Inspection Reports for
The Manor
2071 BARRON RD, POPLAR BLUFF, MO, 63901-1903
Back to Facility Profile17 Reports
Inspection Report — Apr 18, 2025
Plan of Correction
Date: Apr 18, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication administration, infection prevention and control, and other regulatory requirements at The Manor nursing facility.
Findings
The facility failed to follow physician orders for medication and oxygen administration for multiple residents, resulting in significant medication errors and infection control deficiencies. The facility also failed to maintain proper infection control practices, including hand hygiene and use of gloves during insulin administration.
Deficiencies (3)
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders regarding medication and oxygen administration for sampled residents, including Resident #68, #14, and #24. The facility census was 70.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure Resident #68 was free from significant medication errors when staff failed to administer medications as ordered by the physician. The facility census was 70.
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program, including failure to wear gloves during insulin administration for sampled residents and failure to follow enhanced barrier precautions for residents with wounds.
Report Facts
Missed medication opportunities: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT D | Certified Medication Technician | Named in medication administration failure for Resident #68 |
| Director of Nursing (DON) | Involved in re-education and monitoring of medication and oxygen administration | |
| Administrator | Involved in re-education and monitoring of medication and oxygen administration | |
| LPN A | Licensed Practical Nurse | Named in infection control deficiencies related to hand hygiene and glove use |
| CNA B | Certified Nurse Aide | Named in infection control deficiencies related to wound care |
| CNA C | Certified Nurse Aide | Named in infection control deficiencies related to wound care |
Inspection Report — Apr 18, 2025
Life Safety
Date: Apr 18, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to ensure that doors to hazardous areas had self-closing devices installed and failed to maintain the sprinkler system free of corrosion and foreign materials. These deficiencies potentially affected all residents and staff.
Deficiencies (2)
K223 Doors with Self-Closing Devices: The facility failed to ensure doors to hazardous areas had self-closing devices installed as required by NFPA 101. Observations and interviews confirmed doors to the Activity Office and Mechanical Room lacked self-closing devices.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system in accordance with NFPA 25 by not ensuring sprinklers were clean and free of corrosion. Six sprinkler heads in the kitchen were heavily corroded and required replacement.
Report Facts
Number of sprinkler heads replaced: 8
Inspection Report — Mar 1, 2024
Annual Inspection
Date: Mar 1, 2024
Visit Reason
The inspection was the annual survey of The Manor nursing facility to assess compliance with federal and state regulations.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate notification of residents regarding personal funds, incomplete or improper care plans, medication errors, infection control issues, and food safety violations. The facility submitted a plan of correction addressing these issues.
Deficiencies (15)
F550 Resident Rights: The facility failed to ensure staff treated residents with dignity and privacy, including failure to provide privacy during catheter care for a resident.
F569 Notice and Conveyance of Personal Funds: The facility failed to notify residents or responsible parties timely when resident accounts approached or exceeded SSI limits.
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident at least two calendar days before Medicare services ended.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to implement care plans with specific interventions for seven residents to meet individual needs.
F658 Services Provided Meet Professional Standards: The facility failed to follow oxygen orders for one resident and physician orders for medication for another resident.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff used safe transfer techniques for one resident requiring assistance.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to maintain proper positioning and care of indwelling urinary catheters and drainage bags for residents.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain physician orders for oxygen tubing changes and failed to properly monitor residents receiving respiratory care.
F699 Trauma Informed Care: The facility failed to provide trauma-informed care and assessment for a resident with PTSD.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure appropriate documentation and gradual dose reductions for psychotropic medications.
F759 Free of Medication Errors: The facility failed to maintain a medication error rate below 5%, with documented errors affecting residents.
F761 Label/Store Drugs and Biologicals: The facility failed to properly monitor refrigerator temperatures and medication storage conditions.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain food storage areas free of debris, pests, and proper temperature controls.
F867 QAPI/QAA Improvement Activities: The facility failed to develop and implement a Quality Assurance and Performance Improvement plan addressing systemic failures.
F880 Infection Prevention & Control: The facility failed to maintain adequate infection control practices during catheter care and wound care for residents.
Report Facts
Medication error opportunities: 32
Missed medication opportunities: 30
Temperature checks: 3
PIP monitoring duration: 3
Inspection Report — Mar 1, 2024
Life Safety
Date: Mar 1, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to meet several life safety code requirements including grease accumulation in the kitchen hood, inadequate smoke barriers, and blocked electrical panel access. These deficiencies had the potential to affect all occupants of the building.
