appropriately to an allegation of abuse involving one resident and a staff member.
Report Facts
Facility census: 32
Date of alleged abuse: Dec 8, 2023
Date abuse reported to Administrator: Dec 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nurse Assistant | Alleged perpetrator of abuse against Resident #1 |
| Dietary Aide G | Dietary Aide | Witnessed abuse and reported allegation late via text message |
| Dietary Manager I | Dietary Manager | Received text message from Dietary Aide G and reported allegation to Administrator |
| Director of Nursing | Director of Nursing (DON) | Reported abuse to state survey agency and involved in investigation |
| Administrator | Facility Administrator | Received abuse report from Dietary Manager and initiated investigation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility Rocky Ridge Manor to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
The inspection was conducted as an annual recertification survey and licensure inspection/complaint investigation for Rocky Ridge Manor.
Findings
No federal health deficiencies were cited as a result of the annual recertification survey. No state licensure deficiencies were cited as a result of the inspection and complaint investigation.
Inspection Report
Life Safety
Census: 28
Capacity: 65
Deficiencies: 2
Date: Nov 18, 2022
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and building construction standards.
Findings
The facility failed to maintain the smoke resistive properties of corridor doors, with several doors not latching or sealing properly, creating potential fire and smoke hazards. The building was found not to meet the applicable provisions of the 2012 edition of the Life Safety Code.
Deficiencies (2)
K363 Corridor - Doors: The facility failed to ensure all corridor doors latched and sealed properly, allowing potential smoke passage during a fire. Specific doors in resident rooms 308, 303, and 203 had gaps or did not fully close.
A3001 Substantially Constructed/Maintained: The building is not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2).
Report Facts
Facility capacity: 65
Resident census: 28
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 4
Date: Jul 29, 2021
Visit Reason
The visit was conducted as an abbreviated survey triggered by an Immediate Jeopardy (IJ) situation related to physical restraints and allegations of abuse at Rocky Ridge Manor.
Complaint Details
The complaint investigation found an imminent danger class I level violation related to abuse and improper use of physical restraints. The facility was found to have an Immediate Jeopardy level violation which was removed after corrective actions were implemented.
Findings
The facility failed to ensure residents were free from physical restraints imposed for staff convenience without physician orders. An investigation found that a Registered Nurse physically restrained a resident with a bed sheet without proper authorization, leading to an Immediate Jeopardy. The facility implemented corrective actions to address the deficiencies.
Deficiencies (4)
F-604: The resident was physically restrained with a bed sheet against their wishes and without a physician's order. The facility failed to ensure residents were free from physical restraints imposed for discipline or convenience.
F-610: The facility failed to immediately begin an investigation and take steps to protect all residents from abuse when a staff member was witnessed physically restraining a resident. The facility did not report the incident timely to the State Survey Agency.
A-4073: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, as required by regulation.
A-8026: The facility failed to ensure that physical or chemical restraints were authorized by a physician for a specified period of time. The resident was restrained without a physician order.
Report Facts
Facility census: 39
Date of survey: Jul 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in physical restraint and abuse findings involving improper use of a bed sheet restraint |
| SSD D | Social Services Director | Involved in intervention with the restrained resident |
| CNA F | Certified Nurse Aide | Witnessed and reported behaviors related to restraint use |
| LPN C | Licensed Practical Nurse | Reported resident behaviors and involvement in restraint incident reporting |
| NA B | Nurse Aide | Reported on resident behaviors and restraint incident |
| MDS/Care Plan Coordinator G | Provided information on facility training and policies | |
| Medical Director | Primary Physician | Provided statements regarding restraint incident |
| Administrator | Provided statements on facility policies and training |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 19, 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
Routine
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and 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 15, 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: Jun 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
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
Plan of Correction
Census: 42
Deficiencies: 5
Date: Oct 24, 2019
Visit Reason
The inspection was conducted to identify deficiencies related to Medicaid/Medicare coverage notices, code status documentation, respiratory care, bedrails, and immunizations at Rocky Ridge Manor.
Findings
The facility failed to provide required Medicaid/Medicare coverage notices to residents, did not consistently document residents' code status, failed to obtain physician orders and provide proper care for respiratory equipment, did not complete timely side rail assessments, and failed to provide pneumococcal vaccines to residents as required.
