Inspection Reports for
Tipton Oak Manor
601 WEST MORGAN ST, TIPTON, MO, 65081-8214
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
67% occupied
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 47
Capacity: 70
Deficiencies: 7
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for Tipton Oak Manor nursing facility.
Findings
The facility was found deficient in multiple areas including privacy and confidentiality of resident records, care plan timing and revision, professional standards of care, nurse staffing information posting, labeling and storage of drugs and biologicals, and infection prevention and control. Several residents were observed not receiving privacy during care and medication administration, and staff failed to update care plans and maintain professional standards.
Deficiencies (7)
F583 Privacy and Confidentiality of Records. Facility staff failed to respect the privacy of two residents during wound care and medication administration and posted resident names and medical information in a visible day room.
F657 Care Plan Timing and Revision. Facility staff failed to update care plans timely for three residents, including supervision of smoking and cognitive assessments.
F658 Services Provided Meet Professional Standards. Staff failed to maintain professional standards by not checking placement of a gastrostomy tube before feeding and not following physician orders for water flushes.
F732 Posted Nurse Staffing Information. Facility staff failed to post required nurse staffing information daily and maintain policies for posting.
F761 Label/Store Drugs and Biologicals. Facility staff failed to properly label and store insulin pens and medications, and failed to destroy expired or unlabeled medications.
F880 Infection Prevention & Control. Facility staff failed to implement infection control policies, including hand hygiene, use of personal protective equipment, and enhanced barrier precautions for residents with gastrostomy tubes and wounds.
K345 Life Safety Code. The facility completed required fire alarm and emergency generator testing and annual main and circuit breaker assessments.
Report Facts
Facility Census: 47
Facility Census: 70
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Observed entering resident rooms and involved in medication administration and interviews regarding care plans and infection control. |
| Certified Nurse Aid F | Certified Nurse Aid (CNA) | Interviewed regarding privacy concerns and resident name list placement. |
| Certified Medication Technician G | Certified Medication Technician (CMT) | Interviewed regarding resident privacy and medication labeling. |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Observed administering medications and interviewed about medication administration procedures. |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Observed administering medications and interviewed about medication administration procedures. |
| Certified Medication Technician E | Certified Medication Technician (CMT) | Interviewed about medication labeling and expiration dates. |
| Certified Medication Technician D | Certified Medication Technician (CMT) | Interviewed about insulin pen labeling and expiration. |
| Certified Medication Technician C | Certified Medication Technician (CMT) | Interviewed about insulin pen labeling and expiration. |
| Certified Medication Technician G | Certified Medication Technician (CMT) | Interviewed about enhanced barrier precautions and resident risk. |
| Administrator | Facility Administrator | Interviewed regarding care plan updates, nurse staffing posting, and infection control policies. |
Inspection Report
Life Safety
Census: 47
Capacity: 66
Deficiencies: 6
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and maintenance of fire alarm, sprinkler, smoke barriers, HVAC, fire drills, and electrical systems.
Findings
The facility failed to meet several Life Safety Code requirements including incomplete fire alarm system testing and maintenance, inadequate sprinkler system maintenance, failure to maintain smoke/fire barrier walls, non-functioning bathroom exhaust fans, incomplete fire drills, and deficiencies in emergency generator testing and electrical system maintenance.
Deficiencies (6)
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to provide complete and verifiable documentation for sensitivity testing of smoke detectors and annual fire alarm system inspections.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain sprinklers free of obstructions and maintain proper clearance around sprinkler heads, creating potential obstructions.
K372 Smoke Barrier Construction: Facility staff failed to maintain two of two smoke/fire barrier walls by not using rated firestop materials to seal openings.
K521 HVAC: Facility staff failed to provide functioning exhaust ventilation units to vent vapors and odors from resident toilet rooms.
K712 Fire Drills: Facility staff failed to conduct fire drills at various times and under varying conditions on each shift quarterly, including missing first-shift fire drills.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Facility staff failed to inspect, test, and maintain the diesel-fueled emergency generator and essential electrical systems as required.
