Inspection Reports for
The Bishop Spencer Place, Inc
4301 MADISON AVE, KANSAS CITY, MO, 64111-3491
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
10.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
18% occupied
Based on a June 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: 21
Deficiencies: 1
Date: Jun 3, 2025
Visit Reason
The inspection was conducted to assess compliance with protective oversight regulations, specifically regarding the use and documentation of side rails for residents.
Findings
The facility failed to ensure side rails were updated on Physician Orders and that staff were trained on their use. Documentation was lacking for resident assessments, education, and consent related to side rails for three sampled residents.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility did not ensure side rails were updated on Physician Orders or that staff were trained on their use for three sampled residents. Documentation was missing for resident assessments, education, and signed consent for side rails.
Report Facts
Facility census: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Duckstein | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Interviewed regarding staff training and resident assessments for side rails | |
| Certified Medication Technician | CMT | Interviewed about knowledge of side rails usage and training |
| Health Care Administrator | Interviewed about awareness of side rails on residents' beds |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Date: Jul 29, 2024
Visit Reason
The inspection was conducted due to complaints regarding medication errors involving residents at the facility.
Complaint Details
The complaint involved medication errors with three residents: Resident #2 received the wrong medication; Resident #3 was given medication twice due to a family member administering medication without documentation; Resident #1 was given a 10-fold overdose of morphine concentrate, resulting in immediate jeopardy which was later abated.
Findings
The facility failed to ensure residents were free from medication errors, including wrong medication administration, double dosing, and a significant overdose of morphine concentrate. The facility implemented corrective actions during the survey.
Deficiencies (2)
Failure to ensure two sampled residents were free from medication errors, including wrong medication and double dosing.
Failure to ensure one sampled resident was free from a significant medication error involving a 10-fold overdose of morphine concentrate.
Report Facts
Residents affected: 2
Residents affected: 1
Medication overdose amount: 5
Medication ordered dose: 0.5
Facility census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in medication error administering wrong medication to Resident #2 |
| CMT B | Certified Medication Technician | Involved in medication error administering wrong medication to Resident #2 |
| ADON | Assistant Director of Nursing | Administered 5 mL morphine concentrate overdose to Resident #1 and administered Narcan |
| CMT A | Certified Medication Technician | Assisted ADON with medication preparation for Resident #1 overdose incident |
| DON | Director of Nursing | Notified and involved in response to Resident #1 medication overdose |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 4
Date: Jul 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of medication errors at Bishop Spencer Place, Inc.
Complaint Details
At the time of the complaint investigation, the violation was determined to be at an imminent danger Class I level but was lowered to Class II and Level D at exit. The facility had implemented corrective actions and a plan of correction was submitted.
Findings
The facility failed to ensure residents were free from medication errors, with specific incidents involving wrong medication administration to residents #1, #2, and #3. The facility implemented corrective actions and education to prevent further errors.
Deficiencies (4)
F684 Quality of care: The facility failed to ensure two sampled residents were free from medication errors, including administration of wrong medication and double dosing without proper documentation.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure one sampled resident was free from a significant medication error involving a tenfold overdose of morphine concentrate.
A4055 Safe/Effective Medication System: The facility failed to maintain a safe and effective system of medication distribution, administration, control, and use as evidenced by medication errors.
A4075 Nursing Care per Res Condition: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice, contributing to medication errors.
Report Facts
Facility census: 48
Medication error date: Apr 4, 2024
Medication error date: Mar 25, 2024
Medication error date: Jul 12, 2024
Morphine overdose: 5
Morphine overdose factor: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Hollestelle | Healthcare Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| LPN A | Involved in medication errors and corrective discussions | |
| CMT B | Certified Medication Technician | Involved in medication errors and corrective discussions |
| Director of Nursing | DON | Discussed medication errors and corrective actions with staff |
| Assistant Director of Nursing | ADON | Administered incorrect morphine dose and involved in medication error |
Inspection Report
Follow-Up
Census: 16
Capacity: 40
Deficiencies: 6
Date: Feb 6, 2024
Visit Reason
The visit was a follow-up inspection to verify correction of previously cited deficiencies related to elevator certification, fire alarm system inspections, sprinkler system maintenance, and food safety in the facility.
