Inspection Reports for
The Bluffs
3105 BLUFF CREEK DR, COLUMBIA, MO, 65201-3529
Back to Facility Profile10 Reports
Inspection Report — Jan 14, 2025
Routine
Date: Jan 14, 2025
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 health deficiency for failure to provide a safe mechanical lift transfer resulting in a resident injury, and one Missouri state licensure deficiency regarding protective oversight/voluntary leave that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Refer to F689.
Report Facts
residents affected: 1
Inspection Report — Nov 1, 2024
Complaint Investigation
Date: Nov 1, 2024
Visit Reason
CMS-2567 federal nursing home health survey pages and Missouri Department of Health and Senior Services State Form pages are included; the file states this was a complaint investigation.
Complaint Details
The file identifies this as a complaint investigation; the state noted an initial imminent danger determination during the complaint investigation that was later lowered at exit.
Findings
Eighteen deficiencies were cited: nine federal health survey deficiencies addressing notification of changes, resident environment/maintenance, transfer/discharge/bed-hold notices, comprehensive care plans, services/professional standards, accident hazards/transfers and wheelchair safety, food temperature/food service, and infection prevention and control; and nine Missouri state licensure deficiencies that reference and map to those federal findings.
Deficiencies (9)
19 CSR 30-85.042(46) Safe/Effective Medication System: Refer to F658.
19 CSR 30-85.042(55) Medication Storage: Refer to F689.
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Refer to F689.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F656.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: Please refer to F880.
19 CSR 30-85.042(78) Dr Notification-Change in Condition: Refer to F580.
19 CSR 30-85.042(79) Notify Responsible Party-Change in Condition: Refer to F580.
19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure: Refer to F625.
19 CSR 30-88.010(18) Emergency Discharges: Refer to F623.
Report Facts
residents affected: 4
residents affected: 5
residents affected: 7
residents affected: 4
Inspection Report — Nov 1, 2024
Life Safety
Date: Nov 1, 2024
Visit Reason
CMS-2567 federal Life Safety and Emergency Preparedness pages (K and E tags) and Missouri Department of Health and Senior Services State Form; the survey is a Life Safety survey.
Findings
There are 9 federal deficiencies (CMS-2567 K/E tags) addressing emergency preparedness communication, training and testing, sprinkler system maintenance, smoke barrier integrity, fire drills, door inspections, generator testing, and electrical/extension cord practices; and 7 Missouri state licensure deficiencies addressing sprinkler testing/maintenance, smoke barrier walls, fire drill/emergency preparedness plans and evacuation, electrical systems and extension cord use, and employee orientation.
Deficiencies (7)
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Please refer to K353.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Please refer to K372.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: Please refer to E030 and E039.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Please refer to K712.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Please refer to K918.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Please refer to K920.
19 CSR 30-85.042(20) Employee Orientation/Continuing Ed.: Please refer to E037.
Inspection Report — May 20, 2024
Complaint Investigation
Date: May 20, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation citing MO00236191.
Complaint Details
MO00236191; substantiation not stated.
Findings
Four deficiencies were cited: two federal deficiencies for failures related to abuse/neglect policies and reporting alleged violations, and two Missouri state citations referencing development of abuse/neglect policies and reporting to DHSS/DMH. Findings included failure to investigate and to timely report a missing electronic device for one resident.
Deficiencies (2)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Please refer to F607.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Please refer to F609.
Report Facts
residents affected: 1
Inspection Report — Apr 25, 2024
Routine
Date: Apr 25, 2024
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form are included in this file; the survey type is not stated.
Findings
Two deficiencies were cited: one federal and one state. Both relate to food safety practices including poor hand hygiene and glove use, unsanitized thermometers, and inadequate cleaning/maintenance of kitchen floors and appliances.
Deficiencies (1)
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
Inspection Report — Jan 11, 2024
Complaint Investigation
Date: Jan 11, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure form; complaint investigation (MO00229820) was cited in the file.
Complaint Details
MO00229820; substantiation not stated in the report.
Findings
2 deficiencies: one federal deficiency for failure to thoroughly investigate an allegation of abuse/neglect and one state deficiency for failure to develop/implement abuse/neglect policies (state item references the federal finding).
