Deficiencies (last 8 years)
Deficiencies (over 8 years)
27.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
405% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
65% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 3
Date: May 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of verbal abuse by a Certified Nurse Assistant (CNA A) towards Resident #1 on the dementia care unit.
Complaint Details
The complaint involved an allegation that CNA A verbally abused Resident #1 on 05/03/25 by cursing and using derogatory language. CNA B and CNA C witnessed the abuse and left written statements under the administrator's door on 05/03/25 but did not report it to the charge nurse. The administrator found the statements on 05/05/25 and began an investigation. CNA A was terminated on 05/05/25. The facility failed to report the abuse to the State Agency within the required timeframe and did not conduct a thorough investigation as per policy.
Findings
The facility failed to ensure Resident #1 was free from verbal abuse when CNA A used derogatory language including cursing at the resident while providing care. The facility also failed to timely report the abuse to the State Agency and did not conduct a thorough investigation per facility policy. CNA A was terminated after the incident. The administrator found written statements from witnesses two days after the incident and began an investigation.
Deficiencies (3)
Failure to protect Resident #1 from verbal abuse by CNA A who used derogatory language and cursing.
Failure to timely report the staff to resident verbal abuse allegation to the State Agency.
Failure to conduct a timely and thorough investigation of the reported abuse, including failure to interview involved staff, Resident #1, and other residents as required by facility policy.
Report Facts
Facility census: 97
Date of incident: May 3, 2025
Date administrator notified: May 5, 2025
Date survey completed: May 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Named in verbal abuse finding; terminated for cursing at Resident #1 |
| CNA B | Certified Nurse Assistant | Witnessed abuse, provided written statement, did not report to charge nurse |
| CNA C | Certified Nurse Assistant | Witnessed abuse, provided written statement, did not report to charge nurse |
| RN D | Registered Nurse, Charge Nurse | Charge nurse on duty during incident; unaware of abuse allegation |
| LPN E | Licensed Practical Nurse | Provided statement forms to CNA C; unaware of abuse until days later |
| Director of Nurses | Director of Nursing | Unaware of abuse until after administrator notified; responsible for staff in-service |
| Administrator | Facility Administrator | Received written statements late; initiated investigation and terminated CNA A |
Inspection Report
Plan of Correction
Census: 5
Deficiencies: 5
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to identify deficiencies related to fire safety, employee fire safety training, hazardous area requirements, combustible materials storage, and electrical wiring maintenance at Troy Manor.
Findings
The facility failed to document monthly pressure checks on fire extinguishers, ensure fire safety training for all employees, maintain self-closing smoke partition doors, prevent storage of unnecessary combustible materials, and properly maintain electrical wiring. These deficiencies affected multiple residents and were classified as Class II or Class III violations.
Deficiencies (5)
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to document monthly pressure checks on all fire extinguishers. This affected 5 of 5 residents.
19 CSR 30-86.022(6)(A)(1-3) Fire Safety Training Requirements-employees. The facility failed to ensure all employees had fire safety training upon hiring and semi-annually. This deficiency affects 5 of 5 residents.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to install and maintain self-closing smoke partition doors. The smoke partition door of the laundry room was not self-closing. This affected 5 of 5 residents.
19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of. The facility failed to prevent storage of unnecessary combustible materials in resident rooms, increasing the fuel load. This affected 5 of 5 residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to properly maintain electrical wiring, including use of multiple adapters in resident rooms, creating a safety hazard. This affected 33 of 5 residents.
Report Facts
Facility census: 5
Residents affected: 5
Residents affected: 33
Inspection Report
Plan of Correction
Census: 6
Deficiencies: 1
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident transfer and discharge procedures at Troy Manor.
Findings
The facility failed to identify an appropriate discharge location in the 30-day discharge notice for one resident. The discharge letter planned to send the resident to a homeless shelter, which was deemed inappropriate.
Deficiencies (1)
19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: The facility did not identify an appropriate discharge location in the 30-day discharge notice for one resident. The discharge plan involved sending the resident to a homeless shelter, which is not appropriate.
Report Facts
Resident census: 6
Number of sampled residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding discharge and housing options | |
| Acting Administrator | Interviewed regarding discharge letter and facility policies |
Inspection Report
Census: 87
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to food safety and palatability in the facility.