Findings
The facility was found deficient in displaying current elevator inspection certificates, fire alarm notification devices, sprinkler system maintenance, and food safety equipment cleanliness. Corrective actions and plans of correction were submitted and partially implemented.
Deficiencies (6)
19 CSR 30-86.012(25) Elevator Requirements: The facility failed to display a current elevator inspection certificate and provide documentation of monthly elevator testing as required by NFPA standards.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: The facility failed to ensure all fire alarm components, including audio and visual devices, were properly installed and maintained, affecting warning coverage.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: The facility failed to perform and document complete weekly/monthly fire sprinkler system inspections and maintain sprinkler heads free of obstructions.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: The facility failed to maintain sanitary food preparation equipment and keep walk-in freezer floors clean, risking food safety.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: The facility failed to maintain plastic cutting boards in good condition, risking cross-contamination and food safety hazards.
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: The facility failed to clean food-contact surfaces of cooking equipment adequately, risking bacterial contamination.
Report Facts
Facility census: 16
Licensed capacity: 40
Deficiencies cited: 6
Inspection Report
Routine
Census: 53
Deficiencies: 9
Date: Feb 6, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey of Bishop Spencer Place, Inc. to assess compliance with healthcare facility regulations, including resident fund management, PASARR screening, medication administration, pressure ulcer care, respiratory care, medication storage, food safety, infection control, and immunization procedures.
Findings
The facility was found deficient in multiple areas including failure to disperse resident trust funds timely after death, incomplete PASARR Level I screening, improper medication administration and storage, inadequate pressure ulcer care including missing pressure reducing mattress, improper respiratory care including oxygen tubing storage and CPAP maintenance, unlocked medication carts, food safety violations in the kitchen, lapses in infection control practices during wound care and Foley catheter management, and incomplete pneumococcal immunization consent and re-offering.
Deficiencies (9)
Failed to disperse remaining resident trust account funds and provide final accounting within 30 days of death for three sampled residents.
Failed to obtain a complete PASARR Level I Screening for one sampled resident.
Failed to ensure pain patch was not left unattended on resident's breakfast tray and medications were not left for self-administration without nursing supervision.
Failed to ensure a physician ordered Low Air Loss mattress was in place for a resident with a Stage III pressure ulcer.
Failed to ensure oxygen tubing was stored in a dated bag when not in use and CPAP masks were cleaned daily and stored properly for sampled residents.
Failed to ensure medication carts were locked when unattended by nursing staff.
Failed to maintain kitchen sanitation including clean floors, operable thermometers, timely oil changes, and intact cutting boards.
Failed to properly screen for tuberculosis and implement infection control practices during wound care and Foley catheter management.
Failed to complete pneumococcal immunization consent form correctly and failed to re-offer immunization yearly.
Report Facts
Residents census: 53
Resident trust fund remaining balances: 400.57
Resident trust fund remaining balances: 164.17
Resident trust fund remaining balances: 100
Medication carts observed unlocked: 3
Deep fryer oil change frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Accounting Specialist | Responsible for completing forms and returning resident funds after death | |
| Administrator | Responsible for oversight of personal finance account paperwork | |
| Director of Nursing (DON) | Provided multiple interviews regarding PASARR screening, medication administration, wound care, infection control, oxygen therapy, and immunizations | |
| Licensed Practical Nurse (LPN) B | Observed medication pass and provided interview on medication cart locking and medication administration | |
| Registered Nurse (RN)/Wound Care Nurse (WCN) A | Performed wound care and provided interview on wound care practices | |
| Certified Nursing Assistant (CNA) H | Provided interview on oxygen tubing and Foley catheter care | |
| Certified Medication Technician (CMT) C | Provided interview on medication cart locking and hand hygiene | |
| Dietary Manager (DM) | Provided interview on kitchen sanitation and food preparation | |
| Licensed Practical Nurse (LPN) A | Provided interview on CPAP care | |
| Certified Nursing Assistant (CNA) D | Provided interview on CPAP mask care | |
| Assistant Director of Nursing (ADON) | Provided interview on oxygen tubing, CPAP care, medication cart locking, and infection control |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 2
Date: Aug 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to safe and orderly transfer or discharge of residents, specifically focusing on discharge planning and documentation.