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies: See F610.
Inspection Report — Dec 7, 2023
Complaint Investigation
Date: Dec 7, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; complaint investigation (complaint number MO00228299 is cited).
Complaint Details
Complaint number MO00228299 is cited in the file; the document does not state that the allegation was substantiated.
Findings
There are 5 federal health deficiencies covering a damaged resident bed/environment, failure to report alleged abuse, failures to assist dependent residents with meals, unsecured/ unattended medication carts, and infection prevention/PPE failures; and 4 Missouri state licensure deficiencies addressing bed requirements, protective oversight/voluntary leave, mealtime assistance/supervision, and infection control.
Deficiencies (4)
19 CSR 30-85.032(40) Bed Requirements: MO00228299.
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: MO00228299.
19 CSR 30-85.042(71) Mealtime Assistance/Supervision: MO00228299.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: MO00228299.
Inspection Report — Jun 29, 2023
Routine
Date: Jun 29, 2023
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form present in the file; the survey type is not stated.
Findings
The file contains 9 federal health deficiencies and 9 Missouri state licensure deficiencies (18 total). Main topics include failure to notify physician/skin care (MASD), incomplete/comprehensive care plans for oxygen/CPAP and activities, inadequate ADL assistance and showering, unsafe transfer/lift practices and unsecured medication cart, missing/undocumented catheter orders and catheter care, improper medication storage/expired meds, food safety/temperature and hand hygiene lapses, and multiple infection prevention and control failures (hand hygiene, oxygen/CPAP equipment cleaning and wound care).
Deficiencies (10)
A4064 19 CSR 30-85.042(55) Medication Storage: Refer to F761.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: Refer to F689.
A4075 19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F690.
A4076 19 CSR 30-85.042(67) Clean, Dry, Odor Free: Refer to F677.
A4086 19 CSR 30-85.042(77) Infection Control/Communicable Disease: Refer to F880.
A4087 19 CSR 30-85.042(78) Dr Notification-Change in Condition: Refer to F580.
A7002 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: Please refer to F812.
A7015 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Please refer to F812.
A7086 19 CSR 30-87.030(84) Equip/Utensils Air Dried, Self-Drain Utensils: Please refer to F812.
A4064 Refer to F761: (listed again on State Form summary page) Refer to F761.
Report Facts
dependent residents not assisted: 4
residents transferred unsafely: 4
unsecured medication carts observed: 1
Inspection Report — Jun 4, 2021
Life Safety
Date: Jun 4, 2021
Visit Reason
CMS federal health and Life Safety (LSC) survey with accompanying Missouri Department of Health and Senior Services state licensure form; life safety survey.
Findings
21 deficiencies were cited (11 federal life-safety/emergency preparedness tags and 10 Missouri state licensure citations). Main topics include emergency preparedness training, egress/locking doors and delayed-egress devices, emergency lighting testing and documentation, fire alarm testing/documentation, sprinkler system testing/replacement and obstructed/corroded sprinklers, smoke barrier penetrations, fire drill frequency and documentation, egress door inspection/testing, electrical receptacle and essential electrical/generator testing and documentation, medical gas handling education, night-lights in resident rooms, and employee orientation/education.
Deficiencies (10)
19 CSR 30-85.012(125) Night-lights-Required Locations: Based on observation and interview, facility staff failed to provide night-lights in 12 resident rooms or adjacent toilet room and one common toilet room; documentation of night-light inspections was not available.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Please refer to K345.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Please refer to K353.
19 CSR 30-85.022(16) Door Locks: Please refer to K222.
19 CSR 30-85.022(25) Emergency Lighting: Please refer to K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Please refer to K372.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Based on review and interview, facility staff failed to conduct the required fire drills on each shift and maintain complete drill records; some required drills were not documented or were conducted as silent drills.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Please refer to K918.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Please refer to K914 and K918.
