Inspection Reports for
The Manor at Elfindale
1707 W Elfindale St, Springfield, MO 65807, United States, MO, 65807
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
93% occupied
Based on a February 2024 inspection.
Occupancy rate over time
Inspection Report
Life Safety
Census: 93
Capacity: 100
Deficiencies: 4
Date: Feb 7, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Survey were conducted to assess compliance with federal and state regulations for participation in Medicare/Medicaid and fire safety standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including fire alarm system installation, sprinkler system maintenance, smoke barrier construction, and electrical system maintenance. Deficiencies had the potential to affect all 93 residents.
Deficiencies (4)
K341 Fire Alarm System-Installation: The facility failed to ensure smoke detection was installed at the main fire alarm control panel in an area not continuously occupied, violating NFPA 101 (2012 Edition) Section 9.6.1.8.
K353 Sprinkler System-Maintenance and Testing: The facility failed to maintain the sprinkler system in accordance with NFPA 25 standards, missing quarterly tests during the second quarter of 2023.
K372 Subdivision of Building Spaces-Smoke Barrier Construction: The facility failed to ensure smoke barriers were properly sealed, with unsealed gaps around sprinkler pipe penetrations in multiple rooms.
K918 Electrical Systems-Essential Electric System Maintenance and Testing: The facility failed to maintain and document weekly inspections and testing of the diesel generator as required by NFPA 110, with missing documentation for multiple weeks in 2023 and January 2024.
Report Facts
Residents affected: 93
Licensed beds: 100
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for the Manor at Elfindale nursing home following a survey completed on February 2, 2024.
Findings
No health deficiencies were found during the survey.
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
A recertification and complaint survey was conducted to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found to be in substantial compliance with no deficiencies issued related to intake MO00231095.
Report Facts
Sample Size: 18
Supplemental Residents: 0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation to assess compliance with related regulations.
Complaint Details
This was a complaint investigation related to COVID-19 preparedness and infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 5
Date: Dec 3, 2021
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report an allegation of abuse involving two residents to the State Survey Agency within two hours of receiving the allegation.
Complaint Details
The complaint involved failure to report an allegation of abuse involving two residents (Resident #8 and Resident #58) to the State Survey Agency within two hours of receiving the allegation. The facility census was 90. The investigation confirmed the failure to report and lack of documentation.
Findings
The facility failed to report an allegation of abuse involving two residents to the State Survey Agency within the required timeframe. Multiple staff interviews confirmed knowledge of abuse reporting requirements, but the incident was not reported. Additionally, the facility failed to document consent and gap measurements for bed rails for eight residents, and there were sanitation issues in the kitchen including mold buildup in the ice machine, lint buildup in the walk-in freezer vent, and missing or broken light fixture covers in the dry pantry.
Deficiencies (5)
Failed to timely report an allegation of abuse involving two residents to the State Survey Agency within two hours.
Failed to document completion of measurements to ensure no gaps that could cause injury or entrapment and failed to obtain signed consent for use of side rails for eight residents.
Failed to maintain the ice machine in a clean manner; ice reflector shield had mold buildup.
Failed to ensure the air cooling vent in the walk-in freezer was free of lint which could contaminate food.
Failed to ensure two fluorescent light fixtures in the dry storage pantry had covers and one cover was broken, risking contamination of food by broken glass.
Report Facts
Facility census: 90
Sample size: 18
Residents affected by bed rail documentation deficiency: 8
Inspection Report
Plan of Correction
Census: 90
Deficiencies: 3
Date: Dec 3, 2021
Visit Reason
The document is a Plan of Correction submitted by The Manor at Elfindale following a survey conducted from 11/29/2021 through 12/03/2021. It addresses deficiencies cited during the inspection related to abuse reporting, bedrails, and food safety.
Findings
The facility failed to report allegations of abuse involving two residents within the required timeframe and did not document completion of measurements or obtain consent for bedrails for several residents. Additionally, the facility failed to maintain the ice machine and food storage areas in a sanitary condition.
Deficiencies (3)
F609 Reporting of Alleged Violations: The facility failed to report an allegation of abuse involving two residents to the State Survey Agency within two hours of receiving the allegation.