Deficiencies (6)
K324 Cooking Facilities: The facility failed to ensure the range hood was free of grease and debris, posing a risk to occupants. Kitchen hood filters were observed covered with grease and food debris.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers to resist smoke passage, including a broken plexiglass window without fire resistance rating between the dietary office and kitchen.
K911 Electrical Systems - Other: The facility failed to ensure electrical panels had clear working space; bi-fold doors were mounted in front of panels, obstructing safe operation and maintenance.
A2008 Hazardous Areas: Hazardous areas were not separated by at least one-hour fire-resistant construction or protected by an automatic sprinkler system as required.
A2017 Range Hood Certification: The cooking range hood and extinguishing system were not certified at least twice annually as required by NFPA 96, 1998 edition.
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with NFPA 70, 1999 edition, posing a substantial risk to health and safety.
Report Facts
Inspection Report — Sep 8, 2022
Complaint Investigation
Date: Sep 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to pressure ulcer care and treatment at The Manor facility.
Complaint Details
Complaint #MO206691 regarding treatment and services to prevent and heal pressure ulcers was substantiated based on interviews and record reviews.
Findings
The facility failed to follow physician's orders and adequately document and administer wound care and weekly skin assessments for residents with pressure ulcers. Deficiencies were found in the treatment and prevention of pressure ulcers, including incomplete documentation and failure to provide ordered care.
Deficiencies (2)
F658: The facility failed to follow physician's orders for two residents, including inadequate wound care and failure to document weekly skin assessments as ordered.
F686: The facility failed to provide ongoing skin assessments, documentation of treatments, and progress of a pressure ulcer for one resident, resulting in inadequate pressure ulcer care.
Report Facts
Skin treatments not documented: 17
Skin treatments not documented: 13
Skin assessments not documented: 4
Skin assessments not documented: 3
Wound treatments not documented: 4
Wound treatments not documented: 2
Wound treatments not documented: 2
Weekly wound assessments not documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding wound care and documentation issues for Resident #1 |
| Director of Nursing | Director of Nursing (DON) | Interviewed about responsibility for skin assessments and wound care protocols |
Inspection Report — Aug 5, 2022
Annual Inspection
Date: Aug 5, 2022
Visit Reason
Annual inspection survey of The Manor nursing facility to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, ADL care for dependent residents, free from unnecessary psychotropic medications, food safety, pest control, and environmental safety. Deficiencies were documented with specific resident cases and facility policy reviews.
Deficiencies (14)
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with specific interventions for three residents and failed to include resident or guardian participation in care plan conferences.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide consistent care for activities of daily living for two residents, including grooming and hygiene.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure safe transfer techniques and proper use of assistive devices for residents, resulting in unsafe practices.
F758 Free from Unnecessary Psychotropic Medications/PRN Use: The facility failed to ensure proper diagnosis and monitoring of antipsychotic medication for one resident.
F803 Menus Meet Resident Needs/Preparation/Followed: The facility failed to follow the recipe for preparing pureed consistency meals, affecting four residents on a pureed diet.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: The facility failed to store and distribute food under sanitary conditions, increasing risk of food-borne illness.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, resulting in pest infestations affecting multiple residents.
A1108 Air Gap: The facility failed to maintain a suitable air gap between water supply and fixture, violating water safety regulations.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and consistent nursing care in accordance with resident conditions.
A4077 Resident Groomed/Dressed Appropriately: The facility failed to ensure residents were well-groomed and dressed appropriately for the time of day.
A5005 Hot Food Hot, Cold Food Cold: The facility failed to assure hot food is served hot and cold food is served cold.
A6039 Inspect/Rodent Control: The facility failed to maintain premises free of rodents and insects, violating pest control regulations.
A7032 Steam Tables/Warmers Not for Rapid Reheating: The facility used steam tables improperly for rapid reheating of potentially hazardous foods.
A8013 Right to Plan Care/Refuse Treatment: The facility failed to ensure residents were afforded opportunity to participate in planning care and treatment.
Report Facts
Deficiencies cited: 14
Inspection Report — Aug 5, 2022
Life Safety
Date: Aug 5, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to meet requirements for adequate illumination of means of egress and proper functioning of the fire alarm system. Specifically, exit illumination was insufficient and the fire damper above double doors did not close when the fire alarm was activated.
Deficiencies (4)
K281: The facility failed to provide adequate exit illumination for continuous illumination to exit pathways and exit routes, including the unit courtyard exit pathway and rear gate exit route.
