Inspection Reports for
Steelville Senior Living
311 NORTH SPRING ST, STEELVILLE, MO, 65565-5089
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
4% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 4
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The inspection was conducted to assess compliance with food protection and storage regulations at Steelville Senior Living.
Findings
The facility failed to properly store, label, and date open and cooked food items, leading to potential contamination risks. Observations included unsealed food without labels or dates and dirty food carts with dried food debris and hair.
Deficiencies (1)
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Facility staff failed to properly store, label, and date open and cooked food items, risking contamination. Observations included unsealed food without labels or dates and dirty food carts with dried food debris and hair.
Report Facts
Facility census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Tech | CMT | Observed handling food cart and kitchen conditions |
| Dietary Manager | Interviewed regarding food safety and storage training | |
| Director of Nursing | DON | Interviewed about responsibilities for ALF and SNF food safety |
| Administrator | Interviewed about food dating and cleaning responsibilities |
Inspection Report
Routine
Census: 41
Deficiencies: 1
Date: May 19, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety and hygiene standards in the facility's kitchen during the noon meal service.
Findings
Facility staff failed to perform proper hand hygiene to prevent cross-contamination in the kitchen during meal service, as observed through multiple instances of staff not washing hands between glove changes or after touching contaminated surfaces.
Deficiencies (1)
Facility staff failed to perform hand hygiene in a manner to prevent cross-contamination in the kitchen during the noon meal service.
Report Facts
Facility census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook | Observed failing to perform hand hygiene between glove changes and after touching trash can lid | |
| Food Service Assistant (FSA) E | Observed failing to perform hand hygiene when entering kitchen, between glove changes, and after touching trash can lid | |
| Dietary Manager (DM) | Interviewed about hand hygiene expectations and responsibility for staff compliance | |
| Administrator | Interviewed about staff training and hand hygiene policies |
Inspection Report
Plan of Correction
Census: 6
Deficiencies: 1
Date: Sep 30, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and construction regulations as part of a regulatory oversight process.
Findings
The facility failed to maintain the building in good repair, with small penetrations in walls and ceilings that could allow smoke, fire, and gases to travel to unaffected portions of the building. The deficiency affected all six residents present during the inspection.
Deficiencies (1)
19 CSR 30-86.032(2) Substantially Constructed & Maintained: The facility failed to maintain the building in good repair, with small penetrations in the walls and ceilings of the ALF laundry room, mechanical room, and room 141 ceiling. These penetrations could allow smoke, fire, and gases to travel to unaffected portions of the building.
Report Facts
Facility census: 6
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 6
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as an annual survey of Steelville Senior Living to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including management of personal funds, care plan revisions, RN coverage, medication storage and labeling, infection control, and food safety. Several residents lacked appropriate access to funds, care plans were not updated timely, and medication storage practices were inadequate.
Deficiencies (6)
F567 Protection/Management of Personal Funds: Facility staff failed to ensure three residents had appropriate access to their trust fund accounts on weekends.
F657 Care Plan Timing and Revision: Facility staff failed to document and update care plans for residents with catheters and after falls.
F727 RN 8 Hrs/7 Days/Wk, Full Time DON: Facility failed to provide a registered nurse for at least eight consecutive hours a day, seven days a week.
F761 Label/Store Drugs and Biologicals: Facility staff failed to discard expired medications and properly label and store medications in medication carts and storage rooms.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility staff failed to store and serve food at proper temperatures and failed to sanitize kitchen wares adequately.
F880 Infection Prevention & Control: Facility failed to use appropriate infection control procedures including hand hygiene and glove use during resident care.
Report Facts
Facility census: 41
Deficiencies cited: 6
Completion date for plan of correction: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Enke | Laboratory Director or Provider/Supplier Representative | Signed the inspection report and plan of correction |
| Cook G | Mentioned in medication storage and food safety findings | |
| Cook H | Mentioned in medication storage and food safety findings | |
| DA J | Dietary Aide | Mentioned in food temperature monitoring and food safety findings |
| LPN D | Licensed Practical Nurse | Mentioned in medication storage and infection control findings |
| CMT B | Certified Medication Technician | Mentioned in medication storage findings |
| CMT C | Certified Medication Technician | Mentioned in medication storage findings |
| DON | Director of Nursing | Mentioned in RN coverage and infection control findings |
| Administrator | Mentioned in RN coverage and medication storage findings |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire protection standards as part of a regulatory survey.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code with no deficiencies cited. No state licensure deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Census: 7
Deficiencies: 2
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitization regulations at Steelville Senior Living, focusing on food temperature control and kitchen ware sanitization.
