Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
87 residents
Based on a November 2024 inspection.
Census over time
Inspection Report
Routine
Census: 87
Deficiencies: 10
Date: Nov 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident trust fund management, surety bond adequacy, employee background checks, resident assessments, physician order adherence, discharge procedures, food safety, quality assurance meetings, and infection control practices.
Findings
The facility had multiple deficiencies including inaccurate resident trust fund accounting, insufficient surety bond coverage, failure to complete background checks prior to employment, incomplete significant change assessments, inaccurate Minimum Data Set documentation, failure to follow physician orders for resident weights, incomplete discharge summaries, improper food storage and handling, inadequate Quality Assurance committee meetings, and lapses in infection prevention and control practices including failure to implement enhanced barrier precautions and improper PPE use during wound and catheter care.
Deficiencies (10)
Failed to maintain accurate accounting of resident trust fund petty cash with discrepancies noted.
Failed to maintain surety bond at required level based on residents' personal funds balance.
Failed to complete Criminal Background Check, Employee Disqualification List, and Nurse Aide Registry checks prior to employment for three employees.
Failed to complete significant change Minimum Data Set assessment within required timeframe for hospice admission and discharge for one resident.
Failed to document accurate Minimum Data Set assessments for two residents including incorrect discharge location and catheter coding.
Failed to follow physician orders for weekly weights for two residents with multiple missed opportunities.
Failed to complete comprehensive discharge summary including recapitulation of stay, medication reconciliation, and post-discharge plan of care for one resident.
Failed to store and distribute food under sanitary conditions including serving cold food above required temperature, unsealed food packages, and improper glove use by dietary staff.
Failed to maintain quarterly Quality Assessment and Assurance meetings with required members including Medical Director and Infection Preventionist.
Failed to implement infection prevention and control program including improper use of enhanced barrier precautions, lack of signage and PPE availability, failure to wear gowns during wound and catheter care, and lapses in hand hygiene and glove changes during peri care.
Report Facts
Facility census: 87
Resident trust fund petty cash balance: 553.88
Resident trust fund petty cash counted: 453.88
Surety bond amount: 65000
Average monthly balance of residents' personal funds: 43973.75
Required surety bond amount: 66000
New surety bond amount: 75000
Number of employees with incomplete background checks: 3
Number of residents sampled: 18
Missed weekly weight opportunities for Resident #8: 5
Missed weekly weight opportunities for Resident #25: 10
Number of QAPI meetings missing required members: 3
Temperature of cheesecake served: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse J | Licensed Practical Nurse | Named in wound care PPE deficiency |
| Certified Nurse Assistant E | Certified Nurse Assistant | Named in peri care infection control deficiency |
| Certified Nurse Assistant F | Certified Nurse Assistant | Named in peri care infection control deficiency |
| Certified Nurse Assistant G | Certified Nurse Assistant | Named in peri care infection control deficiency |
| Certified Nurse Assistant L | Certified Nurse Assistant | Named in catheter care infection control deficiency |
| Certified Nurse Assistant M | Certified Nurse Assistant | Named in catheter care infection control deficiency |
| Certified Medication Technician H | Certified Medication Technician | Named in catheter care infection control deficiency |
| Certified Nurse Assistant I | Certified Nurse Assistant | Named in catheter care infection control deficiency |
| Certified Nurse Assistant K | Certified Nurse Assistant | Named in catheter care infection control deficiency |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in discharge summary deficiency |
| Administrator | Administrator | Named in multiple deficiencies including QAPI meetings and discharge summary |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including QAPI meetings and discharge summary |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in multiple deficiencies including QAPI meetings and discharge summary |
| Business Office Manager | Business Office Manager | Named in resident trust fund and surety bond deficiencies |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in resident trust fund deficiency |
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in resident trust fund deficiency |
| MDS Coordinator | MDS Coordinator | Named in significant change and MDS accuracy deficiencies |
| Dietary Manager | Dietary Manager | Named in food storage and handling deficiency |
| Infection Preventionist | Infection Preventionist | Named in infection control deficiency |
Inspection Report
Routine
Census: 83
Deficiencies: 4
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, physician orders, dialysis care, medication management, and overall facility operations.
Findings
The facility failed to implement individualized care plans for residents, obtain and maintain physician orders for treatments such as oxygen therapy, provide adequate monitoring and communication for residents receiving dialysis, and ensure expired or discontinued medications were properly discarded. Several residents' care plans lacked specific interventions and measurable goals, and documentation of dialysis assessments and communication was missing.
Deficiencies (4)
Failed to implement a care plan with specific interventions tailored to meet individual needs of five residents.
Failed to obtain physician's orders for four residents for treatments including oxygen therapy.
Failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and dialysis center for two residents receiving dialysis.
Failed to ensure staff discarded expired stock medication and discontinued or expired medications for residents.
Report Facts
Residents affected: 5
Residents affected: 4
Residents affected: 2
Residents affected: 2
Facility census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan requirements and oxygen order deficiencies | |
| Regional Registered Nurse | Interviewed regarding care plan requirements, dialysis communication, and oxygen order deficiencies | |
| Administrator | Interviewed regarding care plan requirements, dialysis policy adherence, and medication management | |
| Licensed Practical Nurse (LPN) I | Interviewed regarding expired medication disposal responsibilities |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 10, 2022
Visit Reason
The inspection was conducted as a standard annual survey of Southbrook Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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