19 CSR 30-85.042(20) Employee Orientation/Continuing Ed.: Please refer to E0037 & K926.
Report Facts
employees_listed: 165
employees_signed_training: 56
employees_not_signed: 109
employees_no_documentation_of_training: 66
sprinklers_sampled: 20
sprinklers_abnormal: 4
portable_oxygen_tanks_unsecured_observed: 3
Inspection Report — Nov 22, 2019
Life Safety
Date: Nov 22, 2019
Visit Reason
CMS-2567 Life Safety survey (K-tag) and Missouri State Form for state licensure; survey identified as Life Safety.
Findings
Two deficiencies were cited: one federal Life Safety deficiency for emergency generator maintenance and lack of annual diesel fuel quality testing, and one Missouri State licensure deficiency referencing the same issue.
Deficiencies (1)
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Please refer to K918.
Report Facts
11 CMS Surveys
Inspection Report — Feb 24, 2025
Routine
Date: Feb 24, 2025
Visit Reason
CMS-2567 federal health survey (Statement of Deficiencies); the survey type is not stated.
Findings
One health deficiency for medication administration errors resulting in a resident receiving another resident's insulin, experiencing hypoglycemia and being sent to the hospital; past noncompliance was noted.
Deficiencies (1)
F760 Residents are Free of Significant Med Errors: The surveyor found staff administered another resident's insulin to a resident, resulting in hypoglycemia and the resident being sent to the hospital; past noncompliance was noted.
Inspection Report — Jan 14, 2025
Routine
Date: Jan 14, 2025
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 health deficiency for failure to provide a safe mechanical lift transfer resulting in a resident injury, and one Missouri state licensure deficiency regarding protective oversight/voluntary leave that references the federal finding.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: Based on interview and record review, facility staff failed to provide a proper mechanical lift transfer for one resident which resulted in a compression fracture of the resident's spine.
Report Facts
residents affected: 1
Inspection Report — Nov 1, 2024
Complaint Investigation
Date: Nov 1, 2024
Visit Reason
CMS-2567 federal nursing home health survey pages and Missouri Department of Health and Senior Services State Form pages are included; the file states this was a complaint investigation.
Complaint Details
The file identifies this as a complaint investigation; the state noted an initial imminent danger determination during the complaint investigation that was later lowered at exit.
Findings
Eighteen deficiencies were cited: nine federal health survey deficiencies addressing notification of changes, resident environment/maintenance, transfer/discharge/bed-hold notices, comprehensive care plans, services/professional standards, accident hazards/transfers and wheelchair safety, food temperature/food service, and infection prevention and control; and nine Missouri state licensure deficiencies that reference and map to those federal findings.
Deficiencies (9)
F580 Notify of Changes (Injury/Decline/Room, etc.): Facility staff failed to notify one sampled resident's physician and resident representative in a timely manner when the resident had a fall with major injury.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility staff failed to maintain resident rooms and bathrooms in clean and good repair, with observations of ripped flooring, gouged and chipped paint, missing drywall and black substance on grout in multiple resident rooms.
F623 Notice Requirements Before Transfer/Discharge: Facility staff failed to provide written notice of resident transfers to the hospital to residents or resident representatives for four of four sampled residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer: Facility staff failed to provide written information about the facility's bed-hold policy at the time of transfer for two of three sampled residents.
F656 Develop/Implement Comprehensive Care Plan: Facility staff failed to develop comprehensive, resident-specific care plans with measurable interventions for five sampled residents.
F658 Services Provided Meet Professional Standards: Staff failed to document required post-fall neurological checks and failed to document removal/placement of medication patches and indications for use for multiple sampled residents.
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to safely transfer residents using mechanical lifts and failed to ensure safe wheelchair and footrest practices and secure treatment/medication carts, placing residents at risk of accidents.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: Facility staff failed to maintain hot food temperatures at or above safe service temperatures for multiple residents at the time of meal service, resulting in cold and unappetizing food.
F880 Infection Prevention & Control: Facility staff failed to follow infection prevention and control practices, including improper reuse/sharing of insulin pens, inadequate hand hygiene and inconsistent use of gowns/gloves/Enhanced Barrier Precautions; an immediate jeopardy determination was initially made during the complaint investigation.
Report Facts
residents affected: 4
residents affected: 5
residents affected: 7
residents affected: 4
Inspection Report — Nov 1, 2024
Life Safety
Date: Nov 1, 2024
Visit Reason
CMS-2567 federal Life Safety and Emergency Preparedness pages (K and E tags) and Missouri Department of Health and Senior Services State Form; the survey is a Life Safety survey.