Report Facts
Facility census: 47
Total capacity: 66
Smoke detectors sensitivity testing: 52
Smoke detectors sensitivity testing: 38
Smoke detectors in alarm system: 81
Fire drills conducted: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Responsible for fire alarm system testing, sprinkler system maintenance, bathroom exhaust fans, emergency generator, and electrical system testing | |
| Administrator | Responsible for ensuring fire alarm system testing, sprinkler system maintenance, fire drills, and electrical system inspections |
Inspection Report
Routine
Census: 47
Deficiencies: 6
Date: Aug 1, 2024
Visit Reason
Routine inspection to assess compliance with regulatory standards including privacy, care planning, medication administration, staffing, medication labeling, infection control, and other nursing home requirements.
Findings
The facility was found deficient in maintaining resident privacy, updating care plans, following physician orders for G-tube feeding, posting nurse staffing information, labeling insulin pens properly, and implementing infection control procedures including enhanced barrier precautions.
Deficiencies (6)
F 0583: Facility staff failed to respect resident privacy during wound care and medication administration and posted care signs with resident names and medical information in a public day room.
F 0657: Facility staff failed to update care plans regarding smoking for three residents, despite observations showing residents smoking unsupervised and carrying cigarettes and lighters.
F 0658: Facility staff failed to check placement of a resident's G-tube prior to feeding and medication administration and did not flush the G-tube as ordered by the physician.
F 0732: Facility staff failed to post nurse staffing information daily in an area accessible to residents and visitors.
F 0761: Facility staff failed to properly label and date opened insulin pens, risking administration of expired or ineffective medication.
F 0880: Facility staff failed to implement infection control procedures including changing gloves and hand hygiene during wound care and medication administration, and failed to provide PPE in close proximity for residents requiring enhanced barrier precautions.
Report Facts
Facility census: 47
Facility census: 70
Water flush amount: 100
Insulin pen expiration: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Mentioned in relation to G-tube feeding and flushing deficiencies |
| LPN B | Licensed Practical Nurse | Mentioned in relation to G-tube feeding and flushing deficiencies |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including privacy, G-tube feeding, care plan updates, infection control |
| Certified Medication Technician (CMT) E | Certified Medication Technician | Mentioned in relation to insulin pen labeling |
| Certified Medication Technician (CMT) G | Certified Medication Technician | Mentioned in relation to infection control knowledge |
| Certified Nurse Aid (CNA) F | Certified Nurse Aid | Mentioned in relation to infection control knowledge and privacy signage |
| Care Plan Coordinator | Mentioned in relation to care plan update deficiencies | |
| Administrator | Administrator | Mentioned in relation to care plan updates, staffing posting, and infection control expectations |
Inspection Report
Routine
Census: 47
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to the facility environment and resident care, including the condition of the physical environment and the provision of personal hygiene and grooming services to residents.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to damaged flooring, stained walls, and poor maintenance. Additionally, staff failed to provide adequate grooming and personal hygiene care to three dependent residents, including facial hair maintenance, nail care, and ensuring residents wore clean clothes.
Deficiencies (2)
F 0584: Facility staff failed to maintain a safe, clean, and homelike environment, with observations of cracked and stained flooring, marked and chipped walls, and unclean toilets in multiple resident rooms and common areas.
F 0677: Facility staff failed to provide necessary care and assistance for activities of daily living to three dependent residents, including failure to maintain facial hair, trim nails, and ensure residents wore clean clothing.
Report Facts
Facility census: 47
Cracked floor tiles: 118
Cracked floor tiles: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide R | Certified Nurse Aide (CNA) | Interviewed regarding environmental concerns and resident grooming care |
| Certified Medication Technician E | Certified Medication Technician (CMT) | Interviewed regarding condition of floors on the unit |
| Registered Nurse G | Registered Nurse (RN) | Interviewed regarding knowledge of cracked tiles and reporting procedures |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance reporting and repair responsibilities |
| Registered Nurse A | Registered Nurse (RN) | Interviewed regarding reporting of environmental concerns and resident grooming |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding maintenance log procedures and repair efforts |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding facility maintenance and expectations for resident care |
Inspection Report
Routine
Census: 47
Deficiencies: 11
Date: Mar 9, 2023
Visit Reason
Routine inspection of Tipton Oak Manor nursing home to assess compliance with regulatory requirements including resident care, environment, medication management, and activities.