Findings
The facility failed to maintain proper food temperatures in refrigerators and cold tables, and did not fully submerge kitchen wares in sanitizer as required. These deficiencies had the potential to affect all residents.
Deficiencies (2)
19 CSR 30-87.030(13) Food-Protection, Temp, Need to Contact DHSS: Facility staff failed to store and serve food at safe temperatures, with refrigerator temperatures documented above the allowed maximum. The census was 7.
19 CSR 30-87.030(72) Food-Contact Surface Sanitizing Requirements: Facility staff failed to sanitize kitchen wares properly by not fully submerging items in sanitizer, risking contamination.
Report Facts
Deficiencies cited: 2
Census: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook G | Named in corrective actions and interviews regarding refrigerator temperature and sanitizing procedures | |
| Dietary Aide (DA) J | Interviewed about food temperature checks | |
| Cook H | Interviewed about refrigerator temperature and reporting | |
| Dietary Manager (DM) | Interviewed about refrigerator temperature logs and sanitizing procedures | |
| Maintenance Director | Interviewed about refrigerator maintenance and temperature monitoring |
Inspection Report
Routine
Census: 41
Deficiencies: 6
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, care planning, staffing, medication management, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including resident access to funds on weekends, incomplete care plans for catheters and falls, inadequate RN coverage, expired and improperly stored medications, unsafe food storage temperatures, improper sanitization of kitchen wares, and failure to follow infection control procedures during wound care, catheter care, perineal care, and blood glucose testing.
Deficiencies (6)
Failed to ensure residents had appropriate access to their trust fund account on weekends.
Failed to document and update care plans regarding catheters and falls for sampled residents.
Failed to provide RN coverage for at least 8 consecutive hours per day, seven days a week.
Failed to discard expired medications and ensure medications were properly labeled and stored; nonmedication items stored in medication refrigerator; loose pills found in medication carts.
Failed to maintain food at safe temperatures; walk-in refrigerator temperatures consistently above 41°F; cold table items served at unsafe temperatures; kitchen wares not fully submerged in sanitizer solution.
Failed to use appropriate infection control procedures including hand hygiene and glove changes during wound care, catheter care, perineal care, and blood glucose testing.
Report Facts
Facility census: 41
Dates without RN coverage: 10
Expired medication count: 4
Medication cart loose pills count: 6
Walk-in refrigerator temperature readings: 50
Cold table food temperatures: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in infection control deficiency related to wound and catheter care |
| CMT B | Certified Medication Technician | Named in medication cart and blood glucose testing deficiencies |
| CNA E | Certified Nurses Aide | Named in infection control deficiency related to perineal care |
| Director of Nursing | Director of Nursing | Interviewed regarding RN coverage and infection control expectations |
| Administrator | Facility Administrator | Interviewed regarding resident funds access and infection control expectations |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature monitoring and sanitization |
| LPN D | Licensed Practical Nurse | Responsible for medication storage room and medication cart checks |
Inspection Report
Plan of Correction
Census: 8
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to assess compliance with infection control procedures related to Legionella testing and water management in the facility.
Findings
The facility failed to follow appropriate infection control procedures by not reporting Category II diseases to the local health authority within the required timeframe. Poorly controlled Legionella growth was found in multiple water samples from the Skilled Nursing Facility, and the Assisted Living Facility water was not sampled for Legionella testing.
Deficiencies (1)
19 CSR 30-86.047(34)(B) Disease/Infection Control, Report Category II: The facility failed to report Category II diseases or findings to the local health authority within three days of first knowledge or suspicion. Poorly controlled Legionella growth was found in water samples from the Skilled Nursing Facility.