Findings
The facility failed to provide food items at a safe and appetizing temperature, posing minimal harm or potential for actual harm to some residents.
Deficiencies (1)
Failed to provide food items at a safe and appetizing temperature.
Inspection Report
Routine
Census: 85
Deficiencies: 8
Date: Oct 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, abuse prevention, infection control, and food service in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to provide hot water at appropriate temperatures, resident-to-resident abuse incidents, failure to timely report and investigate abuse allegations, improper resident repositioning techniques, failure to maintain food at safe temperatures, and inadequate infection control practices.
Deficiencies (8)
Staff failed to treat residents with dignity and respect, including rough handling and yelling at residents.
Residents on the 200 hall did not have access to hot water at appropriate temperatures for two to three months.
Resident-to-resident abuse occurred, including physical harm resulting in a left shoulder fracture and other injuries.
Failure to timely report a staff to resident allegation of abuse to the state agency within required timeframes.
Failure to conduct a thorough investigation of an abuse allegation involving a staff member and a resident.
Staff repositioned a resident by pulling under the arms instead of using a draw sheet, causing discomfort and potential harm.
Food items were served at unsafe and unappetizing temperatures, with hot foods below recommended temperatures.
Staff failed to use appropriate infection control procedures, including handwashing and glove changes, during incontinent care.
Report Facts
Residents affected: 85
Temperature of hot dog: 90
Temperature of chili: 110
Food temperature documented: 175
Number of statements provided: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician B | Certified Medication Technician | Reported abuse allegation involving Resident #4 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Received abuse report from residents and reported to DON |
| Director of Nursing | Director of Nursing (DON) | Responsible for investigating abuse allegations and reporting |
| Certified Nurse Assistant F | Certified Nurse Assistant | Yelled at Resident #8 and was involved in abuse investigation |
| Nurse Assistant G | Nurse Assistant | Witnessed CNA F yelling at Resident #8 |
| Nurse Assistant E | Nurse Assistant | Witnessed resident altercations and reported incidents |
| Licensed Practical Nurse I | Licensed Practical Nurse | Witnessed resident agitation and altercation |
| Certified Nurse Assistant C | Certified Nurse Assistant | Performed incontinent care with infection control deficiencies |
| Nurse Assistant D | Nurse Assistant | Performed incontinent care with infection control deficiencies |
| Nurse Assistant J | Nurse Assistant | Performed incontinent care with infection control deficiencies |
| Certified Nurse Assistant K | Certified Nurse Assistant | Performed incontinent care with infection control deficiencies |
| Director of Therapy | Director of Therapy | Provided expert opinion on proper resident repositioning |
| Administrator | Administrator | Responsible for facility oversight and abuse reporting |
Inspection Report
Plan of Correction
Census: 6
Deficiencies: 10
Date: Apr 16, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Troy Manor, a residential care facility, following an inspection conducted on 04/16/2024.
Findings
The facility was found deficient in multiple areas including failure to provide visual notification devices for hearing-impaired residents, incomplete tuberculosis screening for staff and residents, lack of required personnel records, failure to maintain resident admission records including preferred funeral director and dentist, offensive odors in the facility, and inadequate written notice of discharge for residents.
Deficiencies (10)
19 CSR 30-86.012(24) Deaf Residents-Path to Safety: The facility failed to provide a visual notification device for fire safety for one hearing-impaired resident and lacked a policy for use of such devices.
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure required two-step tuberculosis tests were completed for sampled employees and residents and lacked a policy for TB testing.
19 CSR 30-86.047(20)(I) Personnel Record-physician statement: The facility failed to maintain signed statements by a licensed physician or designee for five sampled staff indicating ability to work in a long-term care facility.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually: The facility failed to complete semi-annual community based assessments for one resident.
19 CSR 30-86.047(58)(A) Resident Record Admission Info: The facility failed to ensure resident records included preferred funeral director and dentist for six residents.
19 CSR 30-87.020(11) No Deodorizers/Sprays to Eliminate Odors: The facility failed to ensure it was free from offensive odors in the assisted living hallway.
19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: The facility failed to provide written 30-day notice of discharge for two residents and failed to provide written notice of discharge to residents and families.
19 CSR 30-88.010(16) Reasons to Transfer/Discharge: The facility failed to ensure appropriate regulatory reasons for discharge for two residents.
