Deficiencies (last 7 years)
Deficiencies (over 7 years)
15.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
180% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 3
Date: Feb 10, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Sunterra Springs Independence following a survey conducted on 02/10/2025. The visit was to assess compliance with federal Medicare and Medicaid requirements related to trauma informed care, sufficient nursing staff, infection control, and other regulatory standards.
Findings
The facility failed to provide trauma informed care for one sampled resident with PTSD, ensure sufficient nursing staff to respond to call lights timely for two sampled residents, and maintain proper infection prevention and control measures for three sampled residents. Deficiencies were noted in care planning, staff awareness, call light response, and infection control practices.
Deficiencies (3)
F699 Trauma-informed care was not provided for one sampled resident with PTSD as the facility failed to identify triggers and include trauma-informed interventions in the care plan. The facility census was 38 residents.
F725 The facility failed to ensure sufficient nursing staff with appropriate competencies to provide timely response to call lights for two sampled residents. The facility census was 38 residents.
F880 The facility failed to establish and maintain an infection prevention and control program, including proper use of enhanced barrier precautions and staff education, for three sampled residents. The facility census was 38 residents.
Report Facts
Facility census: 38
Sampled residents: 12
Residents with infection control deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ron Hicks | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Date: Feb 10, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to provide trauma informed care for a resident with PTSD, insufficient nursing staff to meet resident needs and respond to call lights timely, and failure to implement Enhanced Barrier Precautions during resident care.
Complaint Details
The investigation was complaint-driven based on allegations of failure to provide trauma informed care, insufficient nursing staff, and inadequate infection control practices.
Findings
The facility failed to provide trauma informed care for a resident with PTSD by not including mental health diagnoses and triggers in the care plan and staff were unaware of these triggers. The facility also failed to ensure sufficient nursing staff to respond to call lights in a timely manner, with documented delays up to 39 minutes. Additionally, the facility failed to ensure staff used Enhanced Barrier Precautions (gowns and gloves) consistently when providing care to residents with wounds or on isolation precautions.
Deficiencies (3)
Failure to provide trauma informed care for a resident with PTSD, including lack of care plan focus on PTSD and triggers, and staff unawareness of resident's triggers.
Failure to provide enough nursing staff to meet resident needs and respond to call lights in a timely manner, with documented call light response delays up to 39 minutes.
Failure to ensure staff used Enhanced Barrier Precautions (gowns and gloves) consistently when providing care to residents with wounds or on isolation precautions.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Call light response times (minutes): 39
Facility census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Observed failing to don PPE when required for resident on Enhanced Barrier Precautions |
| CMT A | Certified Medication Technician | Observed failing to don PPE when required for resident on Enhanced Barrier Precautions |
| LPN B | Licensed Practical Nurse | Observed failing to don PPE when required for resident on Enhanced Barrier Precautions |
| Interim Social Services Director | Responsible for care planning PTSD and triggers for resident; acknowledged many residents lacked mental health diagnoses on care plans | |
| Director of Nursing | Director of Nursing | Provided expectations for trauma informed care, call light response times, and Enhanced Barrier Precautions |
| Nurse Practitioner | Nurse Practitioner | Expected mental health diagnoses and PTSD triggers to be on resident care plans |
| Administrator | Administrator | Acknowledged call light response times were substantial and needed staff education |
| CNA A | Certified Nursing Assistant | Unaware of resident's PTSD triggers and how to access care plan |
| Agency RN A | Registered Nurse | Unaware of resident's PTSD diagnosis and triggers |
| LPN A | Licensed Practical Nurse | Reported complaints about call light response times and expected 3-5 minute response |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with wound care standards, specifically regarding the documentation and physician orders for pressure ulcer care upon admission.
Findings
The facility failed to document a comprehensive wound assessment and obtain physician's orders for a pressure ulcer on admission for one sampled resident. The wound care orders were obtained two days after admission, and the comprehensive wound assessment was delayed by four days. Nursing staff did not document detailed wound assessments as expected.
Deficiencies (1)
Failure to document a comprehensive wound assessment and obtain physician's order for a pressure ulcer upon admission.
