8 Reports
Inspection Report — Sep 26, 2023
Complaint Investigation
Date: Sep 26, 2023
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the file documents a complaint investigation and includes complaint number MO00223996.
Complaint Details
MO00223996; substantiation not stated in the document.
Findings
Two deficiencies were cited: a federal quality-of-care deficiency involving a hypoglycemic episode, medication administration error, failure to monitor and notify the physician, and inadequate follow-up that resulted in the resident's death; and a Missouri licensure deficiency for nursing care per resident condition that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: See the deficiency cited at F684.
Report Facts
residents sampled: 6
Inspection Report — Jul 28, 2023
Life Safety
Date: Jul 28, 2023
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CMS-2567 federal Life Safety and Emergency Preparedness surveys (initial completed 2023-07-28, with a revisit completed 2023-10-19) and accompanying Missouri Department of Health and Senior Services State Form pages.
Findings
Eleven federal life-safety and emergency preparedness deficiencies related to emergency preparedness planning and communication, means of egress/exit signage, corridor doors, electrical systems and generator testing, elevators, fire drills, and smoking regulations; and seven Missouri State Form deficiencies addressing exit signage, ashtray/smoking disposal, fire drill requirements, building construction/electrical maintenance and certification, and elevator requirements.
Deficiencies (7)
19 CSR 30-85.022(24) Exit Sign-Maintain/Illuminate: See the deficiency cited at K293.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: The regulation is not met as evidenced by ashtray contents and unsafe ashtray conditions; See the deficiency cited at K741.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: The regulation is not met as evidenced by incomplete fire drill records and missing required drills; See the deficiency cited at K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: The regulation is not met as evidenced by deficiencies in means of egress, corridor doors and electrical systems; See the deficiencies cited at K211, K363 and K918.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: The regulation is not met as evidenced by inadequate electrical wiring/equipment maintenance and missing required testing; See the deficiencies cited at K511 and K914.
19 CSR 30-85.032(31)(B) Electrical System-Certification Every 2 Years: The regulation is not met as evidenced by failure to have an electrical inspection completed every two years as required.
19 CSR 30-85.032(36) Elevator Requirements: See the deficiency cited at K531.
Inspection Report — Feb 21, 2020
Routine
Date: Feb 21, 2020
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) for the same visit; the survey type is not stated.
Findings
18 deficiencies were cited: 10 federal health deficiencies covering assessment accuracy and care planning, activities of daily living and personal care, restorative/mobility services, accident hazards and medication storage, nurse aide in-service training, psychotropic/PRN medication use, food storage/handling, and infection prevention and control; and 8 Missouri state licensure deficiencies citing corresponding 19 CSR rules.
Deficiencies (8)
A4025 19 CSR 30-85.042(23) In-service-Annually, Nursing/Restorative: See the deficiency cited at F730.
A4073 19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: See the deficiency cited at F689.
A4074 19 CSR 30-85.042(67) Nursing Care per Res Condition: See the deficiencies cited at F676 and F758.
A4075 19 CSR 30-85.042(68) Clean, Dry, Odor Free: See the deficiency cited at F677.
A4080 19 CSR 30-85.042(73) Restorative Nursing, Res Out of Bed: See the deficiency cited at F688.
A4085 19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F880.
A7015 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: See the deficiency cited at F812.
A7035 19 CSR 30-87.030(33) Thawing Potentially Hazardous Foods: See the deficiency cited at F812.
Report Facts
residents sampled: 8
residents in certified beds: 9
residents affected (by a specific deficiency): 2
Inspection Report — Aug 12, 2019
Complaint Investigation
Date: Aug 12, 2019
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation MO00158310.
Complaint Details
Complaint MO00158310; determination (substantiated/unsubstantiated) not stated in the file.
Findings
Two deficiencies were cited: one federal health tag for failure to ensure residents were free from accident hazards and provide adequate supervision resulting in an elopement and problems with alarm/door monitoring, and one Missouri State Form citation for protective oversight and voluntary leave that references the federal deficiency.