Findings
The facility failed to provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge. The discharge process for one sampled resident was not properly managed, leading to concerns about discharge planning, communication, and continuity of care.
Deficiencies (2)
F624: The facility did not provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge, as evidenced by failure to arrange safe discharge for a sampled resident. The resident's discharge plan lacked proper communication and coordination with involved parties.
A8008: Prior to or at admission, residents and their representatives were not fully informed in writing of services available and related charges, including Alzheimer's special care services disclosure.
Report Facts
Facility census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Hollestelle | Healthcare Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Aug 29, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to arrange a safe and orderly discharge for a resident (Resident #2) who was discharged to a lodging facility without appropriate outside services in place, despite resident and family concerns.
Complaint Details
The complaint investigation found that the resident was discharged due to insurance no longer paying for the stay, with no options provided for transfer or paying out of pocket. The resident and family expressed concerns about the discharge process and placement at the lodging facility. The resident experienced mental distress and health decline after discharge. The facility did not confirm if services were in place prior to discharge and referrals for long-term care were denied due to the resident's condition and pending state aid insurance.
Findings
The facility failed to ensure a safe discharge for Resident #2, who was discharged to a lodging facility without necessary services or caregiver support. The resident experienced distress and complications due to the rushed and poorly coordinated discharge process, which was driven by insurance limitations and lack of available long-term care placements.
Deficiencies (1)
Failed to arrange for a safe and orderly discharge for one sampled resident when discharged to a lodging facility without outside services in place.
Report Facts
Residents present: 46
Sampled residents: 7
Discharge date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW A | Social Worker | Interviewed regarding discharge process and coordination with resident's family |
| SW B | Social Worker | Interviewed regarding discharge to lodging facility and referral process |
| Administrator | Facility Administrator | Interviewed regarding discharge policies and resident placement |
| Cancer Support SW | Cancer Support Social Worker | Interviewed about resident's distress after discharge and placement concerns |
| Lodging Facility Worker | Interviewed about lodging facility admission requirements and concerns |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 3
Date: Jun 6, 2023
Visit Reason
The inspection was conducted to investigate allegations of misappropriation and exploitation of residents and to assess compliance with professional standards in medication administration.
Findings
The facility was found to have failed to protect residents from exploitation by a staff member who misused resident funds. Additionally, the facility failed to administer prescribed medication properly, specifically two doses of Xarelto for one resident.
Deficiencies (3)
F602 Free from Misappropriation/Exploitation: The facility failed to protect two sampled residents from exploitation when a staff member obtained and used a resident's debit card and accepted personal checks for personal expenses.
F658 Services Provided Meet Professional Standards: The facility staff failed to administer two doses of Xarelto medication as prescribed for one sampled resident, resulting in missed medication opportunities.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the findings in F658.
Report Facts
Facility census: 52
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Hollestelle | Healthcare Administrator | Signed the statement of deficiencies and plan of correction |
| Server A | Staff member involved in exploitation of residents | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff education and medication administration |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding medication administration records |
| LPN A | Licensed Practical Nurse | Documented medication administration issues |
| LPN B | Licensed Practical Nurse | Interviewed about medication administration practices |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Jun 6, 2023
Visit Reason
The inspection was conducted due to allegations of exploitation and failure to administer prescribed medication properly, involving multiple residents.