Findings
The facility had multiple deficiencies including failure to post required hotline information, environmental maintenance issues, improper use of restraints, incomplete care plans, inadequate personal hygiene care, insufficient activities for dependent residents, unsafe resident transfers, lack of physician orders for CPAP use, inappropriate antipsychotic medication use, improper controlled medication counts, and food safety violations including cross-contamination risks.
Deficiencies (11)
F 0575: Facility failed to post required hotline and ombudsman contact information in accessible locations for residents and visitors.
F 0584: Facility failed to maintain a safe, clean, and homelike environment; observed dirty, cracked floors, stained walls, and unclean resident rooms.
F 0604: Facility failed to maintain proper documentation and monitoring for physical restraint use for one resident; restraint consent and physician order were missing.
F 0656: Facility failed to develop and implement comprehensive care plans for four residents, lacking measurable goals and interventions.
F 0677: Facility failed to provide adequate personal hygiene care for three residents, including failure to maintain facial hair, nails, and clean clothing.
F 0679: Facility failed to provide ongoing activities during weekends and failed to invite dependent residents to activities.
F 0689: Facility failed to maintain a safe environment by improperly propelling residents in wheelchairs without foot pedals and failing to use gait belts and adequate staff during transfers.
F 0695: Facility failed to obtain physician orders for CPAP use for one resident and failed to develop a person-centered care plan for CPAP use.
F 0758: Facility failed to ensure appropriate indication for antipsychotic medication use for two residents; one resident's diagnosis did not support use.
F 0761: Facility failed to maintain accurate counts of controlled medications, including medications stored for destruction.
F 0812: Facility staff failed to change gloves and perform hand hygiene as necessary to prevent cross-contamination and failed to clean and sanitize soiled utensils between uses.
Report Facts
Residents present: 47
Cracked floor tiles: 118
Cracked floor tiles: 24
Controlled medications: 6
Dilaudid remaining: 25
Seroquel dose: 25
Zyprexa dose: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to food handling, restraint use, wheelchair safety, and CPAP orders |
| CNA I | Certified Nurse Aide | Named in findings related to unsafe resident transfers and wheelchair propulsion |
| CMT E | Certified Medication Technician | Named in findings related to restraint use, antipsychotic medication, and wheelchair safety |
| DON | Director of Nursing | Named in multiple findings including restraint policy, care plans, medication management, and staff expectations |
| DM | Dietary Manager | Named in findings related to food safety and hand hygiene |
| RN G | Registered Nurse | Named in findings related to care plans, antipsychotic medication, and controlled medication counts |
| CMT H | Certified Medication Technician | Named in findings related to activities and ice scoop sanitation |
| CMT S | Certified Medication Technician | Named in findings related to controlled medication counts |
Inspection Report
Life Safety
Census: 46
Deficiencies: 2
Date: Jan 3, 2023
Visit Reason
The inspection was conducted due to the sprinkler system being out of service, which required evaluation of the extent and duration of the impairment and compliance with fire safety regulations.
Findings
The facility failed to notify all applicable entities of sprinkler system impairments when the water was disconnected due to frozen and broken water lines. The sprinkler system was out of service for more than 10 hours without proper notification and fire watch procedures were not fully implemented.
Deficiencies (2)
K354 Sprinkler System - Out of Service. The facility failed to notify all applicable entities of sprinkler system impairments when water was disconnected due to frozen and broken water lines. The sprinkler system was out of service for more than 10 hours without proper fire watch or notification.
A2036 19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr. The facility did not immediately notify the department and local fire authority and implement an approved fire watch when the sprinkler system was out of service for more than four hours.
Report Facts
Facility census: 46
Inspection Report
Routine
Deficiencies: 0
Date: Oct 5, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
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
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Aug 31, 2022
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving nurse assistant staff at Tipton Oak Manor.
Complaint Details
The complaint was substantiated based on interviews and record reviews showing nurse assistant A verbally and physically abused residents and restrained one resident. The facility suspended and terminated the employee following the investigation.
Findings
The facility failed to ensure residents were free from abuse and neglect, as nurse assistant A verbally and physically abused residents and restrained one resident by placing a recliner behind their wheelchair. The facility suspended and terminated the employee after investigation.