Report Facts
Residents Affected: 36
Residents Affected: 1
Days delay: 2
Days delay: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Assessed resident's coccyx wound on admission but did not document comprehensive wound assessment |
| RN A | Registered Nurse | Transcribed physician order for wound care and treated wound; forgot to transcribe order initially |
| Director of Nursing | Director of Nursing | Provided expectations for wound assessment documentation and physician orders |
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 2
Date: Dec 10, 2024
Visit Reason
The inspection was conducted to assess compliance with federal Medicare and Medicaid requirements related to pressure ulcer prevention and treatment.
Findings
The facility failed to document a comprehensive wound assessment and obtain a physician's order for a pressure ulcer for one sampled resident. The wound care documentation and treatment orders were incomplete and delayed.
Deficiencies (2)
F686 Skin Integrity: The facility failed to document a comprehensive wound assessment and obtain physician's orders for a pressure ulcer for a sampled resident. Wound treatments and assessments were not timely or adequately documented.
A4083 Pressure Sore Prevention/Treatment: The facility did not keep residents free from avoidable pressure sores and failed to provide adequate treatment as required by regulation. Refer to F686 for details.
Report Facts
Resident census: 36
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a missing controlled drug card of 30 oxycodone tablets for one sampled resident (Resident #1).
Complaint Details
The investigation was triggered by a missing card of oxycodone 5 mg, quantity 30 for Resident #1. The facility discovered the medication was missing between 11/29/23 and 12/2/23. A staff member (LPN B) was suspended pending investigation. Surveillance footage showed discrepancies in medication card handling. The Director of Nursing filed a police report and notified the resident and pharmacy. Staff were re-educated on medication handling and reporting procedures.
Findings
The facility failed to ensure that a controlled drug card of 30 oxycodone tablets was properly accounted for, locked, and immediately reported as missing after delivery. Surveillance footage and investigation revealed discrepancies in medication card handling by staff, leading to the missing medication. The deficiency was corrected with staff education and suspension of a suspected employee.
Deficiencies (1)
Failed to ensure a controlled drug card of 30 oxycodone tablets was accounted for, locked, and immediately reported as missing after delivery.
Report Facts
Residents census: 37
Missing oxycodone tablets: 30
Controlled medication cards added: 4
Controlled medication cards delivered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Suspected of mishandling controlled medication cards leading to missing oxycodone |
| LPN A | Licensed Practical Nurse | Reported missing oxycodone to Director of Nursing |
| Unit Manager | Registered Nurse | Signed for medication delivery and handed medication cards to LPN B |
| RN A | Agency Nurse | Counted narcotic cards with LPN B |
| DON | Director of Nursing | Led investigation, filed police report, educated staff on medication procedures |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
The inspection was conducted to investigate a medication discrepancy involving controlled substances, specifically oxycodone, and to ensure compliance with drug labeling and storage regulations.
Findings
The facility failed to ensure proper storage and accounting of controlled drugs, resulting in missing oxycodone tablets. The issue was identified through observation, interviews, and record review, and corrective actions including staff education and policy review were implemented.
Deficiencies (1)
F761 Label/Store Drugs and Biologicals: The facility failed to ensure controlled drugs were properly stored and accounted for, resulting in missing oxycodone tablets and a suspected employee taking narcotic medication.
Report Facts
Resident census: 37
Missing oxycodone tablets: 30
Inspection Report
Routine
Census: 31
Deficiencies: 9
Date: Jun 8, 2023
Visit Reason
Routine inspection of Sunterra Springs Independence nursing home to assess compliance with regulatory requirements including resident rights, staff background checks, care planning, respiratory care, dialysis care, and arbitration agreements.
Findings
The facility had multiple deficiencies including failure to ensure residents' rights to formulate advanced directives were fully honored and documented; incomplete background screening for new employees; failure to provide baseline care plans to residents within 48 hours of admission; lack of discharge recapitulation summaries; inadequate CPR certification tracking; failure to properly assess and educate staff on insulin pump use; improper management and documentation of CPAP and oxygen therapy; incorrect identification and assessment of dialysis access; and incomplete and unclear arbitration agreements.
Deficiencies (9)
Failed to ensure residents were offered the right to formulate and/or obtain existing advanced directives and failed to document efforts.
Failed to ensure background screening through the Certified Nurse Assistant Registry was completed prior to hire for four out of ten new employees.
Failed to provide residents and/or their representatives with a summary of a Baseline Care Plan developed within 48 hours of admission for four sampled residents.
Failed to ensure recapitulation of stay was completed for two sampled residents.