Complaint Details
The complaint investigation revealed exploitation by Server A who obtained and used Resident #1's debit card and accepted personal checks from Resident #2. Server A was terminated following the investigation. The medication administration failure involved Resident #3 missing doses of Xarelto without proper documentation or notification to the physician.
Findings
The facility failed to protect two residents from financial exploitation by an employee who misused a resident's debit card and accepted personal checks from another resident. Additionally, the facility failed to administer prescribed medication (Xarelto) properly to one resident, missing doses without proper documentation or notification to the physician.
Deficiencies (2)
Failed to protect residents from wrongful use of belongings or money, involving misuse of debit card and acceptance of personal checks by an employee.
Failed to administer two doses of Xarelto 20 mg by mouth daily for one resident, with missed doses not documented or reported.
Report Facts
Residents affected: 2
Residents affected: 1
Missed medication doses: 3
Checks given: 3
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Server A | Employee who exploited residents by misusing debit card and accepting personal checks; terminated on 4/17/23 | |
| LPN A | Licensed Practical Nurse | Documented missed medication doses and interviewed regarding medication administration failure |
| LPN B | Licensed Practical Nurse | Documented missed medication doses and interviewed regarding medication administration failure |
| Director of Nursing | Director of Nursing | Interviewed regarding staff education and expectations about resident exploitation and medication administration |
| Administrator | Facility Administrator | Interviewed regarding exploitation investigation and staff education |
| Nurse Practitioner A | Nurse Practitioner | Interviewed regarding lack of notification about missed medication doses |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Dec 21, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect involving two residents at Bishop Spencer Place.
Complaint Details
The complaint investigation was triggered by an incident where Resident #2 verbally abused and physically hit Resident #1. The investigation concluded the abuse was unsubstantiated due to Resident #2's altered mental status caused by a urinary tract infection. Resident #2 had no prior history of aggressive behaviors. The facility implemented 1:1 supervision and notified appropriate parties.
Findings
The facility failed to ensure freedom from verbal and physical abuse as Resident #2 called Resident #1 derogatory names and hit him with a rolled-up newspaper. The investigation found abuse unsubstantiated due to Resident #2's altered mental status related to a urinary tract infection, but the facility failed to prevent the incident.
Deficiencies (2)
F600: The facility failed to ensure freedom from verbal and physical abuse as Resident #2 called Resident #1 derogatory names and hit him twice in the face with a rolled-up newspaper. The facility census was 53 residents at the time of the incident.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, and misappropriation of resident property and funds. This deficiency is related to the F600 abuse finding.
Report Facts
Facility census: 53
Deficiency count: 2
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 16
Date: Jul 19, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for Bishop Spencer Place, Inc., a healthcare facility in Kansas City, MO.
Findings
The facility was found deficient in multiple areas including respiratory care, dialysis services, and food and nutrition services. Deficiencies involved improper oxygen tubing storage, inadequate dialysis communication and care planning, and unsanitary food storage and preparation practices.
Deficiencies (16)
F695 Respiratory care: The facility failed to ensure oxygen nasal cannulas were stored properly in plastic bags when not in use, risking infection control for residents using oxygen therapy.
F698 Dialysis: The facility did not ensure residents receiving dialysis had physician orders specifying dialysis schedules and lacked individualized care plans addressing dialysis needs and communication with dialysis centers.
F800 Food and nutrition services: The facility failed to properly store food in the refrigerated walk-in unit and did not follow sanitary and hygienic practices during food preparation, potentially affecting resident safety.
A6006 Cleaning Food Contact Surfaces: Cleaning compounds were used improperly, leaving toxic residues on food-contact surfaces, posing a hazard to residents and staff.
A6030 Garbage Containers: Garbage and refuse containers were not durable, clean, or rodent-proof, and plastic bags used for storage were inadequate, risking contamination.
A6031 Kitchen Waste Containers Covered: Waste containers in food preparation areas were not kept covered when not in use, risking contamination.