Deficiencies (5)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notices or denial letters for Medicare Part A benefits to sampled residents. The facility census was 42.
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to consistently document a resident's code status and include it in the care plan for one resident in a sample of 17. The facility census was 42.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain physician orders and provide proper cleaning and maintenance for a BiPAP machine for one resident in a sample of 17. The facility census was 42.
F700 Bedrails: The facility failed to obtain physician orders for side rail usage and complete timely side rail assessments for two residents in a sample of 17. The facility census was 42.
F883 Influenza and Pneumococcal Immunizations: The facility failed to provide pneumococcal vaccines or obtain refusals for four residents and failed to provide influenza vaccines or obtain refusals for two residents. The facility census was 42.
Report Facts
Facility census: 42
Sample size: 17
Residents affected: 4
Residents affected: 2
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 24, 2019
Visit Reason
The visit was an annual recertification survey and licensure inspection to assess compliance with life safety code and state licensure requirements.
Findings
No emergency preparedness deficiencies or state licensure deficiencies were cited as a result of this annual recertification and licensure inspection. The facility meets the applicable provisions of the 2012 edition of the Life Safety Code.
Inspection Report
Routine
Census: 42
Deficiencies: 5
Date: Oct 24, 2019
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid regulations including notification of Medicare coverage and liability, code status documentation, respiratory care, side rail safety, and immunization policies and practices.
Findings
The facility was found deficient in multiple areas including failure to provide Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) at Medicare discharge, inconsistent documentation and inclusion of resident code status in care plans, lack of physician orders and cleaning protocols for BIPAP machines, failure to complete timely side rail assessments and obtain physician orders, and failure to provide pneumococcal vaccines and obtain proper consents for influenza vaccines.
Deficiencies (5)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter at initiation, reduction, or termination of Medicare Part A benefits for two residents.
Failed to consistently document a resident's code status and include it in the care plan for one resident.
Failed to obtain physician order and provide proper cleaning and maintenance for a Bilevel Positive Airway Pressure (BIPAP) machine for one resident.
Failed to obtain physician's orders for side rail usage and failed to complete timely side rail assessments including entrapment zone measurements for two residents.
Failed to provide pneumococcal vaccines to four residents following admission and failed to obtain consent prior to administering influenza vaccine for two residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding BIPAP machine use and code status documentation |
| DON | Director of Nursing | Interviewed regarding SNFABN issuance, code status policies, BIPAP orders, side rail process, and immunization procedures |
| BOM | Business Office Manager | Responsible for issuing SNFABN; interviewed about failure to issue notices |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding code status documentation, side rail assessments, and immunization administration |
| CNA B | Certified Nurse Aide | Interviewed about resident code status location |
| CNA D | Certified Nurse Aide | Interviewed about side rail usage |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 7, 2018
Visit Reason
The inspection was conducted as an annual recertification survey and licensure inspection of Rocky Ridge Manor.
Findings
No federal deficiencies were cited as a result of the annual recertification survey. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Annual Inspection
Census: 46
Capacity: 65
Deficiencies: 8
Date: Sep 7, 2018
Visit Reason
Annual recertification survey to assess compliance with Life Safety Code and other regulatory requirements.
Findings
The facility failed to meet several Life Safety Code requirements including delayed egress locking devices, kitchen exhaust hood maintenance, fire sprinkler system maintenance, and electrical system safety in resident rooms. Deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (8)
K222 Delayed egress locking systems failed to unlock doors within required time, potentially affecting all residents, staff, and visitors. The facility had a capacity of 65 with a census of 46.
K324 The kitchen exhaust hood fan was inoperable, allowing grease buildup and smoke hazards, potentially affecting all residents, staff, and visitors.
K352 Fire sprinkler heads near the kitchen exhaust hood were covered with debris and grease, risking delayed activation during a fire.
K911 Electrical system was compromised by furniture placing pressure on outlets in resident rooms, creating a fire hazard.
A2017 Range hood certification was not current as required by NFPA 96 standards.
A2034 Sprinkler system inspection and maintenance requirements were not met as per regulations.
A2037 Exit requirements for unobstructed exits and fire-rated separations were not met.
A3030 Electrical wiring and equipment maintenance did not comply with NFPA 70 standards.
Report Facts
Facility capacity: 65
Census: 46
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