Deficiencies (1)
19 CSR 30-85.042(86) Protective Oversight, Voluntary Leave: See the deficiency cited at F689.
Inspection Report — Mar 22, 2019
Routine
Date: Mar 22, 2019
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CMS-2567 federal health survey (statement of deficiencies) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Eight deficiencies were cited: four federal health-care deficiencies addressing care plan timing/revision, services meeting professional standards, labeling/storage of drugs, and infection prevention and control; and four corresponding Missouri State Form licensure deficiencies citing those federal findings.
Deficiencies (4)
19 CSR 30-85.042(48) Written Orders; Restraints: See the deficiency cited at F658.
19 CSR 30-85.042(64) Medication Labeling: See the deficiency cited at F761.
19 CSR 30-85.042(67) Nursing Care per Res Condition: See the deficiency cited at F658.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: See the deficiency cited at F880.
Report Facts
residents sampled: 8
Inspection Report — Mar 22, 2019
Life Safety
Date: Mar 22, 2019
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Federal Life Safety (CMS-2567) survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Eight deficiencies were cited: four federal Life Safety deficiencies addressing sprinkler installation and coverage, sprinkler maintenance and testing, electrical power cord and power strip use, and oxygen cylinder storage; and four Missouri state licensure deficiencies citing oxygen storage, incomplete sprinkler system, sprinkler testing/maintenance, and electrical wiring and equipment maintenance.
Deficiencies (4)
19 CSR 30-85.022(6) Oxygen Storage: See the deficiency cited at K923.
19 CSR 30-85.022(11)(B) No Complete Sprinkler System Prior to 8/28/07: See the deficiency cited at K351.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: See the deficiency cited at K353.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: See the deficiency cited at K920.
Report Facts
residents in certified beds: 13
oxygen tanks observed: 10
Inspection Report — Jun 19, 2018
Routine
Date: Jun 19, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Ten deficiencies were cited: five federal health survey deficiencies involving resident rights/respectful treatment, care plan revisions, nurse aide in-service training, medication errors, and unsafe/unsanitary kitchen conditions; and five Missouri state licensure deficiencies involving in-service training/TB screening, medication system, nonfood-contact surface cleaning, and dignity/privacy.
Deficiencies (5)
19 CSR 30-85.042(22) In-service Training-Nursing Personnel: See the deficiency cited at F730.
19 CSR 30-85.042(27) Communicable Disease-Employees: Based on interview and record review, the facility failed to properly complete tuberculosis screening/testing on the date of hire for one of four sampled employee files.
19 CSR 30-85.042(47) Safe/Effective Medication System: See the deficiency cited at F759.
19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed: See the deficiency cited at F921.
19 CSR 30-88.010(29) Dignity/Privacy: See the deficiency cited at F550.
Report Facts
residents sampled: 8
medication administration opportunities observed: 34
medication administration errors observed: 10
Inspection Report — Jun 19, 2018
Life Safety
Date: Jun 19, 2018
Visit Reason
CMS-2567 Life Safety survey (K-tagged) and accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not otherwise stated.
Findings
There are five K-tag life safety deficiencies and five Missouri State Form deficiencies. The findings concern corridor width, fire alarm and sprinkler systems being out of service and inadequate fire watch procedures, smoke barrier door operation, and the lack of a remote manual stop station for the emergency generator.
Deficiencies (5)
19 CSR 30-85.012(60) Required Corridor Width: See the deficiency cited at K232.
19 CSR 30-85.022(10)(H) Fire Alarm System-Out of Service > than 4hrs: See the deficiency cited at K346.
19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr: See the deficiency cited at K354.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: See the deficiency cited at K374.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: See the deficiency cited at K918.
Report Facts
residents in certified beds: 12
14 CMS Surveys
Inspection Report — Sep 12, 2024
Complaint Investigation
Date: Sep 12, 2024
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Federal health survey (CMS-2567) — a Recertification and Complaint survey as stated in the Initial Comments; complaint intakes MO00233637 and MO00230818 are referenced.
Complaint Details
Intake MO00233637 and MO00230818 are referenced in the Initial Comments; the record states no deficiencies were issued related to those intakes.
Findings
One federal health deficiency was cited related to drug regimen review: the pharmacist failed to complete monthly medication reviews in a timely manner and had documentation/access issues that prevented review of residents' electronic records.