A7003 Clean Clothing, Hair Restraints: Employees did not use effective hair restraints to prevent contamination of food or food-contact surfaces.
A7025 Hot Food-Storage Temperatures: Hot food storage facilities lacked proper temperature maintenance and monitoring, risking food safety.
A7026 Hot Food-140 Degrees or Above/Transport: Potentially hazardous foods were not maintained at required temperatures during transport and storage.
A7028 Hazardous Food Cooking Temperatures: Foods requiring cooking to specific temperatures were not consistently cooked to safe temperatures, risking foodborne illness.
A7053 Food-Contact Surfaces Accessible for Cleaning: Food-contact surfaces were not accessible for proper cleaning and inspection, risking contamination.
A7056 Nonfood Contact Surfaces, Cleaning: Nonfood contact surfaces were not cleaned frequently enough to prevent accumulation of debris and contamination.
A7064 Kitchenware/Surfaces/Pitchers-Clean/Sanitize: Equipment and food-contact surfaces were not washed, rinsed, and sanitized properly after use, risking contamination.
A7065 Food-Contact Surfaces Washed/Rinsed/Sanitized: Food-contact surfaces were not cleaned as necessary to prevent accumulation of dirt and food particles.
A7067 Nonfood Contact Surfaces, Cleaned as Needed: Equipment surfaces not intended for food contact were not cleaned as often as necessary to prevent contamination.
A7074 Food-Contact Surface Sanitizing Requirements: Food-contact surfaces were not sanitized by immersion for required times and temperatures, risking contamination.
Report Facts
Facility census: 44
Deficiencies cited: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Hollestelle | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
A Life Safety Code Survey was conducted by the Missouri Department of Health and Senior Services at Bishop Spencer Place on 07/19/2022 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found to be in compliance with emergency preparedness requirements and life safety codes. No deficiencies were cited during this inspection.
Inspection Report
Routine
Census: 44
Deficiencies: 4
Date: Jul 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, dialysis care, food safety, and dietary services at the nursing home.
Findings
The facility was found deficient in multiple areas including improper storage of oxygen nasal cannula tubing, lack of physician orders and individualized care plans for residents receiving dialysis, unsanitary food storage and preparation practices in the kitchen, and improper cooking temperatures compromising food quality and safety.
Deficiencies (4)
Failed to ensure oxygen nasal cannula tubing was stored per facility policy when not in use for one sampled resident.
Failed to ensure residents receiving dialysis had physician's orders indicating dialysis location and schedule and to maintain ongoing communication with dialysis centers for two sampled residents.
Failed to properly store food in the refrigerated walk-in unit and to practice sanitary and hygienic practices before, during and after food preparation tasks.
Failed to ensure foods were prepared in accordance with FDA standards to preserve nutrients; pork sausage links were overcooked to temperatures exceeding 200°F.
Report Facts
Facility census: 44
Sampled residents: 12
Temperature of pork sausage links: 200
Inspection completion date: Jul 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding oxygen tubing storage practices |
| Registered Nurse A | Registered Nurse | Interviewed regarding oxygen tubing storage practices |
| Certified Nurse's Aide A | Certified Nurse's Aide | Interviewed regarding oxygen tubing storage practices |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen tubing storage and dialysis communication |
| Registered Nurse B | Registered Nurse | Interviewed regarding dialysis resident assessments and communication |
| Licensed Practical Nurse A | Agency Licensed Practical Nurse | Interviewed regarding dialysis communication practices |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding dialysis resident assessments |
| MDS Coordinator A | MDS Coordinator | Interviewed regarding dialysis care plans and assessments |
| Social Worker B | Social Worker | Interviewed regarding care plan meetings and dialysis care plans |
| Sousse Chef | Sousse Chef | Interviewed regarding food storage and sanitation practices |
| Executive Chef | Executive Chef | Interviewed regarding food storage, sanitation, and cooking practices |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 5
Date: Jun 4, 2021
Visit Reason
The inspection was conducted in response to a complaint investigation regarding the quality of care provided to a resident with diabetes mellitus who experienced diabetic ketoacidosis (DKA) and related complications.