19 CSR 30-88.010(17) Discharge Appeal Rights: The facility failed to provide residents with full and adequate notice of their rights to a hearing before discharge.
19 CSR 30-88.010(36) Personal Clothing/Possessions: The facility failed to ensure personal inventory lists were completed for three residents.
Report Facts
Facility census: 6
Sampled residents: 6
Sampled employees: 5
Deficiencies cited: 10
Inspection Report
Routine
Census: 95
Deficiencies: 5
Date: Apr 9, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards related to activities of daily living assistance, fall prevention, resident safety, and proper use of mobility aids.
Findings
The facility failed to provide adequate assistance with activities of daily living for several residents, including oral hygiene and bathing. Staff did not consistently follow care plans for fall prevention, proper footwear, wheelchair safety, and supervision to prevent elopement and resident-to-resident aggression. Several residents were found with poor hygiene, unsafe wheelchair transport, and lack of fall mats. An elopement incident occurred due to inadequate staff oversight.
Deficiencies (5)
Failure to ensure residents received needed assistance with activities of daily living including oral hygiene and bathing.
Failure to ensure safety of residents by following fall prevention care plans, including proper footwear and fall mat use.
Failure to provide adequate supervision to prevent elopement of a resident.
Failure to protect residents from verbal and physical aggression by another resident.
Failure to ensure proper wheelchair safety including placement of foot pedals during transport.
Report Facts
Residents affected: 5
Residents affected: 6
Facility census: 95
Elopement risk assessment score: 0
Elopement risk assessment score: 2
Elopement risk assessment score: 0
Distance traveled during elopement: 1
Time away from desk: 15
Fall incidents: 2
Fall incident: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding Resident #28's shower refusals and behaviors |
| CNA R | Certified Nurse Assistant | Interviewed regarding shower assistance and documentation for Resident #28 |
| NA D | Nurse Aide | Interviewed regarding oral care and denture care for Resident #34 and Resident #4 |
| NA E | Nurse Aide | Interviewed regarding denture care and shower assistance for Resident #34 and Resident #4 |
| LPN S | Licensed Practical Nurse | Interviewed about oral care frequency for Resident #1 |
| Director of Nursing | Director of Nursing | Interviewed about care expectations, shower schedules, and fall prevention protocols |
| CMT Y | Certified Medication Technician | Interviewed regarding elopement incident and leaving 600 hall desk unattended |
| CNA BB | Certified Nurse Assistant | Interviewed about locating missing residents during elopement incident |
| CMT Z | Certified Medication Technician | Interviewed about assisting in search and return of residents during elopement incident |
| Resident #300 | Interviewed about altercation with Resident #79 | |
| Resident #79 | Interviewed about altercation with Resident #300 | |
| CNA Q | Certified Nurse Assistant | Interviewed about footwear for Resident #19 and wheelchair safety |
| CMT I | Certified Medication Technician | Interviewed about pushing Resident #4 in wheelchair without foot pedals |
Inspection Report
Census: 95
Deficiencies: 15
Date: Apr 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs for call light accessibility, failure to honor resident preferences for waking times, failure to provide timely transfer and bed hold notices, incomplete care plans, inadequate assistance with activities of daily living, insufficient staffing on the special care unit, improper medication administration, unsafe use of bed rails, improper infection control practices, and food service deficiencies.
Deficiencies (15)
Failure to ensure call lights were within reach for residents with physical limitations and failure to provide alternative means for contacting staff.
Failure to honor resident rights and preferences regarding wake-up times, resulting in residents being awakened too early without consideration of their wishes.
Failure to provide timely written notification to residents and representatives regarding hospital transfers and bed hold policies.
Failure to develop and implement comprehensive, person-centered care plans addressing resident depression, rejection of care, and use of antidepressants.
Failure to provide adequate assistance with activities of daily living including oral care, bathing, and incontinence care for multiple residents.
Failure to provide meaningful activities and socialization opportunities for residents, especially on the special care unit, with lack of scheduled activities and insufficient activity staff.
Failure to ensure resident safety by not following fall prevention care plans, improper wheelchair use without foot pedals, and failure to provide protective oversight to prevent elopement and resident altercations.
