Inspection Reports for
The Bishop Spencer Place, Inc
4301 MADISON AVE, KANSAS CITY, MO, 64111-3491
Back to Facility Profile14 Reports
Inspection Report — Jun 3, 2025
Routine
Date: Jun 3, 2025
Visit Reason
Missouri state licensure survey (State Form) with included plan of correction; the survey type is not stated.
Findings
One state deficiency was cited for protective oversight related to the use of bed/side rails, including lack of physician orders, assessments, consents, service plan documentation, and inadequate staff training.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview and record review, the facility failed to ensure physician orders, assessments, consent, and service plan documentation for side rails were in place for three sampled residents and failed to ensure staff were appropriately trained regarding the risks of side rail use. A policy for the use of side rails was requested but not received at the time of exit.
Report Facts
residents sampled: 3
Inspection Report — Jul 29, 2024
Complaint Investigation
Date: Jul 29, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation. Complaint number MO00239368 is listed in the file.
Complaint Details
Complaint number MO00239368 is recorded; the investigation initially determined an imminent danger (Class I) condition which was later downgraded as corrective actions were implemented.
Findings
4 deficiencies were cited: 2 federal deficiencies for quality of care and residents not being free from significant medication errors, and 2 Missouri state citations for safe/effective medication system and nursing care per resident condition; the findings focus on medication administration errors including wrong medication and an overdose of morphine concentrate. The file indicates the complaint investigation initially identified an imminent danger situation that was later downgraded.
Deficiencies (2)
19 CSR 30-85.042(46) Safe/Effective Medication System: Refer to F684.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F760.
Report Facts
residents sampled: 10
residents affected: 2
residents affected: 1
Inspection Report — Feb 6, 2024
Routine
Date: Feb 6, 2024
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Six Missouri State Form deficiencies were cited covering elevator inspection documentation, fire alarm notification devices/strobes, sprinkler system maintenance/testing, food protection/temperature and kitchen sanitation, maintenance of plastic cutting boards, and cleaning of grills/griddles/microwaves.
Deficiencies (6)
19 CSR 30-86.012(25) Elevator Requirements: The facility failed to display a current inspection certificate in their elevator car and failed to provide complete documentation of monthly testing of the elevator's Firefighters' Emergency Recall Operation.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: The facility failed to ensure that audio and visual fire alarm notification devices provided effective coverage; a strobe was not present where required and a device in the service hall was audible only.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: The facility failed to perform and document required weekly/monthly sprinkler system inspections and testing and had concealed ceiling sprinkler head caps offset or missing and no visible sprinkler head in an HVAC closet.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: The facility failed to keep the walk-in freezer floors clean and failed to maintain sanitary food preparation equipment, including a manual can opener with unknown residue.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: The facility failed to maintain plastic cutting boards in good condition to avoid food safety hazards; light blue, red, and yellow cutting boards were excessively scored with plastic bits flaking off.
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: The facility failed to clean food preparation equipment daily; microwaves had splatters on the inside roof and the toaster had crumbs and missing crumb trays.
Report Facts
facility smoke zones: 6
Inspection Report — Aug 29, 2023
Complaint Investigation
Date: Aug 29, 2023
Visit Reason
Federal CMS-2567 health survey and Missouri State Form are included; the file documents a complaint investigation. Complaint number MO000222776 is referenced in the file.
Complaint Details
MO000222776; determination (substantiated/unsubstantiated) not stated in the file.
Findings
Two deficiencies were cited: one federal health survey deficiency concerning failure to provide safe and orderly transfer/discharge preparation and one Missouri state licensure deficiency concerning informed services/charges (Alzheimer's disclosure).
Deficiencies (1)
19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure: See the deficiency cited at F624.
Report Facts
residents sampled: 7
Inspection Report — Jun 6, 2023
Routine
Date: Jun 6, 2023
Visit Reason
This file contains a federal CMS-2567 statement of deficiencies and a Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Three deficiencies were cited: two federal deficiencies addressing resident exploitation/misappropriation and medication administration, and one Missouri state licensure deficiency for nursing care referencing the medication administration finding. Past noncompliance was noted for the exploitation finding.