K344: The fire alarm system did not maintain full functioning order as the fire damper above the double doors leading from the front guest seating area and dining room did not close when the fire alarm was activated.
A2019: The facility did not maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition, as evidenced by the uncorrected fire damper issue.
A2050: The facility failed to provide emergency lighting of sufficient intensity to ensure safety of residents and others using exits, stairways, and corridors, including automatic emergency lighting with battery backup.
Report Facts
Deficiency completion dates: Sep 18, 2022
Plan of correction completion date: Dec 30, 2022
Inspection Report — May 12, 2022
Complaint Investigation
Date: May 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to resident rights, privacy/confidentiality of records, services meeting professional standards, and sufficient nursing staff.
Complaint Details
The investigation was triggered by complaints #M000200978 and #200938. Issues substantiated include delayed response to call lights, lack of privacy during care, failure to follow physician orders, inadequate ADL care, and insufficient nursing staff.
Findings
The facility was found deficient in responding timely to resident call lights, maintaining resident privacy during personal care, following physician orders for treatments, providing consistent care for activities of daily living, and ensuring sufficient nursing staff to meet resident needs.
Deficiencies (5)
F550 Resident Rights: The facility failed to respond to resident call lights in a timely manner for three residents, with delays up to 41 minutes observed.
F583 Personal Privacy/Confidentiality: The facility failed to provide privacy during perineal care for three residents, including failure to close window blinds and privacy curtains.
F658 Services Provided Meet Professional Standards: The facility failed to assess and follow physician's orders for one resident, resulting in missed treatments and improper documentation.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide consistent care for activities of daily living for four residents, with residents left wet for extended periods and missed shower opportunities.
F725 Sufficient Nursing Staff: The facility failed to provide sufficient nursing staff with appropriate competencies to meet resident needs, resulting in delayed care and missed showers.
Report Facts
Residents sampled: 8
Residents with deficiencies: 3
Residents with privacy issues: 3
Residents with ADL care issues: 4
Residents with insufficient nursing staff impact: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to call light response and privacy audit findings |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Involved in treatment assessment and resident care |
| Certified Nurse Aide B | Certified Nurse Aide (CNA) | Observed providing care and involved in privacy and call light response issues |
Inspection Report — Dec 17, 2020
Routine
Date: Dec 17, 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 — Dec 2, 2020
Abbreviated Survey
Date: Dec 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related 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 infection control practices for COVID-19.
Inspection Report — Oct 6, 2020
Routine
Date: Oct 6, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report — Sep 15, 2020
Routine
Date: Sep 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's 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 — May 18, 2020
Routine
Date: May 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/18/20 to assess compliance with CMS and CDC recommended practices and 42 CFR 483.73 regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report — Feb 14, 2020
Annual Inspection
Date: Feb 14, 2020
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and to identify deficiencies in the facility's operations and resident care.
Findings
The facility was found to have multiple deficiencies including failure to develop and implement abuse/neglect policies, failure to timely and accurately transmit resident assessments, inaccuracies in resident assessments, failure to develop baseline care plans, failure to provide oxygen therapy orders and proper labeling, and inadequate infection prevention and control practices.
Deficiencies (10)
F607: The facility failed to develop and implement written policies to prohibit and prevent abuse, neglect, and exploitation of residents. The facility did not check the Certified Nurses' Assistant Registry for all staff prior to hire.
F640: The facility failed to electronically transmit a Minimum Data Set (MDS) assessment in a timely manner for one resident. The facility census was 68.
F641: The facility failed to ensure accuracy of assessments for three residents. Oxygen therapy was not marked for Resident #5 despite receiving oxygen.
F655: The facility failed to develop and implement baseline care plans for one resident that included instructions to address wandering and exit seeking behaviors. The facility census was 68.
F656: The facility failed to develop and implement comprehensive person-centered care plans for multiple residents. The facility census was 68.
F658: The facility failed to include orders for oxygen therapy and properly label enteral feeding tubing for residents requiring enteral feedings.
F880: The facility failed to establish and maintain an infection prevention and control program that included proper hand hygiene and glove use, resulting in failure to maintain infection control practices for multiple residents.
A4029: The facility failed to follow infection control protocols for two new employees regarding tuberculosis screening. The facility census was 68.
A4074: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice for residents.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents and misappropriation of resident property.
