Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
139 residents
Based on a February 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 139
Deficiencies: 9
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident transfers, care planning, medication administration, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in timely notification of resident transfers to hospitals, providing written bed hold policy information, accurate Minimum Data Set (MDS) assessments, comprehensive and updated care plans, consistent assistance with activities of daily living including showering, safe respiratory care including proper orders for oxygen and BIPAP, medication administration with insulin pen priming errors, and infection control practices during catheter care.
Deficiencies (9)
Failed to notify residents and/or representatives in writing of hospital transfers for multiple residents.
Failed to provide written information on bed hold policy at time of hospital transfer for several residents.
Failed to document accurate Minimum Data Set (MDS) assessments for several residents.
Failed to develop and implement complete care plans with specific interventions for individual resident needs.
Failed to update and revise care plans timely to reflect current resident conditions.
Failed to provide consistent resident care for activities of daily living, including showering, resulting in extended periods without showers for some residents.
Failed to obtain physician orders for oxygen administration and BIPAP settings for a resident using these therapies.
Failed to maintain medication error rate below 5%, with insulin pen priming errors observed during administration.
Failed to maintain proper infection control practices and implement Enhanced Barrier Protections during foley catheter care.
Report Facts
Residents affected by transfer notification deficiency: 12
Residents affected by bed hold policy notification deficiency: 4
Medication administration opportunities: 35
Medication administration errors: 3
Medication error rate: 8.57
Number of falls for Resident #34: 12
Shower opportunities missed for Resident #24 in December 2024: 6
Shower opportunities missed for Resident #24 in January 2025: 6
Shower opportunities missed for Resident #55 in December 2024: 7
Shower opportunities missed for Resident #55 in January 2025: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Failed to prime insulin pens prior to administration |
| CMT B | Certified Medication Technician | Failed to prime insulin pens prior to administration |
| CNA E | Certified Nursing Aide | Failed to perform proper hand hygiene and don gown during foley catheter care |
| RN C | Registered Nurse | Provided information on transfer notification and shower schedule |
| ADON | Assistant Director of Nursing | Provided information on transfer notification, shower schedule, and medication administration expectations |
| DON | Director of Nursing | Provided information on transfer notification, shower schedule, medication administration, and infection control expectations |
| Administrator | Provided information on transfer notification, shower schedule, medication administration, and infection control expectations |
Inspection Report
Routine
Census: 137
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically during perineal care for a resident with a Peripherally Inserted Central Catheter (PICC).
Findings
The facility failed to maintain proper infection control practices during perineal care for one resident, including failure to wash hands before and after care and improper use of Enhanced Barrier Precautions (EBP) for a resident with a PICC line. Staff interviews confirmed lapses in following the facility's infection control policies.
Deficiencies (1)
Failure to maintain infection control practices during perineal care for one resident, including not washing hands before and after care and improper use of Enhanced Barrier Precautions.
Report Facts
Census: 137
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Aide | Named in infection control deficiency related to perineal care |
| CNA B | Certified Nursing Aide | Named in infection control deficiency related to perineal care |
| LPN C | Licensed Practical Nurse | Provided interview regarding proper use of Enhanced Barrier Precautions |
| Administrator | Interviewed regarding expectations for infection control practices | |
| Director of Nursing | Interviewed regarding expectations for infection control practices | |
| Assistant Director of Nursing | Interviewed regarding expectations for infection control practices |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of resident-to-resident abuse involving two residents.
Complaint Details
Complaint #MO240165. The complaint involved failure to report a resident-to-resident altercation that resulted in injury. The investigation found no injuries observed at the time for Resident #1, injuries to Resident #2's face and left elbow, and an un-witnessed fall. The facility did not report the incident to the state licensing agency as required.
Findings
The facility staff failed to report an incident where Resident #2 pushed Resident #1, causing a fall that resulted in a head injury requiring staples and a skin tear. The facility did not notify the state licensing agency as required by policy.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Facility census: 141
Date of incident: Aug 16, 2024
Date of admission: Oct 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed and stated she was told by the state licensing agency that reporting was not required unless harm occurred | |
| Administrator | Interviewed and stated expectation that resident-to-resident altercation incidents be reported to the state licensing agency |
Inspection Report
Routine
Census: 141
Deficiencies: 11
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to notify residents and representatives of hospital transfers and bed hold policies; inaccurate resident assessments; incomplete care plans; failure to follow physician wound care orders; inadequate assistance with activities of daily living; improper use and assessment of bed rails; failure to reconcile narcotics at shift changes; and failure to label and date opened medication vials.
Deficiencies (11)
Failed to provide a safe, clean, and comfortable homelike environment with issues such as broken tiles, leaking sinks, foul odors, and pest infestation.
Failed to notify residents and/or representatives in writing of facility-initiated hospital transfers for three residents.