Failure to obtain physician orders for oxygen use, maintain oxygen equipment properly, and ensure oxygen delivery as ordered.
Failure to assess resident need for bed rails, obtain informed consent, and conduct regular inspections for entrapment hazards.
Failure to provide adequate nursing staff on the special care unit to meet resident needs and provide protective oversight.
Failure to ensure nurse aides completed certified nurse aide training within four months of employment.
Failure to prevent significant medication errors when a resident received an incorrect dose of trazodone for ten days.
Failure to provide pureed food items in the proper form consistent with physician orders and facility policy.
Failure to maintain food service areas and equipment in a sanitary condition, including improper storage of scoops, unsealed food containers, dirty microwaves, and unshielded freezer light bulbs.
Failure to implement infection prevention and control practices including proper disinfection of multi-resident use glucometers, hand hygiene, glove use, and incontinence care.
Report Facts
Facility census: 95
Deficiency count: 17
Medication error duration: 10
Staff hire date: Jul 5, 2021
Staff hire date: Jan 16, 2023
Staff hire date: Feb 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Named in medication error and glucometer cleaning deficiency |
| NA E | Nurse Aide | Named in staffing and CNA training deficiencies |
| NA N | Nurse Aide | Named in CNA training deficiency |
| NA O | Nurse Aide | Named in CNA training deficiency |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including staffing, infection control, and care plans |
| Administrator | Administrator | Interviewed regarding staffing and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding food preparation and kitchen sanitation deficiencies |
| NA D | Nurse Aide | Named in infection control and staffing deficiencies |
| CMT Y | Certified Medication Technician | Named in resident elopement incident |
Inspection Report
Plan of Correction
Census: 5
Deficiencies: 7
Date: Feb 21, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and building maintenance regulations, including fire drills, exit sign illumination, fire alarm system testing, dryer venting, wastebasket requirements, building maintenance, and electrical wiring.
Findings
The facility failed to maintain proper records of fire drills, maintain exit sign illumination, test and maintain the fire alarm system semi-annually, ensure clothes dryers were vented properly, use fire-resistant wastebaskets, maintain the building in good repair, and properly maintain electrical wiring. These deficiencies affected all 5 residents present during the inspection.
Deficiencies (7)
19 CSR 30-86.022(5)(E) Fire Drill Records. The facility failed to keep records of all fire drills including time, date, personnel, length, and narrative. Records were missing for 10 of the last 12 months.
19 CSR 30-86.022(8)(C) Exit Sign-Illumination. The facility failed to maintain main exit lighting in good repair; the exit light in the south hall did not illuminate when tested.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to test and maintain the fire alarm system semi-annually as required by NFPA 72, 1999 edition.
19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps. The facility failed to ensure electric clothes dryers were vented to the outside; dryers vented with holes allowing venting inside.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to use only metal or fire-resistant rated wastebaskets; plastic and metal wastebaskets were observed.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to maintain the building in good repair; three ceiling tiles were missing and there was a roof leak causing water damage.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to properly maintain electrical wiring; a six-way plug adapter was used and no current two-year electrical inspection documentation was available.
Report Facts
Facility census: 5
Months missing fire drill records: 10
Ceiling tiles missing: 3
Inspection Report
Plan of Correction
Census: 91
Deficiencies: 2
Date: Sep 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding pressure ulcer prevention and treatment at Troy Manor nursing facility.
Findings
The facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for two residents, resulting in worsening wounds. Documentation and implementation of wound care orders were incomplete or missing, and staff failed to follow consultant wound care orders.
Deficiencies (2)
F686: The facility failed to provide care consistent with professional standards to prevent and treat pressure ulcers, including assessment, monitoring, dressing changes, and following physician and consultant orders for two residents.
A4083: Facilities shall keep residents free from avoidable pressure sores and provide adequate treatment. This regulation was not met as evidenced by Class II deficiency related to F686.
Report Facts
Facility census: 91
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Sep 20, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in residents.
Complaint Details
The complaint investigation found substantiated failures in pressure ulcer care for Residents #5 and #7, including failure to follow physician orders, inadequate wound assessments, and missed dressing changes, resulting in wound deterioration and actual harm.
Findings
The facility failed to consistently and accurately assess, monitor, and treat pressure ulcers for two residents, resulting in worsening wounds and actual harm. Staff did not implement new wound care orders for seven days, failed to measure wounds regularly, and missed dressing changes, leading to deterioration of pressure ulcers.