Complaint Details
The complaint investigation was substantiated. The facility was found to be in Immediate Jeopardy for failing to provide adequate diabetes care and monitoring, resulting in serious harm to the resident.
Findings
The facility failed to notify the resident's physician of a change in condition, failed to respond to elevated blood glucose levels, and failed to monitor the resident's blood sugar as ordered. The resident was discharged with unresolved high blood sugar and subsequently admitted to the hospital ICU with DKA.
Deficiencies (5)
F684 Quality of care was not met as the facility failed to notify the physician or respond to a resident's elevated blood glucose and failed to monitor the resident's blood sugar as ordered, resulting in the resident's hospitalization with diabetic ketoacidosis.
The facility did not have adequate documentation or orders for blood glucose monitoring and failed to follow physician orders for diabetes care, including medication administration and hydration.
Staff failed to properly assess and respond to the resident's condition when the resident was found clammy and lethargic, delaying notification to the physician and appropriate intervention.
The facility's investigation revealed staff confusion and lack of knowledge regarding the resident's diabetes status and blood sugar readings, contributing to inadequate care.
The facility failed to notify the physician and family in a timely manner about the resident's deteriorating condition and discharge plans, leading to delayed hospital admission.
Report Facts
Facility census: 41
Blood glucose readings: 677
Blood glucose readings: 571
Blood glucose readings: 539
Blood glucose readings: 621
Blood glucose readings: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in investigation for failure to notify physician and improper handling of resident's blood sugar readings |
| LPN B | Licensed Practical Nurse | Named in investigation for blood sugar monitoring and reporting issues |
| CNA A | Certified Nursing Assistant | Observed resident's condition and reported incident to nursing staff |
| Director of Nursing | Director of Nursing | Conducted investigation interviews and involved in corrective actions |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 21, 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
Deficiencies: 0
Date: Dec 4, 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
Plan of Correction
Census: 48
Deficiencies: 2
Date: Jul 24, 2020
Visit Reason
The inspection was conducted due to a survey related to a fall incident involving a resident during transport by facility staff.
Findings
The facility failed to provide adequate supervision and assistance to prevent accidents during resident transport, resulting in a resident falling out of a wheelchair. The facility's transportation staff lacked proper training and protocols for safe resident transfer and transport.
Deficiencies (2)
F689: The facility failed to provide adequate supervision and assistance to prevent a resident from falling out of a wheelchair during transport, resulting in injury. Transportation staff lacked training on safe lifting, transferring, and securing residents in wheelchairs and vehicles.
A4073: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, as referenced by the fall incident deficiency.
Report Facts
Facility census: 48
Resident ID: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Transportation Driver A | Named in the fall incident and interviews regarding resident transport | |
| Family Member A | Assisted in resident transport and involved in the fall incident | |
| Facility Administrator | Interviewed regarding facility transportation policies | |
| Facility RN B | Registered Nurse | Interviewed about nursing staff role in resident transport |
| Facility LPN C | Licensed Practical Nurse | Interviewed about discharge and resident transfer procedures |
| Director of Nursing | Responsible for training and compliance monitoring in plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess the facility's compliance with related CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparation and infection control.
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 5
Date: Sep 19, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Bishop Spencer Place, Inc., following a survey conducted on 09/19/2019. The visit was to assess compliance with federal regulations related to care planning, drug regimen review, infection control, dental services, and other nursing home requirements.
Findings
The facility failed to provide baseline care plans for sampled residents, ensure monthly drug regimen reviews with pharmacist recommendations were acted upon, maintain infection control standards, provide timely dental services, and properly manage psychotropic medication use. Deficiencies were noted in documentation, resident and family involvement, and medication management.