Deficiencies (1)
F 600: The facility failed to prevent verbal and physical abuse by nurse assistant A, who verbally abused two residents, physically abused one resident, and restrained another by placing a recliner behind their wheelchair.
Report Facts
Census: 52
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 2
Date: Apr 28, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to accident hazards, supervision, and devices to prevent accidents at Tipton Oak Manor.
Findings
The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall. Staff failed to follow the resident's plan of care requiring two-person assistance for mobility and transfers.
Deficiencies (2)
F 689: The facility did not ensure the resident environment was free of accident hazards and failed to provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall.
A 4075: Each resident did not receive personal attention and nursing care consistent with current acceptable nursing practice, as evidenced by the issues noted in F 689.
Report Facts
Resident census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings related to failure to provide two-person assistance and supervision |
| CNA B | Certified Nursing Assistant | Named in findings related to resident fall and assistance |
| RN D | Registered Nurse | Named in findings related to resident fall and assistance |
| Director of Nursing | Interviewed regarding staffing and assistance issues |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 4
Date: Jan 19, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident safety, infection control, and protective oversight at Tipton Oak Manor.
Findings
The facility was found deficient in ensuring a safe resident environment free of accident hazards related to wheelchair use and foot pedal propulsion. Additionally, deficiencies were noted in infection prevention and control practices, including sanitization of multi-use glucometers and protective oversight during voluntary leave.
Deficiencies (4)
F689 Free of Accident Hazards: Facility staff failed to ensure residents' environment remained free of accident hazards when staff did not properly propel residents in wheelchairs using foot pedals.
F880 Infection Prevention & Control: Facility failed to sanitize multi-use glucometers between resident use, risking spread of infection.
A4074 Protective Oversight: Facility did not ensure 24-hour protective oversight and supervision for residents on voluntary leave.
A4086 Infection Control/Communicable Disease: Facility failed to use acceptable infection control procedures to prevent spread of infection and timely report communicable diseases.
Report Facts
Facility census: 52
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Rothstein | Administrator | Signed the inspection report and plan of correction |
| Director of Nursing | Named in relation to foot pedal use and infection control monitoring |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 9, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal 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
Annual Inspection
Census: 60
Deficiencies: 2
Date: Aug 10, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations regarding resident hydration and nutritional needs at Tipton Oak Manor.
Findings
The facility failed to ensure fluids were readily available for residents requiring thickened liquids and did not have water pitchers or cups with nectar thick liquids at bedside for several residents. The facility also lacked accessible fluids in the dementia unit and hydration carts. Nutritional needs were assessed but no specific deficiencies were cited in that area.
Deficiencies (2)
F 807 Drinks Avail to Meet Needs/Prefs/Hydration: Facility staff failed to ensure fluids were readily available for four residents requiring thickened liquids and for one resident per physician orders. Residents on the dementia unit did not have drinks readily available. Observations showed lack of water pitchers or cups with nectar thick liquids at bedside.
A5001 Nutritional Needs Met, Assess Res, Inform Dr: Each resident shall be served nutritious food and have nutritional needs assessed by qualified professionals. This regulation is not met as evidenced by lack of documentation or evidence in the report.
Report Facts
Facility census: 60
Inspection Report
Deficiencies: 0
Date: Sep 24, 2020
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 24, 2020
Visit Reason
The document is a plan of correction and statement of deficiencies related to a licensure inspection of Tipton Oak Manor conducted on 2020-09-24.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 59
Capacity: 66
Deficiencies: 4
Date: Sep 24, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain exit corridors free of obstructions and unsecured furniture, which could delay evacuation procedures. Additionally, the facility did not conduct fire drills at various times and under varying conditions on each shift quarterly as required.
Deficiencies (4)
K211 Means of Egress - General: Facility staff failed to maintain exit corridors free of obstructions and unsecured furniture, risking delayed evacuation in an emergency. The facility census was 59 with a capacity of 66.
K712 Fire Drills: Facility staff failed to conduct fire drills at various times and under varying conditions on each shift quarterly from September 2019 through August 2020. Records lacked documentation of simulated fire conditions and staff responses.
A2046 Corridor Requirements: Facilities did not maintain corridors free of obstructions, equipment, or supplies not in use. Doors to resident rooms swung into the corridor, violating regulations.