Deficiencies (1)
Failure to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers, including failure to assess, monitor, and change dressings as ordered.
Report Facts
Census: 91
Wound measurements: 6
Wound measurements: 7
Wound measurements: 5.5
Braden Scale score: 19
Braden Scale score: 12
Deficiency duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding failure to transcribe wound care orders and staff not following orders | |
| Consultant Wound Care Nurse Practitioner | Interviewed about wound deterioration and lack of dressing changes | |
| LPN I | Licensed Practical Nurse | Responsible for dressing changes for Resident #7; admitted to missed dressing changes and documentation errors |
| LPN C | Licensed Practical Nurse | Reported charge nurses did not measure wounds and wound nurse measured wounds when working |
| LPN A | Licensed Practical Nurse / Acting Wound Nurse | Performed wound assessments weekly and acted as wound nurse during absence of regular wound nurse |
| Director of Nursing (DON) | Provided expectations for wound assessments, measurements, and dressing changes | |
| Administrator | Stated expectation for staff to follow physician orders regarding wound care |
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
A COVID-19 focused emergency preparedness survey and an abbreviated infection control and notice before transfer/discharge survey were conducted at Troy Manor on August 31, 2023.
Findings
The facility was found to be in compliance with COVID-19 emergency preparedness requirements. However, deficiencies were identified related to failure to provide proper notice before transfer/discharge for one resident and failure to maintain an effective infection prevention and control program, including inadequate staff compliance with PPE use and infection control procedures.
Deficiencies (2)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide a written notice of discharge with required information to one resident and/or resident representative before transfer, violating timing and content requirements.
F880 Infection Prevention & Control: The facility failed to ensure staff changed gloves and washed hands appropriately, failed to implement a surveillance plan for communicable diseases, and did not ensure proper PPE use and infection control procedures during a COVID-19 outbreak.
Report Facts
Facility census: 86
COVID-19 positive cases: 65
COVID-19 positive residents: 41
COVID-19 positive staff: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #16 | Named in transfer/discharge notice deficiency | |
| Registered Nurse (RN) P | Registered Nurse | Involved in resident incident and transfer |
| Director of Nursing (DON) | Director of Nursing | Notified of resident incident and transfer; involved in infection control findings |
| Certified Nurse Aide (CNA) Q | Certified Nurse Aide | Observed providing perineal care with infection control issues |
| Certified Nurse Aide (CNA) I | Certified Nurse Aide | Observed providing perineal care with infection control issues |
| Certified Nurse Aide (CNA) M | Certified Nurse Aide | Observed providing perineal care with infection control issues |
| Nurse Aide (NA) N | Nurse Aide | Observed providing perineal care with infection control issues |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Observed wearing mask improperly |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Reported mask wearing and COVID-19 testing practices |
| Certified Nursing Assistant (CNA) E | Certified Nursing Assistant | Reported mask wearing and COVID-19 testing practices |
| Nursing Assistant (NA) D | Nursing Assistant | Reported mask wearing and COVID-19 testing practices |
| Licensed Practical Nurse (LPN) H | Licensed Practical Nurse | Reported COVID-19 testing and mask wearing practices |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Reported mask wearing and COVID-19 testing practices |
| Director of Nurses (DON) | Director of Nurses | Reported infection control and COVID-19 testing practices |
| Social Services Director (SSD) assistant | Social Services Director assistant | Reported on infection control tracking |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 6
Date: Aug 31, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely and proper discharge notification to a resident transferred to the hospital and denied re-admission, as well as concerns about infection prevention and control practices during a COVID-19 outbreak.
Complaint Details
The complaint investigation was triggered by a failure to provide a written discharge notice to Resident #16 and/or their representative when the facility transferred the resident to the hospital and denied re-admission. The facility census was 86. The investigation also included infection control deficiencies during a COVID-19 outbreak affecting many residents and staff.
Findings
The facility failed to provide a written discharge notice to a resident and/or representative when transferring to the hospital and denying re-admission. Additionally, the facility failed to ensure proper infection prevention and control practices, including glove changing, hand washing, PPE use, COVID-19 case tracking, staff screening, and proper disposal of biohazardous waste during a COVID-19 outbreak. Multiple staff failed to wear masks properly, and COVID-19 testing and screening procedures were inadequately monitored and documented.