Report Facts
Water samples collected: 28
Water samples positive for Legionella: 20
Facility census: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Ender | Administrator | Named in interviews regarding water system management and infection control procedures. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 72
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was conducted following a reported case of Legionella in a resident, to investigate the facility's water management program and infection control related to Legionella bacteria.
Complaint Details
The visit was complaint-related due to a reported case of Legionella in Resident #1, who tested positive on 02/20/24 and died on 02/21/24. The complaint investigation found deficiencies in the water management program and infection control practices.
Findings
The facility failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the water system to inhibit Legionella growth. Testing showed poorly controlled Legionella growth in water samples, and the facility lacked documentation of testing protocols, responsible staff, and acceptable control ranges. One resident tested positive for Legionella and subsequently died. The facility had an immediate jeopardy which was later removed after corrective actions.
Deficiencies (1)
Failure to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility's water systems to inhibit Legionella growth.
Report Facts
Facility census: 48
Total capacity: 72
Legionella samples collected: 28
Legionella positive samples: 20
Legionella CFU/ml levels: 1
Legionella CFU/ml levels: 2
Legionella CFU/ml levels: 4
Legionella CFU/ml levels: 5
Water management team meetings: 2
Water management company visits: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided information about water management program deficiencies, Legionella positive resident, and corrective actions | |
| Maintenance Director | Discussed water system maintenance, chlorination pumps, water testing, and lack of training |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards for Steelville Senior Living.
Findings
No health deficiencies were found during this inspection.
Inspection Report
Life Safety
Census: 47
Capacity: 72
Deficiencies: 17
Date: May 5, 2023
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety regulations and related requirements at Steelville Senior Living.
Findings
The facility was found deficient in multiple areas of life safety code compliance including access to all areas of the building, means of egress, hazardous areas enclosure, fire alarm system installation and maintenance, sprinkler system maintenance, fire drills, smoking regulations, electrical systems, and fire barrier walls. The facility census was 47 with a capacity of 72.
Deficiencies (17)
K100: Facility staff failed to ensure access to all areas of the building; maintenance director accidentally took key home and no policy existed for access.
K211: Facility staff failed to maintain means of egress free of obstructions and impediments, including furniture blocking exits and inadequate signage.
K321: Facility staff failed to ensure doors to hazardous areas were self-closing, positively latched, and resisted passage of smoke.
K341: Facility failed to install and maintain a digital fire alarm communicator per code; two phone lines were shared with fax machine.
K342: Facility failed to install and maintain manual fire alarm pull stations at proper height and location; pull station was mounted too high.
K352: Facility failed to maintain sprinkler system free of foreign materials and obstructions; sprinkler heads were visibly loaded and holes around sprinkler brackets unsealed.
K363: Facility failed to ensure corridor doors were self-closing, positively latched, and resisted passage of smoke; doors were propped open or not latched.
K741: Facility failed to maintain designated smoking areas properly; cigarette waste can was broken and did not self-close.
K753: Facility failed to prohibit use of flammable decorations; candles with wicks were present in common areas.
K911: Facility failed to maintain electrical panels locked to prevent unauthorized access; panels were unlocked and accessible.
K914: Facility failed to maintain complete and verifiable documentation of annual electrical receptacle inspections in resident care rooms.
K918: Facility failed to provide documentation of periodic exercising of emergency generators and circuit breakers as required by code.
K920: Facility failed to prohibit use of extension cords and surge protectors improperly; extension cords were used in resident areas.
K923: Facility failed to properly store combustible materials and oxygen cylinders in designated storage areas; oxygen storage rack was not fire retardant.
K372: Facility failed to maintain smoke barrier walls and doors properly; unsealed gaps and holes were present, and doors did not close or latch correctly.
K374: Facility failed to maintain fire barrier doors properly; fire doors did not close automatically and were held open by magnetic devices.
K712: Facility failed to conduct fire drills at unexpected times as required; all 12 monthly drills were conducted as announced.