A2091 Fire Drills, Evacuation: Facility failed to conduct a minimum of twelve fire drills annually with at least one every three months on each shift, including unannounced drills and simulated resident evacuations.
Report Facts
Facility census: 59
Total capacity: 66
Fire drills reviewed: 9
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 4
Date: Feb 8, 2019
Visit Reason
The document is a Plan of Correction submitted by Tipton Oak Manor in response to deficiencies cited during a survey conducted on 02/08/2019.
Findings
The facility was found deficient in multiple areas including admissions policy, comprehensive care plan development and implementation, professional standards of practice, and food procurement and sanitation. Deficiencies affected all residents and had the potential to impact resident care and safety.
Deficiencies (4)
F620 Admissions Policy: The facility failed to ensure the admission policy did not require residents or responsible parties to waive potential facility liability for loss or damage to personal belongings. This affected 14 of 14 sampled residents.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans with measurable goals and timeframes for 15 of 16 sampled residents, potentially affecting all residents.
F658 Services Provided Meet Professional Standards: The facility failed to maintain professional standards of practice, including accurate physician orders and medication administration for 3 of 14 sampled residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure food safety requirements, including proper drying and storage of kitchenware, and sanitation of food service areas. The census was 55.
Report Facts
Sampled residents affected: 14
Sampled residents affected: 16
Sampled residents affected: 14
Facility census: 55
Inspection Report
Life Safety
Census: 55
Capacity: 66
Deficiencies: 2
Date: Feb 8, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically focusing on the sprinkler system maintenance and testing.
Findings
The facility failed to test and maintain the dry pipe sprinkler system in accordance with the 2011 Edition of NFPA 25. Records did not show documentation of required full flow trip tests for the dry pipe valve for multiple years.
Deficiencies (2)
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to conduct required trip tests of the dry pipe valve with the control valve fully open and quick opening device in service every three years. Records lacked documentation of full flow trip tests from 03/12/15 through 02/06/19.
A2034 Sprinkler System-Test/Maintain: Facilities with sprinkler systems installed prior to August 28, 2007, must inspect, maintain, and test these systems per requirements. This regulation was not met as evidenced by the deficiency at K353.
Report Facts
Facility census: 55
Total capacity: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Boettgen | Administrator | Signed the plan of correction and was interviewed regarding sprinkler system maintenance |
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 2
Date: Feb 23, 2018
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, specifically regarding comprehensive care plans and catheter care for residents.
Findings
The facility failed to meet professional standards in catheter care for a resident, including failure to timely change an indwelling Foley catheter as ordered by the physician. The facility census was 49 at the time of inspection.
Deficiencies (2)
F658: Facility staff failed to change an indwelling Foley catheter for resident #51 as directed by the physician, resulting in a 74-day delay between catheter changes. Documentation of catheter changes was incomplete and inconsistent with physician orders.
A4074: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency cited under F658.
Report Facts
Facility census: 49
Days catheter not changed: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Bretzgen | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Life Safety
Census: 49
Capacity: 66
Deficiencies: 4
Date: Feb 23, 2018
Visit Reason
The inspection was conducted to evaluate compliance with fire safety and life safety code requirements, including means of egress, fire drills, and horizontal exit doors.
Findings
The facility failed to conduct annual inspections of fire egress doors and quarterly fire drills as required. Deficiencies were found in the inspection and maintenance of fire egress doors and the scheduling and documentation of fire drills.
Deficiencies (4)
K211 Means of Egress - General: Facility staff failed to inspect, test, and maintain fire egress doors with panic hardware and special locking arrangements as required, including annual inspections and proper documentation.
K712 Fire Drills: Facility staff failed to conduct fire drills at various times and under varying conditions quarterly, and documentation did not show required simulated fire conditions for all drills.
A2045 19 CSR 30-85.022(20) Horizontal Exit Doors: Horizontal exit doors were not automatically self-closing upon fire alarm activation as required.
A2061 19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: The facility did not conduct the required minimum number of unannounced fire drills including simulated resident evacuation annually.
Report Facts
Facility census: 49
Total capacity: 66
Date survey completed: Feb 23, 2018
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