Deficiencies (1)
F 756 Drug Regimen Review, Report Irregular, Act On CFR(s): facility failed to ensure the pharmacist completed the monthly medication reviews (MMR) in a timely manner for one of five sampled residents reviewed for unnecessary medications. The pharmacist was not linked to the residents' electronic medical records, preventing timely completion of the MMR.
Report Facts
survey sample size: 14
residents reviewed for unnecessary medications: 5
Inspection Report — Sep 11, 2024
Life Safety
Date: Sep 11, 2024
Visit Reason
CMS-2567 Life Safety Code survey (K-tag Life Safety survey) conducted on behalf of the State of Missouri; no complaint numbers are stated in the file.
Findings
4 life safety deficiencies were cited concerning an exit door that did not latch, incomplete quarterly sprinkler inspections, inadequate fire door inspection/documentation and illegible fire rating tags, and a missing load bank test for the emergency generator.
Deficiencies (4)
K 227 Ramps and Other Exits CFR(s): NFPA 101: Based on observation and interview, the facility failed to ensure the fire rated door assembly protecting the exit passageway latched when closed; the stairway door going into the exit passageway would not latch when closed.
K 353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101: Based on document review and interview, the facility failed to ensure quarterly sprinkler inspections were conducted in accordance with NFPA 25; quarterly inspections for the first and second quarters of 2024 were not completed.
K 761 Maintenance, Inspection & Testing - Doors CFR(s): NFPA 101: Based on observation, interview and record review, the facility failed to ensure fire doors were inspected and documented correctly and that individuals performing the inspections could demonstrate required knowledge; fire rating tags were painted and the fire rating was not legible.
K 918 Electrical Systems - Essential Electric Systems CFR(s): NFPA 101: Based on record review and interview, the facility failed to ensure a load bank test was completed on the emergency generator once every 36 months; review of generator reports showed it had been over 36 months since a load bank test was completed.
Report Facts
residents affected: 43
Inspection Report — Sep 26, 2023
Complaint Investigation
Date: Sep 26, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the file documents a complaint investigation and includes complaint number MO00223996.
Complaint Details
MO00223996; substantiation not stated in the document.
Findings
Two deficiencies were cited: a federal quality-of-care deficiency involving a hypoglycemic episode, medication administration error, failure to monitor and notify the physician, and inadequate follow-up that resulted in the resident's death; and a Missouri licensure deficiency for nursing care per resident condition that references the federal finding.
Deficiencies (1)
F684 Quality of Care: Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for one sampled resident after a hypoglycemic episode and medication error, including failure to notify the physician, inadequate monitoring and follow-up, and failures in medication administration that preceded the resident's subsequent death.
Report Facts
residents sampled: 6
Inspection Report — Jul 28, 2023
Life Safety
Date: Jul 28, 2023
Visit Reason
CMS-2567 federal Life Safety and Emergency Preparedness surveys (initial completed 2023-07-28, with a revisit completed 2023-10-19) and accompanying Missouri Department of Health and Senior Services State Form pages.
Findings
Eleven federal life-safety and emergency preparedness deficiencies related to emergency preparedness planning and communication, means of egress/exit signage, corridor doors, electrical systems and generator testing, elevators, fire drills, and smoking regulations; and seven Missouri State Form deficiencies addressing exit signage, ashtray/smoking disposal, fire drill requirements, building construction/electrical maintenance and certification, and elevator requirements.
Deficiencies (11)
E006 Plan Based on All Hazards Risk Assessment: Based on interview and record review, the facility's emergency preparedness plan did not include a documented facility/community-based hazard risk assessment.
E030 Names and Contact Information: The facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all staff and a list/location where staff phone numbers could be found.
K211 Means of Egress - General: The facility failed to ensure emergency exits were maintained free of obstructions; mesh fabric 'stop' signs were draped across exit doors which impeded exits.
K293 Exit Signage: The facility failed to maintain exit signage; multiple exit signs were poorly illuminated or did not illuminate when tested and several internal bulbs were burned out.