Deficiencies (1)
19 CSR 30-85.042(86) Nursing Care per Res Condition: See the deficiency cited at F658.
Report Facts
residents sampled: 6
Inspection Report — Dec 21, 2022
Complaint Investigation
Date: Dec 21, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO00211094) is referenced in the file.
Complaint Details
Complaint MO00211094 is referenced. The investigation conclusion in the file states the allegation of abuse was found unsubstantiated due to Resident #2's altered mental status related to a UTI.
Findings
Two deficiencies were cited: one federal health deficiency for failure to ensure a resident was free from abuse and one Missouri licensure deficiency for failure to develop and implement abuse/neglect policies.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F600.
Report Facts
residents sampled: 1
Inspection Report — Jul 19, 2022
Routine
Date: Jul 19, 2022
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 4 federal deficiencies addressing respiratory/tracheostomy care and suctioning, dialysis care coordination and care planning, food storage/sanitation and kitchen practices, and food nutritive/temperature issues. There are 14 Missouri state deficiencies related to nursing care and multiple food safety, storage, cleaning, temperature and sanitation requirements, most referencing the federal deficiencies.
Deficiencies (14)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F695. Refer to F698.
19 CSR 30-87.020(6) Cleaning Food Contact Surfaces: Refer to F800.
19 CSR 30-87.020(30) Garbage Containers: Refer to F800.
19 CSR 30-87.020(31) Kitchen Waste Containers Covered: Refer to F800.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Refer to F800.
19 CSR 30-87.030(23) Hot Food-Storage, Temperatures: Refer to F804.
19 CSR 30-87.030(24) Hot Food-140 Degrees or Above/Transport: Refer to F804.
19 CSR 30-87.030(26) Hazardous Food Cooking Temperatures: Refer to F804.
19 CSR 30-87.030(51) Food-Contact Surfaces Accessible for Cleaning: Refer to F800.
19 CSR 30-87.030(54) Nonfood Contact Surfaces, Cleaning: Refer to F800.
19 CSR 30-87.030(62) Kitchenware/Surfaces/Pitchers-Clean/Sanitize: Refer to F800.
19 CSR 30-87.030(63) Food-Contact Surfaces Washed/Rinsed/Sanitized: Refer to F800.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: Refer to F800.
19 CSR 30-87.030(72) Food-Contact Surface Sanitizing Requirements: Refer to F800.
Report Facts
residents sampled: 12
Inspection Report — Jun 4, 2021
Complaint Investigation
Date: Jun 4, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey was a complaint investigation as indicated on the State Form.
Findings
Two deficiencies were cited: one federal quality-of-care deficiency concerning failure to notify the physician and to monitor/respond to a resident's critically high blood glucose (resulting in diabetic ketoacidosis and hospitalization), and one Missouri licensure citation for nursing care which references the federal finding. Immediate jeopardy was identified during the investigation and was later removed.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: See the deficiency cited at F684.
Report Facts
residents sampled: 4
Inspection Report — Jul 24, 2020
Routine
Date: Jul 24, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal regarding resident safety during transportation/transfers and lack of supervision/training for transport staff, and one Missouri state licensure deficiency regarding protective oversight for voluntary leave (referencing the federal finding).
Deficiencies (1)
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Refer to F689.
Inspection Report — Sep 19, 2019
Routine
Date: Sep 19, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 5 federal deficiencies addressing baseline care plans, drug regimen review and gradual dose reduction, unnecessary psychotropic/PRN medication use, routine/emergency dental services, and infection prevention/hand hygiene/oxygen tubing storage. There are 4 Missouri state licensure deficiencies citing drug regimen review-monthly, nursing care per resident condition, infection control/communicable disease, and the social service program (each referring to the related federal findings).
Deficiencies (4)
19 CSR 30-85.042(53) Drug Regimen Review-Monthly: Refer to F756.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F758.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-85.042(92) Social Service Program: Refer to F790.
Report Facts
residents sampled: 12
residents affected: 4
residents affected: 2
residents affected: 1
residents affected: 1
residents affected: 3
Inspection Report — Sep 19, 2019
Life Safety
Date: Sep 19, 2019
Visit Reason
Federal Life Safety survey (CMS-2567) with K-tags and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eleven deficiencies were cited: five federal Life Safety deficiencies for fire alarm initiation and testing, smoke detection, fire drills, and door inspection/maintenance; and six Missouri state licensure deficiencies addressing fire alarm system requirements, inspections/records, corridor requirements, and fire drill evacuation.