Failed to notify residents and/or representatives in writing of the bed hold policy at the time of hospital transfer for three residents.
Failed to document accurate Minimum Data Set (MDS) assessments for two residents.
Failed to implement care plans with specific interventions for three residents.
Failed to follow physician wound care orders for four residents with wounds, resulting in missed treatments.
Failed to provide adequate assistance with activities of daily living, including missed showers and unacknowledged resident preferences for eight residents.
Failed to appropriately assess and document informed consent and entrapment risk for bed rail use for 12 residents.
Failed to reconcile narcotics at each shift change for three medication carts.
Failed to label and date opened vials of Insulin Glargine and Tubersol in medication storage.
Failed to conduct regular maintenance assessments and entrapment risk assessments for bed frames, mattresses, and side rails for 12 residents.
Report Facts
Facility census: 141
Missed showers: 25
Missed showers: 18
Missed showers: 17
Missed showers: 12
Missed showers: 7
Missed showers: 14
Missed wound treatments: 17
Missed wound treatments: 27
Missed wound treatments: 14
Missed wound treatments: 20
Missed wound treatments: 10
Missed wound treatments: 10
Missed wound treatments: 6
Missed wound treatments: 7
Missed wound treatments: 8
Missed wound treatments: 7
Missed wound treatments: 4
Missed wound treatments: 3
Missed wound treatments: 3
Missed wound treatments: 6
Missed wound treatments: 9
Missed wound treatments: 17
Missed wound treatments: 10
Missed wound treatments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding narcotic reconciliation and medication vial dating |
| RN B | Registered Nurse | Interviewed regarding narcotic reconciliation and medication vial dating |
| Administrator | Interviewed regarding expectations for resident care, bed rails, narcotic reconciliation, and medication vial dating | |
| Certified Nursing Assistant C | CNA | Interviewed regarding maintenance requisition process |
| Social Services Designee I | Interviewed regarding transfer notification and bed hold policy | |
| MDS Coordinator | Interviewed regarding MDS assessment accuracy and care plan expectations | |
| Licensed Practical Nurse D | LPN | Interviewed regarding wound care |
| Registered Nurse A | RN | Interviewed regarding wound care and skin assessments |
| Director of Nursing | Interviewed regarding wound care expectations | |
| Pharmacy Consultant | Interviewed regarding narcotic reconciliation expectations | |
| Assistant Director of Nursing | ADON | Interviewed regarding narcotic reconciliation and bed rail use |
| Maintenance Director | Interviewed regarding entrapment assessments for side rails | |
| Care Plan/MDS Coordinator | Interviewed regarding bed rail care plan documentation |
Inspection Report
Annual Inspection
Census: 131
Deficiencies: 6
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to maintaining a safe, clean, and homelike environment, accurate resident assessments, care planning, use of restraints and side rails, and physical safety features such as handrails.
Findings
The facility was found deficient in maintaining a safe and clean environment with multiple ceiling tile issues and stains, failed to accurately code Minimum Data Set (MDS) assessments for several residents, did not develop or update individualized comprehensive care plans with specific interventions for residents, failed to properly assess and monitor the use of bed rails and side rails, and did not ensure handrails in hallways were securely attached.
Deficiencies (6)
Facility failed to maintain a safe, clean, comfortable, and homelike environment with multiple stained, broken, or missing ceiling tiles and vents.
Facility failed to accurately code the Minimum Data Set (MDS) assessments for six residents.
Facility failed to develop and implement individualized comprehensive care plans with specific interventions for two residents.
Facility failed to update and revise care plans with specific interventions tailored to meet the needs of two residents.
Facility failed to appropriately assess the use of bed rails/side rails for two residents, including lack of documentation of alternative methods, monitoring, and assessments.
Facility failed to ensure handrails on the 200 and 500 halls were properly attached to the wall.
Report Facts
Residents sampled: 26
Facility census: 131
Deficiencies cited: 6
Dates of maintenance requests: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding maintenance reporting and broken equipment | |
| Housekeeping staff E | Interviewed regarding reporting broken equipment and housekeeping issues | |
| Certified Nurse Aide (CNA) D | Interviewed regarding reporting broken equipment | |
| Licensed Practical Nurse (LPN) F | Interviewed regarding maintenance concerns and paging maintenance staff | |
| Maintenance Director | Interviewed regarding responsibility for facility maintenance and requisition process | |
| Administrator | Interviewed regarding maintenance requisitions and roof replacement | |
| MDS Coordinator | Interviewed regarding accuracy and responsibility for Minimum Data Set assessments and care plans | |
| Director of Nursing (DON) | Interviewed regarding resident assessments, care plans, and side rail assessments | |
| Certified Nursing Assistant (CNA) C | Interviewed regarding resident bed/chair alarm use | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding bed/chair alarm checks |
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