Failed to have a process to ensure CPR certified staff were available on all shifts and to identify CPR certified staff on schedules.
Failed to assess one resident to ensure he could monitor and maintain his insulin pump and failed to educate staff on insulin pumps.
Failed to ensure physician's orders for one resident's CPAP and oxygen use until five days after readmission, failed to ensure proper cleansing and storage of CPAP equipment, and failed to ensure oxygen tubing was dated and properly stored for two residents.
Failed to ensure one resident's hemodialysis access was correctly identified in physician's orders, treatment records, and care plan, and was correctly assessed by licensed nurses.
Failed to ensure arbitration agreements signed by three residents included explanation in a manner understood, that arbitration was not a condition of admission, residents' right to communicate with state officials, and contained a neutral arbitrator and agreed venue.
Report Facts
Facility census: 31
Sampled residents: 12
New employees sampled: 10
Residents affected by advanced directives deficiency: 5
Residents affected by baseline care plan deficiency: 4
Residents affected by discharge summary deficiency: 2
CPR certified staff: 11
Residents affected by insulin pump deficiency: 1
Residents affected by CPAP and oxygen care deficiency: 2
Residents affected by dialysis care deficiency: 1
Residents affected by arbitration agreement deficiency: 3
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 12
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to investigate complaints related to advance directives, abuse/neglect policies, baseline care plans, discharge summaries, CPR certification, quality of care, oxygen administration, dialysis, arbitration agreements, and tuberculosis screening.
Complaint Details
The complaint investigation found multiple deficiencies related to residents' rights, care planning, staff qualifications, and regulatory compliance. The facility census was 31 residents during the investigation.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, incomplete background screening for employees, inadequate baseline care plans, incomplete discharge summaries, lack of CPR certification for staff, deficiencies in quality of care and oxygen administration, improper dialysis care, failure to obtain signed arbitration agreements, and incomplete tuberculosis screening for employees.
Deficiencies (12)
F578 Advance Directives: The facility failed to ensure five sampled residents were offered the right to formulate advance directives and documentation was incomplete.
F607 Abuse/Neglect Policies: The facility failed to ensure background screening through the CNA Registry was completed prior to hire for four of ten new employees.
F655 Baseline Care Plan: The facility failed to provide a baseline care plan within 48 hours of admission for four sampled residents.
F678 CPR Certification: The facility failed to ensure all staff were CPR certified and knowledgeable about CPR procedures.
F684 Quality of Care: The facility failed to assess and monitor residents' insulin pump and glucose monitoring devices properly.
F695 Respiratory/Tracheostomy Care: The facility failed to ensure proper physician orders and care for CPAP and oxygen use for sampled residents.
F698 Dialysis: The facility failed to ensure proper care and documentation for one resident's hemodialysis access and treatment.
F847 Arbitration Agreements: The facility failed to ensure three sampled residents signed binding arbitration agreements as required.
A4017 Criminal Background Check Request: The facility failed to request criminal background checks within two working days for new employees.
A4031 Communicable Disease-Employees: The facility failed to implement policies to screen employees for communicable diseases.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A8010 Advance Directive Requirements: The facility failed to inform residents and representatives annually about advance directives and related policies.
Report Facts
Facility census: 31
Sampled residents: 12
New employees sampled: 10
CPR certified staff: 11
Deficiencies cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee J | Licensed Practical Nurse (LPN) | Mentioned in relation to incomplete TB testing and CPR certification |
| Employee A | Registered Nurse (RN) | Mentioned in relation to incomplete TB testing and CPR certification |
| Employee B | Dietary Aide | Mentioned in relation to incomplete TB testing and CPR certification |
| Employee E | Housekeeper | Mentioned in relation to incomplete TB testing |
| Admissions Coordinator | Responsible for admission agreements and advance directives | |
| Social Services Director (SSD) | Responsible for providing information on advance directives | |
| Regional Nurse/Interim Director of Nursing (DON) | Mentioned in relation to advance directives and CPR certification | |
| Human Resources (HR)/Payroll Director | Responsible for background screening and TB testing | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding advance directives and CPR certification | |
| Certified Nursing Assistant (CNA) C | Interviewed regarding CPR certification and oxygen care | |
| Certified Medication Technicians (CMT) A | Interviewed regarding CPR certification | |
| Regional Nurse Consultant Interim Director of Nursing (DON) | Interviewed regarding CPR certification | |
| Administrator | Mentioned in relation to CPR certification and arbitration agreements |
Inspection Report
Life Safety
Census: 31
Capacity: 38
Deficiencies: 4
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as an Emergency Preparedness portion of a Life Safety Code Survey to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility was found non-compliant with the 2012 edition of the Life Safety Code due to deficiencies in fire alarm system testing and maintenance, and fire drill documentation and execution. Specific issues included incomplete fire alarm inspection documentation and failure to conduct quarterly fire drills with required documentation.