Deficiencies (6)
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K761.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: Refer to K342 and K347.
19 CSR 30-85.022(10)(C) Fire Alarm System-Inspections/Certifications: Refer to K345.
19 CSR 30-85.022(10)(F) Fire Alarm System Records: Refer to K345.
19 CSR 30-85.022(21) Corridor Requirements: Refer to K761.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Refer to K712.
Report Facts
residents/staff potentially affected: 45
residential population in specific hallways: 41
Inspection Report — Sep 16, 2019
Routine
Date: Sep 16, 2019
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 state deficiencies citing inadequate fire drill documentation and scheduling, and incomplete/absent semi-annual visual inspection/documentation of the facility's fire alarm system.
Deficiencies (2)
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on interview and record review, the facility failed to ensure fire drills were thoroughly documented and scheduled at unexpected, varying times; completed fire drills lacked required components and documentation.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: Based on interview and record review, the facility failed to provide and maintain complete and current documentation of semi-annual visual testing of the fire alarm system and its battery testing, with no provision of a semi-annual visual inspection from 9/1/18 to 9/1/19.
Inspection Report — Aug 2, 2018
Routine
Date: Aug 2, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated in the forms.
Findings
Ten deficiencies were cited: four federal health deficiencies addressing dialysis care, medication labeling/storage, food procurement/food preparation sanitation, and garbage/refuse disposal; and six Missouri state licensure violations addressing medication storage, nursing care per resident condition, outside storage areas, food protection/temperature/notification, safe food-contact materials, and food-contact surface sanitation.
Deficiencies (6)
19 CSR 30-85.042(56) Medication Storage: Refer to F761.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F698.
19 CSR 30-87.020(36) Outside Storage Areas: Refer to F814.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Refer to F812.
19 CSR 30-87.030(63) Food-Contact Surfaces Washed/Rinsed/Sanitized: Refer to F812.
Report Facts
residents sampled: 16
Inspection Report — Aug 2, 2018
Life Safety
Date: Aug 2, 2018
Visit Reason
CMS-2567 federal Life Safety (K tags) and Emergency Preparedness (E tags) forms and Missouri Department of Health and Senior Services State Form; the Initial Comments identify this as a Recertification Survey.
Findings
Seven deficiencies were cited: four federal deficiencies (three Life Safety K-tags and one Emergency Preparedness E-tag) involving kitchen range hood grease buildup, missing initiating devices for the fire alarm in the kitchen, and kitchen corridor doors that did not resist smoke passage; and three Missouri state deficiencies that reference the same range hood, fire alarm, and construction/door issues.
Deficiencies (3)
19 CSR 30-85.022(9) Range Hood Certification: Refer to K324.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: Refer to K341.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
16 CMS Surveys
Inspection Report — Jul 29, 2024
Complaint Investigation
Date: Jul 29, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation. Complaint number MO00239368 is listed in the file.
Complaint Details
Complaint number MO00239368 is recorded; the investigation initially determined an imminent danger (Class I) condition which was later downgraded as corrective actions were implemented.
Findings
4 deficiencies were cited: 2 federal deficiencies for quality of care and residents not being free from significant medication errors, and 2 Missouri state citations for safe/effective medication system and nursing care per resident condition; the findings focus on medication administration errors including wrong medication and an overdose of morphine concentrate. The file indicates the complaint investigation initially identified an imminent danger situation that was later downgraded.
Deficiencies (2)
F684 Quality of Care: The facility failed to ensure sampled residents were free from medication errors; residents #2 and #3 experienced medication administration errors (wrong medication given and a resident given medication twice).
F760 Residents are Free of Significant Med Errors: The facility failed to ensure a sampled resident was free from a significant medication error when morphine concentrate (5 mL/100 mg) was administered instead of the physician-ordered 0.5 mL (10 mg); immediate jeopardy was identified and later removed.
Report Facts
residents sampled: 10
residents affected: 2
residents affected: 1
Inspection Report — Feb 6, 2024
Routine
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
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 — Aug 29, 2023
Complaint Investigation
Date: Aug 29, 2023
Visit Reason
Federal CMS-2567 health survey and Missouri State Form are included; the file documents a complaint investigation. Complaint number MO000222776 is referenced in the file.