Report Facts
Facility census: 47
Total capacity: 72
Fire drills conducted: 12
Fire drills conducted unannounced: 0
Inspection Report
Routine
Census: 47
Deficiencies: 4
Date: May 5, 2023
Visit Reason
Routine inspection conducted to assess compliance with food safety and sanitation regulations at Steelville Senior Living.
Findings
Multiple deficiencies were found related to food protection, storage, and sanitation practices, including failure to protect food from contamination, improper labeling and dating of food items, storage of dented cans, and inadequate sanitization of utensils and equipment.
Deficiencies (4)
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS. Facility staff failed to protect, label, and date stored food to prevent cross contamination and outdated use. Staff also failed to sanitize thermometers between uses. The facility census was 47.
19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected. Facility staff failed to store food in a manner to prevent cross contamination, with food items found on the floor and hanging over boxes. The facility census was 47.
19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap. Facility staff failed to ensure the ice machine drained through an air gap, and lacked a policy for air gap maintenance. The facility census was 47.
19 CSR 30-87.030(84) Equip/Utensils Air Dried, Self-Drain Utensils. Facility staff failed to sanitize kitchenware to air dry prior to use, risking food-borne pathogens. The facility census was 47.
Report Facts
Facility census: 47
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 11
Date: May 5, 2023
Visit Reason
The inspection was conducted as an annual survey of Steelville Senior Living to assess compliance with health and safety regulations.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, food safety and sanitation practices, and infection prevention and control. Multiple observations and interviews revealed issues with raised floor transition strips, damaged walls, food storage and labeling, and hand hygiene practices.
Deficiencies (11)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a clean, homelike environment as evidenced by raised floor transition strips that impeded wheelchair access and damaged walls with paint chips and debris.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility staff failed to protect, label, and date stored food, maintain kitchen equipment and flooring in a sanitary manner, and ensure proper sanitation of the ice machine and food thermometers.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection control program, including proper hand hygiene, catheter care, and use of personal protective equipment, leading to increased risk of infection.
A3026 Call System Requirements: Facility staff failed to ensure wireless nurse call pagers were carried and utilized properly, resulting in delayed responses to resident call lights.
A4086 Infection Control/Communicable Disease: Facility failed to report communicable diseases within required timeframes and implement infection control procedures to prevent spread.
A6012 Floor Surfaces: Floors and floor coverings were not maintained in good repair, with damaged and dirty areas that did not provide a safe environment.
A7015 Food-Protected, Temp, Need to Contact DHSS: Food was not properly protected from contamination and temperature controls were inadequate.
A7016 Food-Clean Containers, Storage, Covers: Food containers were not stored in clean covered containers during preparation and service.
A7017 Food-Stored Above the Floor, Protected: Food containers were not stored above the floor in a manner that protected from contamination.
A7042 Ice Store/Dispense, No Contamination, Air Gap: Ice machine lacked an air gap between drain pipes and floor drain, risking contamination.
A7086 Equip/Utensils Air Dried, Self-Drain Utensils: Equipment and utensils were not air dried or stored in a self-draining position, increasing risk of contamination.
Report Facts
Facility census: 47
Inspection Report
Routine
Census: 47
Deficiencies: 3
Date: May 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident environment, food safety, infection control, and catheter care at Steelville Senior Living.
Findings
The facility failed to maintain a clean, homelike environment with raised floor transition strips causing accessibility issues, damaged walls and floors, and inadequate reporting of maintenance issues. Food safety violations included improper labeling, storage, and sanitation practices. Infection control lapses were observed with staff failing to perform proper hand hygiene and catheter care, increasing risk of infection.
Deficiencies (3)
Failed to maintain resident rooms clean and in good repair, including raised floor transition strips preventing easy wheelchair access.
Failed to protect, label, and date stored food; failed to maintain kitchen equipment and flooring in a clean sanitary manner; failed to ensure ice machine drained through an air gap; failed to sanitize thermometer between uses; failed to allow kitchenware to air dry.
Failed to use appropriate infection control procedures including hand hygiene during care and catheter care, resulting in potential infection risk.