Deficiencies (6)
Failed to provide timely written discharge notice to resident and/or representative upon transfer and denial of re-admission.
Failed to ensure staff changed gloves and washed hands as indicated during care provision.
Failed to implement surveillance plan for identifying, tracking, and monitoring communicable diseases including COVID-19 among residents and staff.
Failed to ensure staff wore masks properly and used appropriate PPE during COVID-19 testing and outbreak.
Failed to ensure unvaccinated staff were screened upon entrance and failed to monitor and track screenings.
Failed to ensure proper disposal of biohazardous materials (PPE) in red biohazard bags; PPE disposed in regular trash.
Report Facts
Facility census: 86
COVID-19 positive cases: 65
COVID-19 screenings recorded: 7
COVID-19 testing frequency: 3
Resident #16 transfer time: Exact admission and discharge dates redacted
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN P | Registered Nurse | Involved in incident where resident punched nurse; notified Director of Nursing |
| Director of Nursing | Director of Nursing (DON) | Notified of resident incident; provided statements on discharge notice policies and infection control expectations |
| CNA Q | Certified Nurse Aide | Observed providing perineal care without proper glove changes and barrier use |
| CNA I | Certified Nurse Aide | Observed providing perineal care without proper glove changes and barrier use |
| CNA M | Certified Nurse Aide | Observed providing perineal care without proper glove changes and hand washing |
| NA N | Nurse Aide | Observed providing perineal care without proper glove changes and hand washing |
| CMT F | Certified Medication Technician | Observed wearing broken N95 mask; admitted not vaccinated and not screened |
| LPN A | Licensed Practical Nurse | Observed wearing N95 mask improperly; acknowledged improper use |
| Maintenance Director | Maintenance Director | Admitted not vaccinated; described COVID-19 testing and screening practices |
| Housekeeping/Floor Tech O | Housekeeping/Floor Technician | Described cleaning practices and improper disposal of PPE waste |
| Housekeeping and Laundry Supervisor | Housekeeping and Laundry Supervisor | Described expectations for cleaning and disposal of COVID-19 waste |
| CNA Q | Certified Nurse Aide | Described COVID-19 testing and copier cleaning practices |
| LPN H | Licensed Practical Nurse | Performed COVID-19 testing wearing mask and gloves but no gown or face shield |
| LPN B | Licensed Practical Nurse | Performed COVID-19 testing wearing mask and gloves |
| Director of Nurses | Director of Nurses (DON) | Provided infection control expectations and COVID-19 testing and screening policies |
| Social Services Director Assistant | Social Services Director Assistant | Described staff COVID-19 screening practices and lack of tracking |
| Corporate Quality Assurance Nurse Consultant | Corporate Quality Assurance Nurse Consultant | Provided guidance on infection tracking and COVID-19 policies |
| Administrator | Facility Administrator | Provided statements on mask use, COVID-19 testing, screening, and waste disposal policies |
| LPN C | Licensed Practical Nurse | Described COVID-19 testing and screening practices |
| CNA E | Certified Nursing Assistant | Described COVID-19 testing and screening practices |
| LPN J | Licensed Practical Nurse | Described COVID-19 testing and screening practices |
| Nursing Assistant D | Nursing Assistant | Described COVID-19 testing and screening practices |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
Annual survey inspection of Troy Manor nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Apr 26, 2023
Visit Reason
The inspection was conducted due to complaints regarding significant medication errors involving two residents, including incorrect transcription and administration of medications.
Complaint Details
The visit was complaint-related due to allegations of medication errors involving Residents #1 and #12. The immediate jeopardy began on 2023-01-06 and was removed on 2023-04-25 after corrective actions were implemented.
Findings
The facility failed to ensure residents were free from significant medication errors, including a transcription error that caused Resident #1 to receive haloperidol instead of metoprolol for 97 days, resulting in adverse health effects and hospital transfer. Resident #12 received extra doses of Ozempic due to a transcription error. The facility's policies and fail-safes failed to prevent these errors.
Deficiencies (2)
Staff failed to correctly transcribe an admission order for metoprolol tartrate, administering haloperidol instead to Resident #1 for 97 days, causing lethargy, difficulty swallowing, and slurred speech requiring hospital transfer.