Complaint Details
MO000222776; determination (substantiated/unsubstantiated) not stated in the file.
Findings
Two deficiencies were cited: one federal health survey deficiency concerning failure to provide safe and orderly transfer/discharge preparation and one Missouri state licensure deficiency concerning informed services/charges (Alzheimer's disclosure).
Deficiencies (1)
F624 Preparation for Safe/Orderly Transfer/Dischrg: Based on interview and record review, the facility failed to arrange for a safe and orderly discharge for one sampled resident who was discharged to a lodging facility without required post-discharge arrangements and supports.
Report Facts
residents sampled: 7
Inspection Report — Jun 6, 2023
Routine
Date: Jun 6, 2023
Visit Reason
This file contains a federal CMS-2567 statement of deficiencies and a Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Three deficiencies were cited: two federal deficiencies addressing resident exploitation/misappropriation and medication administration, and one Missouri state licensure deficiency for nursing care referencing the medication administration finding. Past noncompliance was noted for the exploitation finding.
Deficiencies (2)
F602 Free from Misappropriation/Exploitation: Based on interview and record review, the facility failed to protect two sampled residents from exploitation when a staff member obtained and used a resident's debit card and accepted checks from another resident for personal expenses.
F658 Services Provided Meet Professional Standards: Based on interview and record review, facility staff failed to administer prescribed Xarelto (an anticoagulant) as documented on the MAR for one sampled resident, with missed documentation and missed doses.
Report Facts
residents sampled: 6
Inspection Report — Dec 21, 2022
Complaint Investigation
Date: Dec 21, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation (MO00211094) is referenced in the file.
Complaint Details
Complaint MO00211094 is referenced. The investigation conclusion in the file states the allegation of abuse was found unsubstantiated due to Resident #2's altered mental status related to a UTI.
Findings
Two deficiencies were cited: one federal health deficiency for failure to ensure a resident was free from abuse and one Missouri licensure deficiency for failure to develop and implement abuse/neglect policies.
Deficiencies (1)
F600 Free from Abuse and Neglect: Based on interview and record review, the facility failed to ensure one sampled resident was free from verbal and physical abuse when another resident called the resident insulting names and struck the resident twice in the face with a rolled up newspaper.
Report Facts
residents sampled: 1
Inspection Report — Jul 19, 2022
Routine
Date: Jul 19, 2022
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 4 federal deficiencies addressing respiratory/tracheostomy care and suctioning, dialysis care coordination and care planning, food storage/sanitation and kitchen practices, and food nutritive/temperature issues. There are 14 Missouri state deficiencies related to nursing care and multiple food safety, storage, cleaning, temperature and sanitation requirements, most referencing the federal deficiencies.
Deficiencies (4)
F 695 Respiratory/Tracheostomy Care and Suctioning: Based on observation, interview, and record review the facility failed to ensure nasal cannula tubing and cannulas were stored per facility policy (not kept in plastic bags) for a sampled resident requiring oxygen.
F 698 Dialysis: Based on observation, interview and record review the facility failed to ensure dialysis residents had physician orders specifying location and schedule and failed to ensure consistent communication and individualized dialysis care plans for sampled residents.
F 800 Provided Diet Meets Needs of Each Resident: Based on observation, interview and record review the facility failed to properly store food in the refrigerated walk-in and to practice sanitary/hygienic procedures in the kitchen (undated/uncold items, dirty/unclean containers and equipment, facial hair not restrained, etc.), potentially affecting residents receiving food from the kitchen.
F 804 Nutritive Value/Appear, Palatable/Prefer Temp: Based on observation, interview and record review the facility failed to ensure foods were prepared and held at appropriate temperatures and in a manner that preserved nutritive value (issues with cooking/temperature of sausage links and overcooking of vegetables noted).
Report Facts
residents sampled: 12
Inspection Report — Jul 19, 2022
Life Safety
Date: Jul 19, 2022
Visit Reason
CMS-2567 (federal emergency preparedness and life safety) and Missouri State Form (state licensure); the Life Safety Code survey was conducted.
Findings
No federal emergency preparedness or life safety deficiencies were cited and no state licensure deficiencies were cited.
Inspection Report — Jun 4, 2021
Complaint Investigation
Date: Jun 4, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey was a complaint investigation as indicated on the State Form.