Report Facts
Facility census: 47
Dented cans: 3
Food packages: 13
Food packages: 9
Food packages: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Assistant | Named in infection control deficiency related to hand hygiene and glove use |
| NA D | Nurse Aid | Named in infection control deficiency related to hand hygiene and glove use |
| Maintenance Director | Mentioned regarding maintenance reporting and awareness of raised floor strips and paint chips | |
| Administrator | Mentioned regarding maintenance reporting and awareness of facility environment issues | |
| Director of Nursing | Mentioned regarding maintenance reporting and infection control expectations | |
| DM | Dietary Manager | Mentioned regarding food labeling, storage, and sanitation practices |
| LPN E | Licensed Practical Nurse | Mentioned regarding infection control and catheter care |
| Nurse Practitioner | NP | Mentioned regarding catheter care and infection risk |
| CNA G | Certified Nurse Assistant | Mentioned regarding catheter care and infection risk |
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 2
Date: Feb 28, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to notification of changes in resident condition and failure to notify the physician about pressure ulcers.
Findings
The facility failed to notify the resident's physician about newly identified pressure ulcers and did not follow required notification procedures for changes in resident condition. Interviews and record reviews confirmed these deficiencies.
Deficiencies (2)
F580 Notification of Changes: The facility failed to promptly notify the resident's physician about newly identified pressure ulcers and changes in the resident's condition as required by regulation.
A4087 Physician Notification-Change in Condition: Facility staff did not notify the resident's physician in accordance with emergency treatment policies after a significant change in condition occurred.
Report Facts
Resident census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Enke | LNHA | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Oct 21, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged sexual abuse by a staff member (cook A) towards a resident.
Complaint Details
The complaint investigation was substantiated. The facility documented inappropriate sexual text messages and pictures sent by a cook to a resident lacking mental capacity to consent. The cook was terminated, and the incident was reported to police and state agencies.
Findings
The facility failed to ensure a resident was free from sexual abuse when a staff member sent inappropriate sexual text messages and pictures to the resident. The staff member was terminated, and the facility implemented corrective actions including staff education and monitoring.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent sexual abuse when a staff member sent inappropriate sexual text messages and pictures to a resident. The staff member was terminated and corrective actions were initiated.
A4074 Protective Oversight, Voluntary Leave: The facility did not meet requirements for protective oversight and supervision during voluntary leave. Refer to F600 for details.
Report Facts
Facility census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook A | Cook | Named in sexual abuse finding and termination |
| Donna Enloe | CNHA | Signed the report and plan of correction |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 4
Date: Aug 5, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for Steelville Senior Living.
Findings
The facility failed to provide adequate assistance with activities of daily living, sufficient nursing staff, timely medication administration, and proper infection control procedures. Multiple deficiencies were cited related to resident care, staffing, medication errors, and infection prevention.
Deficiencies (4)
F677 ADL Care Provided for Dependent Residents: Facility staff failed to ensure 10 of 13 sampled residents received necessary assistance with bathing and personal hygiene. Observations showed residents with dry skin, greasy hair, and infrequent bathing.
F725 Sufficient Nursing Staff: Facility failed to provide sufficient nursing staff to meet resident needs, resulting in inadequate showers and delayed medication administration with a 93% error rate for two residents.
F759 Free of Medication Error Rates 5 Percent or More: Facility failed to maintain medication error rates below 5%, with a 93% error rate observed for two residents due to 28 medication errors.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and use of protective barriers, leading to risk of infection spread.
Report Facts
Resident census: 46
Medication error rate: 93
Medication errors observed: 28
Certified Nursing Aides (CNA) staffing: 1.8
Certified Nursing Aides (CNA) staffing: 3.8
Certified Medication Technicians (CMT) staffing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding shower schedules and staffing | |
| Certified Nurse Assistant B | CNA | Interviewed about shower schedules and staffing |
| Certified Medication Technician D | CMT | Interviewed about medication administration and error rates |
| Licensed Practical Nurse A | LPN | Interviewed about staffing and medication administration |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
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: May 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
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
Census: 45
Deficiencies: 4
Date: Dec 6, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care planning, catheter care, application of ace wraps and compression stockings, and medication storage and labeling at Steelville Senior Living.