Deficiencies (4)
K345 Fire Alarm System - Testing and Maintenance: The facility did not have itemized locations of fire alarm system components recorded on their annual fire alarm inspection documentation as required by NFPA 72. This affected all residents, staff, and visitors.
K712 Fire Drills: The facility failed to conduct quarterly fire drills at varying times on each work shift and lacked required documentation and components for fire drills as specified by NFPA standards. This affected all residents and employees.
A2020 Complete Fire Alarm Systems: The facility did not have inspections and written certifications of the complete fire alarm system completed annually by an approved qualified service representative as required by NFPA 72.
A2061 Fire Drill Requirements, Evacuation: The facility did not conduct a minimum of twelve fire drills annually with at least one every three months on each shift, including simulated resident evacuation involving local fire or emergency services as required by regulation.
Report Facts
Facility census: 31
Total capacity: 38
Fire drills required annually: 12
Fire drills required per shift: 1
Fire drills unannounced: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding fire alarm inspection reports and fire drill discrepancies | |
| Administrator | Interviewed regarding annual inspection report and fire alarm component listings |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 7
Date: Sep 29, 2021
Visit Reason
The inspection was conducted due to complaints and allegations involving failure to notify physicians of resident condition changes, diversion of controlled medications, failure to report abuse and injuries of unknown origin, failure to respond appropriately to alleged violations, failure to withhold CPR per resident's DNR order, and failure to ensure proper narcotic counts and staff training.
Complaint Details
The complaint investigation involved multiple allegations including failure to notify physicians, diversion of medications, failure to report abuse and injuries, failure to investigate abuse allegations, failure to withhold CPR per DNR, and narcotic count discrepancies. The facility census was 37 residents. Several residents and staff were interviewed, and multiple records were reviewed. The investigation found multiple deficiencies in compliance with regulatory requirements.
Findings
The facility failed to notify a physician of significant weight gain for a resident, failed to prevent diversion of Lorazepam from one resident to others, failed to timely report and fully investigate allegations of abuse and injuries of unknown origin, failed to withhold CPR per a resident's DNR order, failed to ensure narcotic counts were properly documented and signed, and failed to provide required CNA training hours. Investigations were incomplete or delayed, and policies were not fully followed.
Deficiencies (7)
Failed to notify physician of weight gain for Resident #37 being treated for edema.
Failed to prevent diversion of Lorazepam from Resident #41 to Residents #16 and #149.
Failed to timely report allegations of abuse and injuries of unknown origin to the State Agency for Residents #10 and #16, and misappropriation of controlled substances.
Failed to fully investigate allegations of abuse and injuries of unknown origin for Residents #10 and #16.
Failed to withhold CPR per Resident #150's DNR order.
Failed to ensure shift change narcotic counts were completed and signed by both oncoming and off-going nursing staff.
Failed to ensure Certified Nurse Assistants received twelve hours of training based on performance reviews.
Report Facts
Facility census: 37
Weight gain: 10.4
Weight gain: 4.5
Lorazepam tablets diverted: 5
Narcotic count unsigned opportunities: 12
Narcotic count unsigned opportunities: 14
Narcotic count unsigned opportunities: 17
Narcotic count unsigned opportunities: 12
Narcotic count unsigned opportunities: 2
Narcotic count unsigned opportunities: 12
Narcotic count unsigned opportunities: 8
Narcotic count unsigned opportunities: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Charge Nurse and former Director of Nursing | Named in medication diversion and abuse investigation findings |
| RN B | Charge Nurse and Unit Manager | Named in medication diversion and abuse investigation findings |
| CNA F | Certified Nurse Assistant | Named in abuse allegation involving Resident #16 |
| LPN E | Licensed Practical Nurse | Named in resident injury assessments and incident reporting |
| CNA G | Certified Nurse Assistant | Named in abuse allegation investigation |
| Director of Nursing | Director of Nursing | Responsible for investigations and staff training |
| Administrator | Facility Administrator | Responsible for investigations and reporting |
| Corporate Nurse | Corporate Nurse | Conducted abuse investigation |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in abuse investigation and medication diversion |
| Certified Medication Technician A | Certified Medication Technician | Named in narcotic count and training interviews |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 13
Date: Sep 29, 2021
Visit Reason
The inspection was the annual survey of Sunterra Springs Independence nursing facility to assess compliance with federal regulations and investigate allegations of abuse, neglect, and misappropriation.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant resident changes, failure to prevent misappropriation of medications, failure to report alleged abuse promptly, inadequate in-service training for nursing personnel, and failure to provide basic life support including CPR. The facility census was 37 residents during the survey.