Deficiencies (5)
F655 Baseline Care Plan: The facility failed to provide a baseline care plan to four sampled residents and/or their representatives within 48 hours of admission as required.
F756 Drug Regimen Review: The facility failed to ensure pharmacist recommendations for Gradual Dose Reduction were acted upon for two sampled residents.
F758 Free Unnecessary Psychotropic Medications/PRN Use: The facility failed to ensure psychotropic medications were properly managed, including limitations on PRN orders and documentation of rationale.
F790 Routine/Emergency Dental Services: The facility failed to assist residents in obtaining routine and emergency dental care and did not document timely dental services for one sampled resident.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, including hand hygiene and storage of oxygen tubing.
Report Facts
Facility census: 46
Sampled residents: 12
Residents with baseline care plan deficiency: 4
Residents with drug regimen review deficiency: 2
Residents with PRN psychotropic medication deficiency: 1
Residents with dental services deficiency: 1
Residents with infection control deficiency: 3
Inspection Report
Routine
Census: 46
Deficiencies: 5
Date: Sep 19, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, medication management, dental services, infection control, and other aspects of facility operations.
Findings
The facility failed to provide baseline care plans to residents and/or their representatives within 48 hours of admission, did not ensure pharmacy gradual dose reduction recommendations were acted upon with physician rationale, failed to limit PRN psychotropic medication orders to 14 days with proper re-evaluation, did not ensure dental services were obtained for a resident with poor dental condition, and failed to ensure proper hand hygiene and oxygen tubing storage practices.
Deficiencies (5)
Failed to provide baseline care plans to residents and/or their representatives within 48 hours of admission for four sampled residents.
Failed to ensure pharmacy gradual dose reduction recommendations were acted upon including physician rationale for not reducing medications for two sampled residents.
Failed to ensure PRN psychotropic medication orders were limited to 14 days with physician re-evaluation and documentation for one sampled resident receiving hospice services.
Failed to ensure dental services were obtained for one sampled resident with teeth in poor repair.
Failed to ensure hand hygiene during personal care for one sampled resident and failed to ensure infection control best practices for oxygen tubing storage for two sampled residents.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Facility census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in hand hygiene deficiency for Resident #8 |
| LPN A | Licensed Practical Nurse, Unit Manager | Named in PRN psychotropic medication and oxygen tubing storage deficiencies |
| RN A | Registered Nurse | Named in pharmacy recommendation and dental services deficiencies |
| RN B | Registered Nurse, Assistant Director of Nursing | Named in pharmacy recommendation and PRN psychotropic medication deficiencies |
| Social Worker A | Social Worker | Named in dental services deficiency |
| DON | Director of Nursing | Named in multiple deficiencies including hand hygiene and oxygen storage |
| MDS Coordinator | Minimum Data Set Coordinator, previous Director of Nursing | Named in multiple deficiencies including pharmacy recommendations and oxygen storage |
| Administrator | Named in pharmacy recommendation and oxygen storage deficiencies |
Inspection Report
Life Safety
Census: 46
Capacity: 57
Deficiencies: 5
Date: Sep 19, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and emergency preparedness at Bishop Spencer Place, Inc.
Findings
The facility was found not in compliance with several fire safety requirements including manual fire alarm pull stations, fire alarm system testing and maintenance, smoke detection, fire drills, and fire door inspections. The facility census was 46 residents with a licensed capacity of 57 beds.
Deficiencies (5)
K342 Fire Alarm System - Initiation: The facility failed to install a manual fire alarm pull station in a visible and accessible location near the main dining room. This affects approximately 45 residents and staff in an emergency.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to provide and maintain complete documentation of semi-annual visual testing of the fire alarm system components and batteries.
K347 Smoke Detection: The facility failed to ensure smoke detection devices were installed in three areas open to corridors and not continuously occupied, potentially affecting 41 residents in two smoke compartments.