Findings
The facility failed to update care plans to reflect significant resident conditions, did not follow physician orders for catheter care and application of ace wraps or compression stockings, and failed to properly store and label medications including expired items in medication carts.
Deficiencies (4)
Failure to update care plans to include dialysis, wounds, catheter use, and leg wraps for multiple residents.
Failure to maintain professional standards in catheter care including tubing touching the floor and failure to follow catheter change orders.
Failure to apply ace wraps or compression stockings as ordered for multiple residents.
Failure to store and label medications properly, including expired insulin pens, eye drops, and outdated pain medications.
Report Facts
Facility census: 45
Weight loss percentage: 22.56
Catheter change intervals: 30
Medication expiration: 28
Hydrocodone order dates: 365
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Interviewed regarding catheter care, medication procedures, and ace wrap responsibilities |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter change orders, medication storage, and care plan updates |
| MDS Coordinator | Interviewed regarding care plan updates and resident condition changes | |
| CNA B | Certified Nursing Assistant | Interviewed regarding catheter bag handling and ace wrap application |
| LPN F | Licensed Practical Nurse | Interviewed regarding catheter change procedures and physician order verification |
| CMT G | Certified Medication Technician | Interviewed regarding medication expiration awareness and cart management |
| LPN D | Licensed Practical Nurse | Interviewed regarding ace wrap application and documentation |
| CMT A | Certified Medical Technician | Interviewed regarding ace wrap removal and treatment administration |
| CNA A | Certified Nursing Assistant | Interviewed regarding application of TED hose and ace wraps |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 5
Date: Dec 6, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to care plan deficiencies, medication administration, and storage issues at Steelville Senior Living.
Complaint Details
The visit was complaint-related, focusing on care plan deficiencies, catheter care, medication administration, and medication storage. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure comprehensive care plans were updated and followed, particularly for residents requiring dialysis and catheter care. Staff did not consistently follow physician orders for catheter care and medication administration, and medication storage was found to be unsafe.
Deficiencies (5)
F657 Care Plan Timing and Revision: The facility failed to ensure staff reviewed and revised care plans to include dialysis treatment and catheter care for residents. The care plan for Resident #1 was not updated after a motor vehicle accident causing multiple wounds.
F658 Services Provided Meet Professional Standards: Staff failed to maintain professional standards by not following physician orders for catheter care and application of ace wraps for multiple residents. Observations showed catheter bags and tubing were often on the floor, risking infection.
F761 Label/Store Drugs and Biologicals: The facility failed to store and label medications properly, including expired medications and insulin pens with unclear expiration dates. Medication carts contained outdated drugs.
A4063 Medication Storage: The facility did not store medications at appropriate temperatures or secure them properly, risking contamination and misuse.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions, including failure to follow care plans for catheter and ace wrap use.
Report Facts
Facility census: 45
Deficiencies cited: 5
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 6, 2019
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements and licensure standards at Steelville Senior Living.
Findings
The facility met the applicable provisions of the 2012 Life Safety Code and related documents with no deficiencies in emergency preparedness or licensure inspection.
Inspection Report
Plan of Correction
Census: 16
Deficiencies: 1
Date: Dec 6, 2019
Visit Reason
The inspection was conducted to evaluate compliance with medication review and resident condition documentation requirements, specifically focusing on monthly summaries for residents.
Findings
The facility failed to complete monthly summaries of residents' general condition and needs for two of three sampled residents. The monthly summaries for several months in 2019 were missing, and the MDS Coordinator acknowledged responsibility for the deficiencies.
Deficiencies (1)
19 CSR 30-88.047(58)(B) Resident Condition/Medication Review: The facility did not complete monthly summaries of residents' general condition and needs for two of three sampled residents for multiple months in 2019.
Report Facts
Facility census: 16
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 13
Date: Jan 25, 2019
Visit Reason
Annual inspection survey conducted at Steelville Senior Living to assess compliance with federal regulations and state requirements.
Findings
The facility was found deficient in multiple areas including abuse/neglect policies, admissions policy, notice requirements before transfer/discharge, baseline care plans, infection prevention and control, medication administration, food safety, and psychotropic drug use. Several residents' records and facility policies were reviewed and found lacking in compliance with regulatory standards.