Deficiencies (13)
F580 Notification of Changes: The facility failed to notify the physician of weight gain for a resident being treated for edema and did not follow policy for timely notification of significant changes.
F602 Free from Misappropriation/Exploitation: The facility failed to prevent unauthorized removal of Lorazepam from one resident to others and did not report or investigate the misappropriation properly.
F609 Reporting of Alleged Violations: The facility failed to report allegations of abuse and injuries of unknown origin to the State Survey Agency within required timeframes.
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to provide basic life support including CPR to a resident requiring emergency care prior to EMS arrival.
F730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to ensure certified nurse assistants received required annual in-service training.
F755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to maintain accurate controlled narcotic counts and reconcile discrepancies timely.
A4024 In-service Training-Nursing Personnel: The facility failed to ensure nursing personnel received sufficient in-service training related to problems, needs, care of residents, and infection control.
A4029 Communicable Disease-Employees: The facility failed to implement policies to screen employees for communicable diseases and prevent exposure to residents.
A4070 Controlled Substance Reconcile/Record: The facility failed to maintain accurate records of controlled drugs and reconcile discrepancies.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4086 Dr Notification-Change in Condition: The facility failed to notify the physician of accident, injury, or significant change in resident condition as required.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property.
A8025 Report A/N to DHSS/DMH When Needed: The facility failed to immediately report suspected abuse or neglect to the department and State Agency.
Report Facts
Facility census: 37
Deficiencies cited: 12
Narcotic count sheet unsigned opportunities: 12
Narcotic count sheet unsigned opportunities: 14
Narcotic count sheet unsigned opportunities: 17
Inspection Report
Life Safety
Census: 37
Capacity: 38
Deficiencies: 12
Date: Sep 29, 2021
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility was found to have multiple deficiencies related to delayed-egress locking arrangements, fire alarm system installation and maintenance, sprinkler system installation, evacuation and relocation plans, and fire door inspections. The facility census was 37 residents with a licensed capacity of 38 beds at the time of the survey.
Deficiencies (12)
K222 Egress Doors: The facility failed to ensure proper signage was located on all facility exit doors with delayed-egress locking devices, affecting approximately 34 residents and staff. The locks must be electrical locks that release upon loss of power and be part of a supervised automatic sprinkler and smoke detection system.
K341 Fire Alarm System - Installation: The facility failed to ensure all fire alarm notification devices, specifically strobe lights, were installed to provide effective visual coverage in the laundry area. The facility census was 37 with a capacity of 38 residents.
K345 Fire Alarm System - Testing and Maintenance: The facility did not have complete and verifiable documentation of fire alarm system inspections and semi-annual visual inspections as required by NFPA 72. The census was 37 residents with a capacity of 38.
K351 Sprinkler System - Installation: The facility failed to ensure the spray pattern of a sprinkler head in the beauty shop was not obstructed, potentially affecting residents in one of three smoke compartments. The census was 37 residents with a licensed capacity of 38.
K711 Evacuation and Relocation Plan: The facility failed to include several protocols in the resident evacuation plan, including relocation details, emergency contacts, and procedures for sheltering or total evacuation, potentially affecting all residents and staff.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to conduct a complete annual visual and functional assessment of smoke barrier and fire resistive rating corridor and egress door assemblies, potentially allowing malfunction and spread of fire or smoke.
A2018 Complete Fire Alarm System Requirements: The facility did not meet requirements for a complete fire alarm system including manual pull stations and interconnected smoke detectors. This deficiency was classified as Class II.