Staff failed to correctly transcribe an order for Ozempic, resulting in Resident #12 receiving two additional doses when the medication was to be administered weekly.
Report Facts
Duration of incorrect medication administration: 97
Facility census: 87
Medication dosage: 50
Medication dosage: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Admitted to transcription error entering haloperidol instead of metoprolol. |
| RN K | Registered Nurse | Investigated medication error for Resident #1's haloperidol order. |
| RN F | Registered Nurse | Discovered transcription error for Resident #12's Ozempic order and corrected it. |
| Medical Director | Physician | Oversaw care of Residents #1 and #12, aware of medication errors and related adverse effects. |
| Administrator | Notified of immediate jeopardy and medication errors, involved in corrective actions. | |
| Consultant Pharmacist | Conducted pharmacy reviews including for Resident #1, did not identify the transcription error. |
Inspection Report
Plan of Correction
Census: 84
Deficiencies: 2
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically related to comprehensive care plans and resident care following a change in condition resulting in hospitalization for sepsis.
Findings
The facility failed to assess and document care according to professional standards for one resident who experienced a change in condition leading to hospitalization. Documentation and communication deficiencies were noted regarding the resident's condition, medication administration, and response to treatment.
Deficiencies (2)
F658 Services Provided Meet Professional Standards: The facility failed to assess and document care according to professional standards for one resident with a change in condition resulting in hospitalization for sepsis.
A4075 Nursing Care per Resident Condition: 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 in F658.
Report Facts
Facility census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding resident condition assessment and documentation |
| Administrator | Administrator | Interviewed regarding documentation and assessment following resident fall and change in condition |
| Licensed Practical Nurse A | Licensed Practical Nurse | Charge nurse on 3/28/23, involved in resident care and monitoring |
| Restorative Assistant | Restorative Assistant | Interviewed about resident condition on 3/28/23 |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to assess and document assessments according to professional standards for one resident who experienced a change in condition resulting in hospitalization for sepsis.
Complaint Details
The complaint investigation found that staff failed to assess and document the resident's condition changes, delayed physician notification, and delayed emergent care, contributing to the resident's decline and hospitalization for sepsis. The deficiency was substantiated with minimal harm and affected a few residents.
Findings
The facility failed to properly assess and document changes in the resident's condition, including response to medication changes and post-fall assessments. Staff delayed notifying the physician and obtaining emergent care, resulting in the resident's decline and hospitalization for sepsis with minimal harm.
Deficiencies (1)
Failure to assess and document assessments according to professional standards for a resident with a change in condition resulting in hospitalization for sepsis.
Report Facts
Facility census: 84
Blood pressure readings: 213
Blood pressure readings: 93
Blood pressure readings: 53
Blood pressure readings: 40
Oxygen saturation: 80
White Blood Cell count: 6.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Charge nurse on 3/28/23 who monitored resident and called physician |
| Director of Nursing | Director of Nursing | Provided interview regarding staff responsibilities and resident decline |
| Administrator | Administrator | Provided interview regarding documentation and emergent care expectations |
| Resident's physician | Physician | Provided interview regarding resident's decline and sepsis diagnosis |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Dec 21, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident's elopement and supervision during smoking breaks.
Complaint Details
The complaint investigation found the violation to be at an imminent danger Class I level initially, later lowered to Class II after corrective actions. The resident was found walking along a busy highway after leaving the facility unsupervised during a smoking break.
Findings
The facility failed to ensure adequate supervision of a resident at high risk for elopement during smoking breaks, resulting in the resident leaving the facility undetected and being found by police. The facility implemented corrective actions to address the supervision deficiencies.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision to Resident #1, who had a history of elopement and mental illness, allowing the resident to leave the facility grounds undetected during a scheduled smoking break.
A4074 Protective Oversight, Voluntary Leave: The facility did not meet the requirement for protective oversight and supervision for residents on voluntary leave, contributing to the risk of elopement.