K363 Corridor - Doors: The facility failed to maintain corridor doors so there were no impediments to closing and failed to ensure positive latching hardware; door wedges, props and a deadbolt were observed preventing doors from closing.
K511 Utilities - Gas and Electric: The facility failed to maintain electrical wiring in compliance with applicable codes; electrical panels and outlets were obstructed or had improper clearances and some outlets lacked required GFCI protection.
K531 Elevators: The facility failed to ensure elevators were maintained in good repair and have current certifications; documentation was missing for one or more passenger/service elevators and for 2022/2023 inspections.
K712 Fire Drills: The facility failed to ensure fire drills were completed on each shift, quarterly, as required; records showed missing drills for some quarters/shifts.
K741 Smoking Regulations: The facility failed to ensure ashtray contents were properly disposed and that ashtrays of noncombustible material and safe design were provided; observations found cigarette butts, ash and improper ash receptacles in designated smoking areas.
K914 Electrical Systems - Maintenance and Testing: The facility failed to ensure non-hospital grade electrical receptacles in resident sleeping areas were tested annually and lacked documentation of required testing.
K918 Electrical Systems - Essential Electric System Maintenance & Testing: The facility failed to ensure weekly visual inspections and monthly load testing and documentation of the emergency generator and its transfer switch per NFPA requirements.
Inspection Report — May 11, 2023
Routine
Date: May 11, 2023
Visit Reason
Federal health survey (CMS-2567); the survey type is not stated.
Findings
One federal health deficiency was cited for Free from Abuse and Neglect involving forceful handling and verbal abuse of a resident; past noncompliance was noted.
Deficiencies (1)
F600 Free from Abuse and Neglect: Based on observation, interview and record review, Certified Medication Technician (CMT) C yelled at and physically forced Resident #4 to his/her room, grabbed the resident's left wrist and pulled it across the resident's neck and chest while moving the wheelchair, causing the resident to be verbally and emotionally upset. The facility's investigation substantiated the allegation and CMT C was relieved of duties/terminated.
Inspection Report — Nov 17, 2020
Routine
Date: Nov 17, 2020
Visit Reason
CMS-2567 federal forms for a COVID-19 Focused Infection Control survey and a COVID-19 Focused Emergency Preparedness survey as stated in the Initial Comments; the survey type is COVID-19 focused and no complaint numbers are cited.
Findings
No deficiencies were cited. The COVID-19 focused Emergency Preparedness and Infection Control surveys found the facility to be in compliance with the applicable requirements.
Inspection Report — Jun 22, 2020
Routine
Date: Jun 22, 2020
Visit Reason
CMS-2567 health (F) form and CMS-2567 emergency preparedness (E) form; both are COVID-19 Focused surveys as stated on the F000 (page 1) and E000 (page 2) Initial Comments.
Findings
No survey deficiencies were cited; both the COVID-19 Focused Infection Control survey (F000) and the COVID-19 Focused Emergency Preparedness survey (E000) found the facility to be in compliance with the referenced requirements.
Inspection Report — Feb 21, 2020
Routine
Date: Feb 21, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) for the same visit; the survey type is not stated.
Findings
18 deficiencies were cited: 10 federal health deficiencies covering assessment accuracy and care planning, activities of daily living and personal care, restorative/mobility services, accident hazards and medication storage, nurse aide in-service training, psychotropic/PRN medication use, food storage/handling, and infection prevention and control; and 8 Missouri state licensure deficiencies citing corresponding 19 CSR rules.
Deficiencies (10)
F641 Accuracy of Assessments: Facility staff failed to accurately code the Minimum Data Set (MDS) for a resident's diagnoses and behaviors during record review and interview, with the sample noted as eight and the census 24 with nine residents in certified beds.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to update comprehensive care plans to include behaviors and vision impairments for reviewed residents, affecting two of eight sampled residents.
F676 Activities Daily Living (ADLs)/Mntn Abilities: The facility failed to assess and provide language and hearing assistive devices or document residents' primary language and communication needs for a sampled resident, with a sample of eight.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide consistent nail and perineal care for dependent residents, with observations of long, jagged fingernails and inadequate nail hygiene for residents reviewed.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide restorative therapy assessment or services and follow-through for a resident with limited range of motion and contractures, despite orders and observed need.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure resident environment and medication/solution storage were free of hazards, with an unsecured bottle of chlorhexidine gluconate observed in a shared bathroom.