A2020 Fire Alarm System Inspections/Certifications: The facility failed to have annual inspections and written certifications of the complete fire alarm system by a qualified service representative. This deficiency was classified as Class II.
A2034 Sprinkler System-Test/Maintain: The facility failed to inspect, maintain, and test sprinkler systems in accordance with requirements. This deficiency was classified as Class II.
A2047 Exit Sign Requirements: The facility failed to place proper exit signs at required exits, including signage bearing the word EXIT in plain, legible block letters. This deficiency was classified as Class II.
A2061 Fire Drill Requirements, Evacuation: The facility failed to conduct a minimum of twelve fire drills annually with at least one every three months on each shift, including unannounced drills and simulated resident evacuations. This deficiency was classified as Class III.
A2065 Fire Safety Training Requirements: The facility failed to provide required fire safety training elements including prevention, detection, evacuation procedures, and response to alarms. This deficiency was classified as Class III.
Report Facts
Facility census: 37
Total capacity: 38
Residents affected: 34
Fire drills required: 12
Fire drills frequency: 1
Inspection Report
Routine
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 28, 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 federal 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: Dec 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal 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: Oct 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 2
Date: Sep 11, 2020
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with infection prevention and control requirements related to COVID-19.
Findings
The facility failed to ensure proper documentation of health screenings and temperature checks for staff, with missed screenings for two sampled employees. The infection prevention and control program did not meet requirements, and the facility lacked a designated staff member to ensure completion of screening forms.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to ensure documentation of health screenings and temperature readings for two sampled staff members. The screening process was conducted on an honor system without designated staff to ensure completion.
A4029 Communicable Disease-Employees: The facility did not develop and implement policies to ensure employees are screened for communicable diseases and do not expose residents.
Report Facts
Facility census: 30
Date of survey: Sep 11, 2020
Inspection Report
Routine
Deficiencies: 0
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal 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
Plan of Correction
Census: 36
Deficiencies: 6
Date: Aug 14, 2019
Visit Reason
The inspection was conducted to evaluate compliance with federal and state regulations regarding bed hold policies, baseline care plans, infection control, activity programs, food safety, and other care standards at Sunterra Springs Independence nursing facility.
Findings
The facility was found deficient in multiple areas including failure to provide proper bed hold notices, develop baseline care plans within 48 hours of admission, provide individualized activities, maintain food safety and infection control standards, and ensure proper documentation and implementation of care plans and policies.
Deficiencies (6)
F625 Notice of bed hold policy and return before transfer was not provided to sampled residents or documented properly.
F655 The facility failed to develop baseline care plans within 48 hours of admission for sampled residents and did not provide required summaries to residents or representatives.
F679 The facility failed to provide individualized activities to meet the interests and needs of sampled residents.
F803 The facility failed to use standardized recipes and provide adequate guidance for mechanically altered diets, affecting resident nutrition.
F812 The facility failed to procure, store, prepare, and serve food in accordance with established food safety requirements.
F880 The facility failed to establish and maintain an infection prevention and control program to prevent communicable diseases and infections.
Report Facts
Facility census: 36
Resident samples: 15
Resident samples: 7
Inspection Report
Life Safety
Census: 36
Capacity: 38
Deficiencies: 20
Date: Aug 14, 2019
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and the Life Safety Code of the National Fire Protection Association.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to perform an all hazards analysis, incomplete emergency preparedness program elements, and deficiencies in fire safety systems such as fire barriers, exit signage, fire alarm systems, and fire drills. These deficiencies potentially affected all residents and staff.
Deficiencies (20)
E004: The facility failed to perform an all hazards analysis specific to the location and hazards likely to occur, affecting all residents. The facility census was 36 with a licensed capacity of 38.
E015: The facility failed to include key elements in the Emergency Preparedness Program such as emergency water bottle locations, sewer system failure plans, and proper temperature ranges in the electrical outage policy, affecting all residents.
E032: The facility failed to develop and maintain an emergency preparedness communication plan including backup communication methods beyond landline and mobile phones, affecting all residents and staff.
E037: The facility failed to maintain documentation of emergency preparedness training and testing, including full-scale exercises and staff knowledge, affecting all residents and staff.
K161: The facility failed to ensure fire barriers around pipes in the west mechanical room were properly caulked with fire-rated material, potentially affecting at least 16 residents in one smoke zone.