K712 Fire Drills: The facility failed to ensure fire drills were thoroughly documented and scheduled at varying and unexpected times on all shifts, affecting staff preparedness for fire emergencies.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to conduct annual visual and functional inspections of 19 fire doors, risking malfunction and spread of fire and smoke in the smoke compartments.
Report Facts
Facility census: 46
Licensed capacity: 57
Fire doors inspected: 19
Inspection Report
Life Safety
Census: 18
Capacity: 40
Deficiencies: 2
Date: Sep 16, 2019
Visit Reason
The inspection was conducted to evaluate compliance with fire drill requirements and fire alarm system inspections in the Assisted Living Facility.
Findings
The facility failed to conduct required fire drills in a timely and representative manner and lacked proper documentation. The facility also failed to provide and maintain complete semi-annual visual inspection documentation of the fire alarm system as required by NFPA codes.
Deficiencies (2)
19 CSR 30-86.022(5)(D) Fire Drill Requirements were not met as fire drills were not conducted quarterly on each shift with varying simulated conditions and lacked required documentation. The ALF census was 18 residents with a licensed capacity of 40.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications were incomplete as the facility failed to provide and maintain documentation of semi-annual visual testing of the fire alarm system components and battery testing.
Report Facts
Facility census: 18
Licensed capacity: 40
Inspection Report
Life Safety
Census: 51
Capacity: 57
Deficiencies: 4
Date: Aug 2, 2018
Visit Reason
A Life Safety Code Survey was conducted as a Recertification Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found not in compliance with NFPA standards related to cooking facilities grease buildup, fire alarm system installation, and corridor door fire resistance. Deficiencies had the potential to affect all residents, visitors, staff, and volunteers.
Deficiencies (4)
K324 Cooking facilities were not maintained free of grease buildup in the range hood, creating a fire hazard. Observations showed heavy grease deposits and dripping inside the flue and on fire suppression nozzles.
K341 The fire alarm system lacked proper installation of initiating devices such as smoke detectors or heat sensors in the kitchen. This deficiency could impair effective fire warning.
K363 Kitchen corridor doors did not resist smoke passage or latch properly, lacking compliance with fire door standards. Swing doors had upper hinge gaps and could not be latched when shut.
E001 The facility failed to establish and maintain a comprehensive Emergency Preparedness program including documentation, communication plans, and sheltering procedures. This affected all residents, family, visitors, and staff.
Report Facts
Facility capacity: 57
Resident census: 51
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melvin Steele | Administrator | Signed the report and plan of correction |
Inspection Report
Annual Inspection
Census: 51
Capacity: 57
Deficiencies: 7
Date: Aug 2, 2018
Visit Reason
Annual inspection of Bishop Spencer Place, Inc., a skilled nursing facility, to assess compliance with federal and state regulations including dialysis care, medication storage, and food safety.
Findings
The facility was found deficient in ensuring accurate and timely dialysis weight monitoring and physician notification, proper medication storage including expired medications, and food safety practices such as refrigeration and waste disposal. Multiple deficiencies were cited related to dialysis care, medication storage, food procurement, and refuse disposal.
Deficiencies (7)
F698 Dialysis. The facility failed to ensure accurate daily weights were completed and physician notified for weight fluctuations in dialysis residents.
F761 Label/Store Drugs and Biologicals. The facility failed to properly store medications and check for expired medications in the medication room.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to refrigerate open sauce jugs, maintain sanitary cutting boards, and keep garbage containers covered.
F814 Dispose Garbage and Refuse Properly. The facility failed to properly contain waste in lidded dumpsters to prevent pest harboring and feeding.
A4063 Medication Storage. Facilities must store medications at appropriate temperatures and separately from foodstuffs and chemicals; this was not met.
A4074 Nursing Care per Resident Condition. Each resident must receive personal attention and nursing care consistent with acceptable nursing practice; this was not met.
A6036 Outside Storage Areas. Outside storage areas must be large enough and kept clean; this was not met.
Report Facts
Facility census: 51
Licensed capacity: 57
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