Findings
Two deficiencies were cited: one federal quality-of-care deficiency concerning failure to notify the physician and to monitor/respond to a resident's critically high blood glucose (resulting in diabetic ketoacidosis and hospitalization), and one Missouri licensure citation for nursing care which references the federal finding. Immediate jeopardy was identified during the investigation and was later removed.
Deficiencies (1)
F684 Quality of Care: Based on interview and record review, the facility failed to notify the resident's physician of a change in condition and failed to respond to and monitor Resident #1's critically elevated blood glucose, which resulted in diabetic ketoacidosis and hospitalization/ICU care.
Report Facts
residents sampled: 4
Inspection Report — Dec 21, 2020
Routine
Date: Dec 21, 2020
Visit Reason
CMS-2567 federal health and emergency preparedness survey; a COVID-19 Focused Infection Control survey and a COVID-19 Focused Emergency Preparedness survey were conducted.
Findings
No federal health or emergency preparedness deficiencies were cited; the facility was found to be in compliance with CMS and CDC recommended practices.
Inspection Report — Dec 4, 2020
Routine
Date: Dec 4, 2020
Visit Reason
Federal CMS-2567 form (health survey with Emergency Preparedness section). The form documents a COVID-19 Focused Infection Control and Emergency Preparedness survey.
Findings
No deficiencies were cited. The surveyor found the facility in compliance with CMS/CDC infection control recommendations and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report — Jul 24, 2020
Routine
Date: Jul 24, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal regarding resident safety during transportation/transfers and lack of supervision/training for transport staff, and one Missouri state licensure deficiency regarding protective oversight for voluntary leave (referencing the federal finding).
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure resident safety during transportation and transfer; Resident #51 slid from his/her wheelchair into a facility transport van during discharge transport and staff did not provide appropriate nursing assistance or consistently follow safe transfer procedures, and transport staff lacked sufficient training and processes to safely lift/secure residents.
Inspection Report — May 26, 2020
Routine
Date: May 26, 2020
Visit Reason
Federal CMS-2567 health and emergency preparedness forms; a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey were stated.
Findings
No deficiencies were cited. The COVID-19 focused emergency preparedness and infection control surveys found the facility to be in compliance with applicable CMS/CDC guidance and 42 CFR 483.73.
Inspection Report — Sep 19, 2019
Routine
Date: Sep 19, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 5 federal deficiencies addressing baseline care plans, drug regimen review and gradual dose reduction, unnecessary psychotropic/PRN medication use, routine/emergency dental services, and infection prevention/hand hygiene/oxygen tubing storage. There are 4 Missouri state licensure deficiencies citing drug regimen review-monthly, nursing care per resident condition, infection control/communicable disease, and the social service program (each referring to the related federal findings).
Deficiencies (5)
F655 Baseline Care Plan: Based on observation, interview and record review, the facility failed to provide a baseline care plan to four sampled residents (Residents #98, #100, #252 and #250) out of 12 sampled residents.
F756 Drug Regimen Review: Based on observation, interview and record review, the facility failed to ensure Gradual Dose Reduction (GDR) pharmacy recommendations were acted upon, including lack of physician rationale, for two sampled residents (Residents #45 and #18) out of 12 sampled residents.
F758 Unnecessary Psychotropic Meds/PRN Use: Based on interview and record review, the facility failed to ensure PRN psychotropic/antianxiety medication orders were limited and re-evaluated for a resident receiving hospice services (Resident #25), with orders continued beyond the required period without appropriate documentation.
F790 Routine/Emergency Dental Svcs in SNFs: Based on observation, interview and record review, the facility failed to ensure dental services were obtained for one sampled resident (Resident #249) who had teeth in poor repair.
F880 Infection Prevention & Control: Based on observation, interview and record review, the facility failed to ensure proper hand hygiene during personal care and appropriate storage/handling of oxygen tubing for sampled residents (including Residents #8, #6 and #249).
Report Facts
residents sampled: 12
residents affected: 4
residents affected: 2
residents affected: 1
residents affected: 1
residents affected: 3
Inspection Report — Sep 19, 2019
Life Safety
Date: Sep 19, 2019
Visit Reason
Federal Life Safety survey (CMS-2567) with K-tags and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eleven deficiencies were cited: five federal Life Safety deficiencies for fire alarm initiation and testing, smoke detection, fire drills, and door inspection/maintenance; and six Missouri state licensure deficiencies addressing fire alarm system requirements, inspections/records, corridor requirements, and fire drill evacuation.