K293: The facility failed to place exit signs at or above the door from the kitchen into the dining room, affecting the ability of dietary employees to find the exit.
K345: The facility failed to ensure semi-annual fire alarm inspections were conducted and documented, affecting all residents and staff.
K372: The facility failed to maintain smoke barrier walls to resist passage of smoke in the attic area above the west mechanical room, potentially affecting all residents and staff in three smoke zones.
K711: The facility failed to maintain a written evacuation and relocation plan and failed to document fire drills and emergency response training, potentially affecting at least 10 therapy employees and residents.
K712: The facility failed to maintain documentation of monthly fire drills and emergency response training, affecting residents and staff.
K916: The facility failed to install and maintain an alarm annunciator panel in the east hall maintenance shop and failed to maintain monthly generator testing documentation, affecting all residents and staff.
K918: The facility failed to maintain annual load bank testing and fuel testing for the emergency generator and failed to maintain transfer switch testing documentation, affecting all residents and staff.
A2020: The facility failed to have complete fire alarm systems inspections and certifications as required annually.
A2047: The facility failed to place exit signs bearing the word EXIT in required locations and maintain continuous illumination of exit signage.
A2054: The facility failed to maintain smoke section walls and doors to resist passage of smoke as required.
A2059: The facility failed to maintain fire drills and emergency preparedness plans including phased response and evacuation instructions.
A2063: The facility failed to keep records of all fire drills including evacuation times and special problems.
A3001: The facility failed to maintain the building in good repair and comply with construction standards.
A4013: The facility failed to develop policies and procedures covering personnel practices, admission, discharge, emergency treatment, and residents' rights.
A4015: The facility failed to fully inform personnel of policies and duties.
Report Facts
Facility census: 36
Licensed capacity: 38
Residents affected: 16
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 8
Date: Aug 20, 2018
Visit Reason
Annual survey conducted from 8/13/18 to 8/20/18 to assess compliance with federal and state regulations for Sunterra Springs Independence.
Findings
The facility was found deficient in multiple areas including resident council responsiveness, abuse/neglect policies, transfer/discharge notice requirements, CPR certification, accident prevention, and food safety. Several deficiencies were cited with varying severity levels.
Deficiencies (8)
F565 Resident/Family Group and Response: The resident council meetings were not properly responded to, with lack of documentation and follow-up on resident concerns from May, June, and July 2018. Six residents attended the group meeting during the survey.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to check the Employee Disqualification List (EDL) for two sampled employees out of eight newly hired staff prior to or upon hire.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and/or their representatives in writing of transfer/discharge reasons and failed to send required notices to the Ombudsman for sampled residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility did not notify residents or their representatives of the bed-hold policy before transferring or discharging a sampled resident.
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to ensure staff were properly certified in CPR, allowing online-only certification and expired certifications for some staff.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to correctly use a mechanical lift and lock wheelchair wheels during resident transfer, risking resident safety.
F803 Menus Meet Resident Needs/Prep in Advance/Followed: The facility failed to ensure correct standardized recipes were followed, affecting nutritional adequacy for residents on pureed diets.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain appropriate cold food temperatures during lunch service, potentially affecting all residents served.
Report Facts
Facility census: 22
Number of sampled employees: 8
Number of sampled residents: 3
Number of sampled residents: 19
Inspection Report
Life Safety
Census: 22
Capacity: 38
Deficiencies: 4
Date: Aug 20, 2018
Visit Reason
A Life Safety Code Survey was conducted as a Recertification Survey by the Missouri Department of Health and Senior Services to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in compliance with emergency preparedness and fire alarm system requirements. Deficiencies included missing state and federal emergency contact information in the emergency operational preparedness plan and incomplete fire alarm system testing and maintenance documentation.
Deficiencies (4)
E001 Emergency Operational Preparedness program lacked required contact information, updates, and procedures to ensure resident safety during emergencies. The facility census was 22 residents with a capacity of 38.
K345 Fire Alarm System testing and maintenance was incomplete, lacking semi-annual visual inspections and detailed documentation of fire alarm components and testing results.
A2020 Fire Alarm System inspections and certifications were not completed annually by a qualified service representative as required by NFPA 72.
A4013 Facility policies and procedures did not fully cover required operational areas including emergency preparedness and resident safety.
Report Facts
Facility census: 22
Total capacity: 38
Document
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
No findings or content related to facility inspection or compliance are present in the document.
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