F730 Nurse Aide Perform Review-12 hour/yr In-Service: The facility failed to ensure certified nurse aides received the required 12 hours of in-service training annually and had complete documentation of competencies and training.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure PRN psychotropic medication orders were limited and re-evaluated as required, with missing end dates and insufficient documentation for PRN psychotropic use for reviewed residents.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary food storage and handling practices, with multiple opened, undated/unlabeled food packages and inappropriate food thawing/storage observed in the kitchen affecting food served to residents.
F880 Infection Prevention & Control: The facility failed to maintain elements of an infection prevention and control program, including annual TB assessment/testing and related documentation for residents and staff.
Report Facts
residents sampled: 8
residents in certified beds: 9
residents affected (by a specific deficiency): 2
Inspection Report — Feb 21, 2020
Life Safety
Date: Feb 21, 2020
Visit Reason
CMS-2567 Life Safety / Emergency Preparedness form and a Missouri Department of Health and Senior Services licensure (State Form) were included; the CMS Initial Comments reference the Life Safety Code, so the inspection is classified as life_safety.
Findings
No federal life safety or emergency preparedness deficiencies were cited on the CMS-2567 (Initial Comments only). The Missouri State Form licensure inspection cited no state licensure deficiencies.
Inspection Report — Aug 12, 2019
Complaint Investigation
Date: Aug 12, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation MO00158310.
Complaint Details
Complaint MO00158310; determination (substantiated/unsubstantiated) not stated in the file.
Findings
Two deficiencies were cited: one federal health tag for failure to ensure residents were free from accident hazards and provide adequate supervision resulting in an elopement and problems with alarm/door monitoring, and one Missouri State Form citation for protective oversight and voluntary leave that references the federal deficiency.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview and record review, the facility failed to provide protective oversight for a cognitively impaired resident who eloped from the chapel and was unsupervised outside for approximately 12 minutes; investigation and staff interviews revealed alarms and emergency door monitoring and staff response were inadequate.
Inspection Report — Mar 22, 2019
Routine
Date: Mar 22, 2019
Visit Reason
CMS-2567 federal health survey (statement of deficiencies) and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Eight deficiencies were cited: four federal health-care deficiencies addressing care plan timing/revision, services meeting professional standards, labeling/storage of drugs, and infection prevention and control; and four corresponding Missouri State Form licensure deficiencies citing those federal findings.
Deficiencies (4)
F657 Care Plan Timing and Revision: The facility failed to revise residents' care plans to reflect current needs and wound treatments for sampled residents, with missing documentation of wound treatment and hospice coordination for residents reviewed.
F658 Services Provided Meet Professional Standards: The facility failed to ensure services met professional standards and physician orders by not obtaining diagnoses for antibiotic use, not ensuring application of ordered Prevalon boots, and not documenting a diagnosis for PRN antianxiety medication for a resident.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure insulin vials and flexpens were labeled with date opened, expiration date and resident name; observations found opened insulin products without required labeling.
F880 Infection Prevention & Control: The facility failed to implement infection prevention procedures and an adequate annual review, with staff observed not performing appropriate hand hygiene and peri-care and facility policies and staff practice deficiencies noted.
Report Facts
residents sampled: 8
Inspection Report — Mar 22, 2019
Life Safety
Date: Mar 22, 2019
Visit Reason
Federal Life Safety (CMS-2567) survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Eight deficiencies were cited: four federal Life Safety deficiencies addressing sprinkler installation and coverage, sprinkler maintenance and testing, electrical power cord and power strip use, and oxygen cylinder storage; and four Missouri state licensure deficiencies citing oxygen storage, incomplete sprinkler system, sprinkler testing/maintenance, and electrical wiring and equipment maintenance.
Deficiencies (4)
K351 Sprinkler System - installation: Based on observation and interview, the facility failed to provide sprinkler coverage in the closet near the boiler room entrance and in an exterior storage room, creating potential to affect occupants on the ground floor.