Findings
There are 9 federal deficiencies (CMS-2567 K/E tags) addressing emergency preparedness communication, training and testing, sprinkler system maintenance, smoke barrier integrity, fire drills, door inspections, generator testing, and electrical/extension cord practices; and 7 Missouri state licensure deficiencies addressing sprinkler testing/maintenance, smoke barrier walls, fire drill/emergency preparedness plans and evacuation, electrical systems and extension cord use, and employee orientation.
Deficiencies (9)
E030 Names and Contact Information: Based on interview and record review, facility staff failed to develop and maintain an emergency preparedness communication plan that included names and contact information for all staff.
E037 EP Training Program: Based on interview and record review, facility staff failed to provide and document required emergency preparedness training to all staff at the required frequency.
E039 EP Testing Requirements: Based on interview and record review, facility staff failed to ensure participation in required full-scale or facility-based functional emergency exercises and did not document required testing/exercise participation.
K353 Sprinkler System - Maintenance and Testing: Based on observation, interview and record review, facility staff failed to inspect, test and maintain the wet and dry pipe sprinkler systems and did not maintain complete monthly inspection documentation for the period reviewed.
K372 Subdivision of Building Spaces - Smoke Barrier: Based on observation, interview and record review, facility staff failed to maintain smoke barrier walls as smoke tight; observations included fallen sheetrock and unsealed penetrations in attic smoke barriers.
K712 Fire Drills: Based on interview and record review, facility staff failed to conduct required fire drills at various times and under varying conditions on each shift and did not fully document simulated conditions for drills.
K761 Maintenance, Inspection & Testing - Doors: Based on observation, interview and record review, facility staff failed to inspect non-rated door assemblies located within means of egress annually and observed a door to the electrical room that did not self-close.
K918 Electrical Systems - Essential Electric System: Based on observation, interview and record review, facility staff failed to inspect, test and maintain the emergency generator in accordance with requirements and did not maintain complete documentation of monthly 30-minute load tests.
K920 Electrical Equipment - Power Cords and Extension Cords: Based on observation, interview and record review, facility staff failed to maintain electrical cord and surge protector practices and allowed extension cords and improper surge protector use in resident care areas (multiple resident rooms and offices observed).
Inspection Report — May 20, 2024
Complaint Investigation
Date: May 20, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation citing MO00236191.
Complaint Details
MO00236191; substantiation not stated.
Findings
Four deficiencies were cited: two federal deficiencies for failures related to abuse/neglect policies and reporting alleged violations, and two Missouri state citations referencing development of abuse/neglect policies and reporting to DHSS/DMH. Findings included failure to investigate and to timely report a missing electronic device for one resident.
Deficiencies (2)
F 607 Develop/Implement Abuse/Neglect Policies: Based on record review and interview, staff failed to follow the facility's Abuse & Neglect policy by not investigating an allegation of misappropriation of property and failing to contact local law enforcement within the required timeframe for one resident.
F 609 Reporting of Alleged Violations: Based on interviews and record review, the facility failed to report a missing electronic device for one resident to the Department of Health and Senior Services within the required timeframe, which had the potential to affect all residents.
Report Facts
residents affected: 1
Inspection Report — Apr 25, 2024
Routine
Date: Apr 25, 2024
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form are included in this file; the survey type is not stated.
Findings
Two deficiencies were cited: one federal and one state. Both relate to food safety practices including poor hand hygiene and glove use, unsanitized thermometers, and inadequate cleaning/maintenance of kitchen floors and appliances.
Deficiencies (1)
F 812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observation, interview and record review, staff failed to perform hand hygiene or sanitize/change gloves between tasks and did not sanitize thermometers between uses. Kitchen floors and appliances were observed dirty and not properly cleaned, creating potential for spread of bacteria and affecting all residents.
Inspection Report — Jan 11, 2024
Complaint Investigation
Date: Jan 11, 2024
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure form; complaint investigation (MO00229820) was cited in the file.
Complaint Details
MO00229820; substantiation not stated in the report.