Report Facts
Sampled residents: 17
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E | Named in failure to check CNA Registry and TB screening deficiencies | |
| Employee F | Named in failure to check CNA Registry and TB screening deficiencies | |
| Licensed Practical Nurse B | LPN | Named in tube feeding labeling deficiency |
Inspection Report — Feb 11, 2020
Life Safety
Date: Feb 11, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain functioning emergency lighting, maintain the facility free of combustible decorations, and maintain the facility free of temporary wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K291 Emergency Lighting: The facility failed to maintain functioning emergency lighting as evidenced by a non-functioning emergency light by the front entrance television. The facility census was 68.
K753 Combustible Decorations: The facility failed to maintain the facility free of combustible decorations as two wicked candles were observed mounted on a wall in room 43. The facility census was 68.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain the facility free of temporary wiring, including power strips used improperly in multiple locations. The facility census was 68.
A2009 Combustible Materials, Unnecessary: The storage of unnecessary combustible materials in the building is prohibited and this regulation was not met. See K753.
A2050 Emergency Lighting: Facilities must have emergency lighting of sufficient intensity with automatic transfer switch and battery testing. This regulation was not met. See K291.
A3037 Extension Cords/Duplex Receptacles: Extension cords must be UL-approved and used properly. This regulation was not met. See K920.
Report Facts
Inspection Report — Dec 14, 2018
Annual Inspection
Date: Dec 14, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity with uncovered urinary catheter bags, inadequate surety bond amounts for residents' personal funds, failure to maintain a safe and homelike environment due to rusted bedside tables, failure to provide written notification of bed hold policy upon resident transfer, incomplete comprehensive assessments after significant changes, inaccurate coding of assessments, incomplete comprehensive care plans, failure to post nurse staffing data, improper psychotropic medication management, and unsafe food storage practices.
Deficiencies (11)
F550 Resident Rights: The facility failed to ensure a resident's dignity with a properly covered urinary catheter bag for one resident out of four observed.
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain the bond amount at least one and one-half times the average monthly balance of residents' personal funds for the last twelve months.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a comfortable homelike environment for three residents with bedside tables showing moderate rust and disrepair.
F625 Notice of Bed Hold Policy: The facility failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer for five sampled residents.
F637 Comprehensive Assessment After Significant Change: The facility failed to recognize and complete a significant change assessment for one resident with a decline in status.
F641 Accuracy of Assessments: The facility failed to accurately code the Minimum Data Set (MDS) assessments for residents receiving oxygen and hospice services.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans for four residents, including care plans for smoking and oxygen use.
F684 Quality of Care: The facility failed to ensure one resident had an updated hospice coordinated plan of care and failed to provide a care plan for smoking.
F732 Posted Nurse Staffing Information: The facility failed to post nurse staffing data daily in a prominent and accessible location for residents and visitors.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to ensure proper diagnosis and documentation for antipsychotic medication dose reductions and PRN orders for one resident.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, including ice buildup in the freezer and unclean kitchen storage areas.
Report Facts
Sample size: 18
Sample size: 5
Sample size: 18
Sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Mentioned in relation to expectations for urinary catheter bag coverage and monitoring MDS coding and care plans. |
| Business Office Manager | Business Office Manager (BOM) | Mentioned regarding bond amount compliance. |
| Administrator | Administrator | Mentioned regarding bond amount, bed hold policy notification, and kitchen cleanliness. |
| Certified Nurse Aide D | Certified Nurse Aide (CNA) | Mentioned regarding urinary catheter bag coverage. |
| Registered Nurse E | Registered Nurse (RN) | Mentioned regarding urinary catheter bag coverage. |
| MDS Coordinator | MDS Coordinator | Mentioned regarding completion and accuracy of MDS assessments. |
| Social Service Designee | Social Service Designee (SSD) | Mentioned regarding bed hold policy notification. |
| Activity Director | Activity Director | Mentioned regarding smoking evaluations and resident smoking behavior. |
Inspection Report — Dec 14, 2018
Life Safety
Date: Dec 14, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to maintain adequate exit illumination, exit signage, and hazardous area enclosure ratings, potentially affecting all residents and staff. Observations included lack of exit illumination on an exit pathway, missing exit signage at gates, and an unsealed opening above the hot water heater.
Deficiencies (3)
K281: The facility failed to maintain adequate exit illumination, including exit discharge lighting, as evidenced by an exit pathway lacking illumination. This potentially affected all residents and staff.
K293: The facility failed to maintain adequate exit signage, with gates leading to courtyards lacking exit signs. This potentially affected all residents and staff.
K321: The facility failed to maintain hazardous area enclosure ratings, with an unsealed opening above the hot water heater. This potentially affected all residents and staff.
Report Facts
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