Deficiencies (13)
F607 Abuse/Neglect Policies. The facility failed to check the Certified Nurses' Assistant (CNA) Registry for new employees, missing federal indicators for abuse/neglect for three of eight sampled employees.
F620 Admissions Policy. The facility's admission policy required residents to waive potential liability for loss of personal property, which is not permitted by regulation.
F623 Notice Requirements Before Transfer/Discharge. The facility failed to provide timely and adequate notice of transfer or discharge to residents and their representatives for 13 of 13 sampled residents.
F655 Baseline Care Plan. Facility staff failed to complete baseline care plans within 48 hours of admission for 10 of 14 sampled residents.
F658 Services Provided Meet Professional Standards. Facility failed to follow acceptable standards for medication administration for three of 14 sampled residents, leaving medications unattended.
F677 ADL Care Provided for Dependent Residents. Facility failed to provide adequate assistance with activities of daily living, including bathing, for multiple residents.
F758 Free from Unnecessary Psychotropic Medications/PRN Use. Facility failed to ensure psychotropic medications were limited to 14 days and properly documented for residents with PRN orders.
F759 Medication Error Rates. Facility failed to maintain medication error rates below 5%, with a 7.69% error rate observed during the survey.
F803 Menus Meet Resident Needs/Prepared in Advance/Followed. Facility failed to follow the diet spread sheet for meals, including food preparation and serving temperatures.
F804 Nutritive Value/Palatable/Prefer Temp. Facility failed to reheat pureed foods to required temperatures and failed to serve food items at safe temperatures.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. Facility failed to store food properly to prevent contamination, including unlabeled and uncovered food items.
F838 Facility Assessment. Facility failed to conduct and update a comprehensive facility assessment to determine resources needed for residents.
F880 Infection Prevention & Control. Facility failed to maintain an effective infection control program, including hand hygiene, cleaning, and disinfection practices.
Report Facts
Census: 43
Medication error rate: 7.69
Medication opportunities observed: 26
Medication errors: 2
Inspection Report
Life Safety
Census: 43
Deficiencies: 1
Date: Jan 25, 2019
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety and related regulations at Steelville Senior Living.
Findings
The facility met emergency preparedness requirements with no deficiencies. However, a Class II deficiency was found related to hot water temperatures exceeding regulatory limits in resident rooms, with water temperatures recorded up to 140°F.
Deficiencies (1)
19 CSR 30-85.012(97) Hot Water 105-120 Degrees F. Facility staff failed to maintain water temperatures between 105-120°F in resident rooms, with observed temperatures up to 140°F in multiple rooms.
Report Facts
Facility census: 43
Water temperature: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding water booster temperature settings and observations | |
| Maintenance Supervisor | Responsible for monitoring and adjusting water temperatures as part of corrective actions | |
| Administrator | Signed the plan of correction |
Inspection Report
Census: 10
Deficiencies: 2
Date: Jan 25, 2019
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements for residents and staff, and to evaluate hot food storage temperatures and food safety practices at Steelville Senior Living.
Findings
The facility failed to properly screen residents and staff for tuberculosis as required by state regulations, with missing or incomplete tuberculosis skin test documentation. Additionally, the facility failed to maintain hot food items at the required temperature and did not document food temperatures consistently.
Deficiencies (2)
19 CSR 30-86.047(19) TB Screen Residents & Staff. The facility failed to screen one staff member and three residents for tuberculosis according to state regulations, with missing or incomplete test documentation.
19 CSR 30-87.030(23) Hot Food-Storage, Temperatures. The facility failed to maintain hot food items at or above 135°F and failed to document all hot and cold food temperatures on the steam table prior to service.
Report Facts
Facility census: 10
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 17, 2018
Visit Reason
This document reports the results of an initial certification survey for Steelville Senior Living.
Findings
No deficiencies were cited as a result of this initial certification survey. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 17, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and Emergency Preparedness requirements for Steelville Senior Living.
Findings
The Emergency Preparedness portion of the survey did not result in deficiencies. The facility met the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA). No state licensure deficiencies were cited as a result of this inspection.
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