Findings
2 deficiencies: one federal deficiency for failure to thoroughly investigate an allegation of abuse/neglect and one state deficiency for failure to develop/implement abuse/neglect policies (state item references the federal finding).
Deficiencies (1)
F610 Investigate/Prevent/Correct Alleged Violation: Based on interview and record review, facility staff failed to complete a thorough investigation when a resident reported missing quarters; staff did not interview additional residents, witnesses or family members and the investigation lacked documentation of resident and witness interviews.
Inspection Report — Dec 7, 2023
Complaint Investigation
Date: Dec 7, 2023
Visit Reason
Federal health survey (CMS-2567) and Missouri Department of Health and Senior Services State Form; complaint investigation (complaint number MO00228299 is cited).
Complaint Details
Complaint number MO00228299 is cited in the file; the document does not state that the allegation was substantiated.
Findings
There are 5 federal health deficiencies covering a damaged resident bed/environment, failure to report alleged abuse, failures to assist dependent residents with meals, unsecured/ unattended medication carts, and infection prevention/PPE failures; and 4 Missouri state licensure deficiencies addressing bed requirements, protective oversight/voluntary leave, mealtime assistance/supervision, and infection control.
Deficiencies (5)
F584 Safe/Clean/Comfortable/Homelike Environment: Based on observation, record review, and interview, staff failed to provide a clean, safe, comfortable homelike environment when staff failed to ensure one resident's (Resident #2) bed was in good repair.
F609 Reporting of Alleged Violations: Based on record review and interviews, facility staff failed to report an allegation of employee-to-resident verbal abuse for one resident to the Department of Health and Senior Services within the two-hour required timeframe.
F677 ADL Care Provided for Dependent Residents: Based on observation, interview, and record review, facility staff failed to assist two dependent residents with their meals, leaving meal trays untouched and residents not fed in a timely manner.
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview, and record review, facility staff failed to ensure medications and sharps were secured when medication carts were left unattended and unlocked, leaving medications accessible.
F880 Infection Prevention & Control: Based on observation, interview and record review, facility staff failed to follow acceptable infection control practices for COVID-19, including staff entering COVID-19 positive resident rooms without N95 respirators and related PPE/signage deficiencies.
Inspection Report — Jun 29, 2023
Routine
Date: Jun 29, 2023
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form present in the file; the survey type is not stated.
Findings
The file contains 9 federal health deficiencies and 9 Missouri state licensure deficiencies (18 total). Main topics include failure to notify physician/skin care (MASD), incomplete/comprehensive care plans for oxygen/CPAP and activities, inadequate ADL assistance and showering, unsafe transfer/lift practices and unsecured medication cart, missing/undocumented catheter orders and catheter care, improper medication storage/expired meds, food safety/temperature and hand hygiene lapses, and multiple infection prevention and control failures (hand hygiene, oxygen/CPAP equipment cleaning and wound care).
Deficiencies (8)
F580 Notify of Changes (Injury/Decline/Room, etc.): Based on observation, interview and record review, facility staff failed to notify one resident's physician when staff identified Moisture Associated Skin Damage (Resident #64) and failed to obtain treatment orders.
F656 Develop/Implement Comprehensive Care Plan: Based on observation, interview and record review, facility staff failed to develop comprehensive person-centered care plans addressing residents' medical and nursing needs, including documenting oxygen/CPAP use and activity preferences for multiple residents.
F677 ADL Care Provided for Dependent Residents: Based on observation, interview, and record review, facility staff failed to assist four out of six sampled dependent residents with grooming and bathing as needed, resulting in poor hygiene for several residents.
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview, and record review, facility staff failed to transfer multiple residents using mechanical lifts and failed to follow safe lift procedures and secure equipment, placing residents at risk of accidents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Based on observation, interview, and record review, facility staff failed to obtain and document physician orders and catheter change/discontinuation details for an indwelling urinary catheter for Resident #3.
F761 Label/Store Drugs and Biologicals: Based on observation, interview, and record review, facility staff failed to store and label medications in a safe and effective manner, with loose and expired medications found in medication storage rooms and carts.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observation, interview and record review, facility staff failed to maintain proper food temperatures, failed to perform required hand hygiene and sanitizing techniques, and a missing ceiling tile was noted in the food preparation area.