K353 Sprinkler System - Maintenance and Testing: Based on observation, interview and record review, the facility failed to maintain sprinkler heads free of debris, paint and corrosion and failed to ensure escutcheon plates fit tightly, with multiple dirty, painted, rusted or dusty sprinkler heads observed throughout the building.
K920 Electrical Equipment - Power Cords and Extension Cords: Based on observation and interview, the facility failed to prohibit the use of extension cords for more than temporary use and failed to ensure inappropriate use of power strips and extension cords was prevented, with appliances observed plugged into power strips and extension cords in use.
K923 Gas Equipment - Cylinder and Container Storage: Based on observation and interview, the facility failed to ensure full oxygen tanks were separated from empty tanks and failed to maintain a system to identify full and empty oxygen cylinders for one oxygen storage room, with racks lacking signs to distinguish full from empty.
Report Facts
residents in certified beds: 13
oxygen tanks observed: 10
Inspection Report — Jun 19, 2018
Routine
Date: Jun 19, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Ten deficiencies were cited: five federal health survey deficiencies involving resident rights/respectful treatment, care plan revisions, nurse aide in-service training, medication errors, and unsafe/unsanitary kitchen conditions; and five Missouri state licensure deficiencies involving in-service training/TB screening, medication system, nonfood-contact surface cleaning, and dignity/privacy.
Deficiencies (5)
F550 Resident Rights/Exercise of Rights: Based on observation, interview and record review, staff engaged in a loud verbal argument in a resident use area and agency staff treated residents disrespectfully, including an incident involving Resident #7; residents and family interviews reported agency staff were disrespectful.
F657 Care Plan Timing and Revision: Based on observation, interview and record review, the facility failed to revise care plans with new interventions for falls, oxygen, diet orders, fluid restriction and hospice services for five of eight sampled residents.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: Based on interview and record review, the facility failed to have a system to ensure CNAs received the required 12 hours of in-service training, with missing documentation in multiple long-term employee files.
F759 Free of Medication Error Rts 5 Prcnt or More: Based on observation, interview and record review, the facility failed to ensure an acceptable medication error rate; out of 34 opportunities observed, 10 errors occurred (29.41% error rate) and multiple medication administration and documentation issues were observed.
F921 Safe/Functional/Sanitary/Comfortable Environ: Based on observation and interview, the facility failed to keep kitchen equipment and areas clean, with build-up of grease, grime and splatters on the steamer, grill, stove, ovens and deep fat fryer and pooled grease on the floor.
Report Facts
residents sampled: 8
medication administration opportunities observed: 34
medication administration errors observed: 10
Inspection Report — Jun 19, 2018
Life Safety
Date: Jun 19, 2018
Visit Reason
CMS-2567 Life Safety survey (K-tagged) and accompanying Missouri Department of Health and Senior Services State Form pages; the survey type is not otherwise stated.
Findings
There are five K-tag life safety deficiencies and five Missouri State Form deficiencies. The findings concern corridor width, fire alarm and sprinkler systems being out of service and inadequate fire watch procedures, smoke barrier door operation, and the lack of a remote manual stop station for the emergency generator.
Deficiencies (5)
K232 Aisle, Corridor, or Ramp Width: Based on observation, the facility failed to maintain corridors serving as exit access at least 8 feet in width; corridors measured 6 feet which had the potential to affect resident safety.
K346 Fire Alarm System - Out of Service: Based on interview and record review, the facility failed to develop an adequate fire watch policy for staff to follow when the fire alarm system was out of service; the deficiency had the potential to affect all occupants.
K354 Sprinkler System - Out of Service: Based on interview and record review, the facility failed to develop an adequate fire watch policy when the sprinkler system was impaired; the facility's policy lacked required elements.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: Based on observation and interview, the facility failed to maintain smoke partition doors so they released and closed automatically with fire alarm activation; one door on the basement level failed to release and close.
K918 Electrical Systems - Essential Electric System: Based on observation and interview, the facility failed to provide a remote manual stop station for the emergency generator; the generator located in the basement did not have the required remote manual stop station.
Report Facts
residents in certified beds: 12
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