F700 Bedrails: The facility failed to document measurements and obtain informed consent for the use of side rails for eight residents, risking injury or entrapment.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain the ice machine and food storage areas in a clean and sanitary condition, including mold on the ice reflector shield and missing or broken light fixture covers.
Report Facts
Facility census: 90
Residents with bedrail issues: 8
Inspection Report
Life Safety
Census: 90
Capacity: 100
Deficiencies: 3
Date: Dec 3, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including sprinkler system maintenance and testing.
Findings
The facility failed to meet the applicable provisions of the 2012 edition of the Life Safety Code, specifically regarding sprinkler system maintenance and testing. Observations revealed sprinkler heads obstructed by paint and fuzzy buildup, missing or loose escutcheon rings, and excessive lint accumulation around gas-fired dryers, posing fire hazards.
Deficiencies (3)
K353 Sprinkler System - The facility failed to keep sprinkler heads free from obstruction by paint and fuzzy buildup, and had missing or loose escutcheon rings, risking sprinkler function during a fire.
K500 Building Services - The facility failed to maintain the back and surrounding areas of three gas-fired dryers free of lint buildup, creating a fire hazard.
A2034 Sprinkler System-Test/Maintain - Facilities with sprinkler systems installed prior to August 28, 2007, must inspect, maintain, and test systems per regulations; this was not met as evidenced by K353.
Report Facts
Facility capacity: 100
Resident census: 90
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
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. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation to assess compliance with relevant CMS and CDC guidelines.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's 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 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 3, 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 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 26, 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 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 23, 2019
Visit Reason
The document is an annual inspection report for the Manor at Elfindale nursing home, conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 23, 2019
Visit Reason
The inspection was conducted as an annual licensure inspection of the facility to assess compliance with health and safety regulations.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 23, 2019
Visit Reason
The inspection was conducted as an Emergency Preparedness and Life Safety Code survey for the facility.
Findings
No deficiencies were cited as a result of the Emergency Preparedness survey or the Licensure Inspection. The facility meets the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association.
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 2
Date: Sep 27, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Complaint Details
The complaint investigation was substantiated as the facility failed to report an allegation of abuse within the required timeframe. The allegation involved a resident reporting a man masturbating in the doorway of the resident's room. The facility reported the allegation to DHSS nine hours after it was made.
Findings
The facility failed to report an allegation of abuse made by a resident to the state licensing agency within the required two-hour timeframe. Interviews and record reviews confirmed delays in reporting and inadequate documentation of the incident.
Deficiencies (2)
F609: The facility failed to report an allegation of abuse to the state licensing agency within the required two-hour timeframe as mandated by regulation.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents as required by state regulation.
Report Facts
Census: 100
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Reported the abuse allegation and was interviewed regarding the incident | |
| LPN B | Licensed Practical Nurse | Interviewed about the abuse incident and reporting |
| LPN C | Licensed Practical Nurse | Interviewed about the abuse incident and reporting |
| RN C | Registered Nurse | Interviewed about the abuse incident and reporting |
| Director of Nursing | Director of Nursing | Interviewed about abuse reporting policies and procedures |
| Social Services Director | Social Services Director | Interviewed about abuse reporting and investigation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 11, 2018
Visit Reason
Annual licensure inspection of the facility to assess compliance with state and federal long-term care regulations.
Findings
The facility was found to be in compliance with 42 CSR 483.70 (a) Requirements for Long-Term Care Facilities. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Annual Inspection
Census: 88
Capacity: 100
Deficiencies: 1
Date: May 11, 2018
Visit Reason
Annual recertification survey to assess compliance with the Life Safety Code and other regulatory requirements.
Findings
The facility failed to conduct required quarterly fire drills during the last week of the month as required by NFPA 101, potentially affecting resident and staff safety. No emergency preparedness or state licensure deficiencies were cited.
Deficiencies (1)
K712 Fire Drills: The facility did not conduct required quarterly fire drills during the last week of the month, failing to meet NFPA 101 requirements. This deficient practice could delay staff reaction to fire alarms and affect all residents, staff, and visitors.
Report Facts
Facility capacity: 100
Census: 88
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