F880 Infection Prevention & Control: Based on observation, interview, and record review, facility staff failed to maintain an effective infection prevention and control program, including failures in hand hygiene, wound care procedures, and sanitary handling/maintenance of oxygen/CPAP equipment.
Report Facts
dependent residents not assisted: 4
residents transferred unsafely: 4
unsecured medication carts observed: 1
Inspection Report — Jun 4, 2021
Life Safety
Date: Jun 4, 2021
Visit Reason
CMS federal health and Life Safety (LSC) survey with accompanying Missouri Department of Health and Senior Services state licensure form; life safety survey.
Findings
21 deficiencies were cited (11 federal life-safety/emergency preparedness tags and 10 Missouri state licensure citations). Main topics include emergency preparedness training, egress/locking doors and delayed-egress devices, emergency lighting testing and documentation, fire alarm testing/documentation, sprinkler system testing/replacement and obstructed/corroded sprinklers, smoke barrier penetrations, fire drill frequency and documentation, egress door inspection/testing, electrical receptacle and essential electrical/generator testing and documentation, medical gas handling education, night-lights in resident rooms, and employee orientation/education.
Deficiencies (11)
E037 EP Training Program: Facility staff failed to provide required emergency preparedness training to all staff on an annual basis and training documentation was incomplete for many employees.
K222 Egress Doors: Facility staff failed to maintain egress doors and locking arrangements in accordance with NFPA; delayed-egress locking devices and access-control arrangements were not maintained or made readily accessible and some doors did not alarm or provide required audible signals.
K291 Emergency Lighting: Facility staff failed to inspect, test and maintain emergency lighting fixtures and failed to provide complete and verifiable documentation of monthly 30-second tests and the required annual 1.5-hour functional tests.
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to provide and maintain complete documentation of inspection, testing and maintenance of the fire alarm system and some alarm devices (magnetic delayed egress locks) did not alarm upon actuation.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain and document sprinkler system inspection, testing and corrective actions; sampled sprinkler heads showed abnormalities and records did not document replacement or corrective testing.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Facility staff failed to maintain smoke barrier walls free of openings and failed to provide inspections and documentation; observed unsealed gaps, seams and holes compromising smoke barriers.
K712 Fire Drills: Facility staff failed to conduct required fire drills on each shift and to maintain required drill records; some drills were conducted as silent drills outside of established requirements.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to inspect, test and maintain egress and fire doors and failed to maintain verifiable documentation of door inspections and testing.
K914 Electrical Systems - Maintenance and Testing: Facility staff failed to assess electrical receptacles in resident care rooms for physical integrity, continuity of grounding and retention force and did not maintain an itemized list of receptacles tested.
K918 Electrical Systems - Essential Electric Syste[m] Maintenance and Testing: Facility staff failed to inspect, test and maintain the emergency generator and essential electrical systems and failed to provide complete documentation of monthly/annual load and breaker testing.
K926 Gas Equipment - Qualifications and Training of Personnel: Facility staff failed to provide required education and training regarding safe handling and usage requirements for medical gases and cylinders to staff.
Report Facts
employees_listed: 165
employees_signed_training: 56
employees_not_signed: 109
employees_no_documentation_of_training: 66
sprinklers_sampled: 20
sprinklers_abnormal: 4
portable_oxygen_tanks_unsecured_observed: 3
Inspection Report — Nov 22, 2019
Life Safety
Date: Nov 22, 2019
Visit Reason
CMS-2567 Life Safety survey (K-tag) and Missouri State Form for state licensure; survey identified as Life Safety.
Findings
Two deficiencies were cited: one federal Life Safety deficiency for emergency generator maintenance and lack of annual diesel fuel quality testing, and one Missouri State licensure deficiency referencing the same issue.
Deficiencies (1)
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Based on observation, interview and record review, facility staff failed to inspect and test the emergency generator in accordance with applicable NFPA standards and failed to conduct an annual diesel fuel quality test; records from November 2018 through November 2019 did not contain documentation of diesel fuel quality testing and staff interviewed were not aware of the annual testing requirement.
Report Facts
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