Deficiencies (5)
K342 Fire Alarm System - Initiation: Based on observation, interview and record review the facility failed to have a manual fire alarm pull station located conspicuous and accessible near the main dining room/dining area.
K345 Fire Alarm System - Testing and Maintenance: Based on interview and record review the facility failed to provide and maintain complete and current documentation of the semi-annual (visual) testing of the fire alarm system components and battery testing.
K347 Smoke Detection: Based on observation, interview and record review the facility failed to ensure areas open to corridors were protected with smoke detection devices, leaving several alcove/office areas without smoke detection.
K712 Fire Drills: Based on interview and record review the facility failed to ensure fire drills were thoroughly documented and scheduled at unexpected, staggered times and lacked required components of drill documentation (such as who activated the alarm, local fire department being called, and audibility of alarms).
K761 Maintenance, Inspection & Testing - Doors: Based on interview and record review the facility failed to conduct required annual visual and functional inspections and testing of fire and smoke door assemblies and maintain required records of those inspections and testing.
Report Facts
residents/staff potentially affected: 45
residential population in specific hallways: 41
Inspection Report — Aug 2, 2018
Routine
Date: Aug 2, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated in the forms.
Findings
Ten deficiencies were cited: four federal health deficiencies addressing dialysis care, medication labeling/storage, food procurement/food preparation sanitation, and garbage/refuse disposal; and six Missouri state licensure violations addressing medication storage, nursing care per resident condition, outside storage areas, food protection/temperature/notification, safe food-contact materials, and food-contact surface sanitation.
Deficiencies (4)
F698 Dialysis: The surveyor found staff failed to ensure accurate and/or daily weights were completed per physician orders and failed to notify the physician of fluctuating weight for a resident receiving dialysis.
F761 Label/Store Drugs and Biologicals: The surveyor found the facility failed to properly store medications and to check and discontinue use of expired medications, including medications stored under the sink and insulin pens not dated or not dated when first used.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The surveyor found the facility failed to refrigerate opened potentially hazardous food items, failed to maintain sanitary cutting boards and utensils, and failed to keep a kitchen garbage container covered, practices that potentially affected residents who ate food from the kitchen.
F814 Dispose Garbage and Refuse Properly: The surveyor found the facility failed to properly contain waste in lidded dumpsters, with multiple dumpsters observed with lids flipped open or lids not closing properly.
Report Facts
residents sampled: 16
Inspection Report — Aug 2, 2018
Life Safety
Date: Aug 2, 2018
Visit Reason
CMS-2567 federal Life Safety (K tags) and Emergency Preparedness (E tags) forms and Missouri Department of Health and Senior Services State Form; the Initial Comments identify this as a Recertification Survey.
Findings
Seven deficiencies were cited: four federal deficiencies (three Life Safety K-tags and one Emergency Preparedness E-tag) involving kitchen range hood grease buildup, missing initiating devices for the fire alarm in the kitchen, and kitchen corridor doors that did not resist smoke passage; and three Missouri state deficiencies that reference the same range hood, fire alarm, and construction/door issues.
Deficiencies (4)
K 324 Cooking Facilities: Based on observation, interview, and record review, the facility failed to ensure that a range hood and exhaust system were maintained free of grease buildup; heavy grease buildup was observed inside the flue and on nozzles creating a potential fire hazard.
K 341 Fire Alarm System - Installation: Based on observations, interview, and record review, the facility failed to ensure that initiating devices (smoke detectors or heat sensors) were installed in the kitchen to provide effective coverage and activation of the fire alarm.
K 363 Corridor - Doors: Based on observations, interview, and record review, the facility failed to install kitchen corridor doors that resisted the passage of smoke and had means suitable for keeping the doors latched; swing doors had portions that would not resist smoke passage and could not be latched.
E 001 Establishment of the Emergency Program (EP): Based on record review and interview, the facility failed to establish and maintain a comprehensive emergency preparedness program, including methods for sharing the plan with residents/families and procedures for sheltering in place and roles under federal waivers.
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