Report Facts
Facility census: 92
Temperature: 56
Speed limit: 60
Resident count during smoke break: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Responsible for supervising residents during smoking breaks; failed to ensure Resident #1 returned inside | |
| CNA B | Certified Nurse Aide | Assisted residents during smoking break and reported Resident #1 missing |
| CNA C | Certified Nurse Aide | Noticed Resident #1 missing and alerted charge nurse |
| RN D | Registered Nurse | Notified administrator and Director of Nursing about missing resident and called 911 |
| Administrator | Notified of Immediate Jeopardy and involved in corrective action planning | |
| Director of Nursing | Notified of missing resident and involved in corrective action planning |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 5
Date: Oct 27, 2022
Visit Reason
The inspection was conducted in response to allegations of sexual abuse between two residents at the facility.
Complaint Details
The complaint investigation was substantiated as the facility failed to protect residents from sexual abuse and failed to report the incident timely to the state survey agency.
Findings
The facility failed to protect one resident from sexual abuse by another resident. The facility also failed to report the incident to the state survey agency within the required timeframe and did not ensure sufficient nursing staff to meet residents' needs.
Deficiencies (5)
F600 Freedom from Abuse and Neglect: The facility failed to protect one resident from sexual abuse by another resident and did not report the incident to the state survey agency within the required timeframe.
F609 Reporting of Alleged Violations: The facility failed to report a known incident of resident to resident sexual abuse within two hours as required by regulations.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure four residents received necessary assistance with activities of daily living to maintain good grooming and personal hygiene.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision to one resident with a history of elopement, allowing the resident to leave the facility unattended.
F725 Sufficient Nursing Staff: The facility failed to provide sufficient nursing staff to meet the needs of residents, including those on the Special Care Unit.
Report Facts
Facility census: 84
Sample size for review: 12
Residents requiring assistance with ADLs: 4
Residents requiring assistance with bathing: 60
Residents totally dependent on staff for bathing: 13
Residents requiring assistance with transfers: 29
Residents requiring assistance with toileting: 12
Residents requiring assistance with eating: 32
Residents occasionally or frequently incontinent of bladder: 55
Residents occasionally or frequently incontinent of bowel: 24
Inspection Report
Plan of Correction
Census: 106
Deficiencies: 3
Date: Dec 27, 2021
Visit Reason
The inspection was conducted to investigate allegations of abuse, neglect, and misappropriation of resident property at Troy Manor nursing facility.
Findings
The facility failed to ensure a resident was free from verbal abuse by a Certified Nurse Assistant (CNA) who used vulgar language and refused to assist the resident. Additionally, the facility failed to prevent misappropriation of narcotic medications by a Registered Nurse (RN). The CNA was terminated and the RN was terminated due to medication errors and policy violations.
Deficiencies (3)
F 600: The facility failed to ensure freedom from abuse and neglect as evidenced by a CNA verbally abusing a resident and refusing to assist the resident. The CNA was terminated and the deficiency was corrected.
F 602: The facility failed to prevent misappropriation of resident property when an RN misappropriated residents' narcotic medications. The RN was terminated due to medication errors and policy violations.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. This deficiency was linked to F 602.
Report Facts
Facility census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Assistant | Named in verbal abuse and neglect findings |
| RN D | Registered Nurse | Named in narcotic medication misappropriation findings |
Inspection Report
Life Safety
Census: 5
Deficiencies: 4
Date: Apr 15, 2021
Visit Reason
The inspection was a fire safety portion of the licensure inspection conducted on 04/15/2021 to assess compliance with fire alarm system testing, maintenance, hazardous area requirements, and electrical wiring certifications.
Findings
The facility failed to test and maintain the complete fire alarm system as required by NFPA 72, 1999 edition. Hazardous rooms were not separated by a one-hour fire barrier, and the facility lacked a current electrical wiring certification.
Deficiencies (4)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. No semi-annual fire alarm system inspection had been conducted.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications. The facility failed to have inspections and written certifications of the complete fire alarm system completed by an approved qualified service representative at least annually.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to ensure hazardous rooms were separated by a one-hour fire barrier from the rest of the facility. Doors to hazardous areas were hollow core and lacked smoke detectors.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to complete a current electrical wiring certification. The last certification was completed on 02/15/2019.
Report Facts
Facility census: 5
Inspection Report
Routine
Deficiencies: 0
Date: Dec 9, 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
Abbreviated Survey
Deficiencies: 0
Date: Nov 17, 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
Census: 111
Capacity: 111
Deficiencies: 17
Date: Oct 28, 2020
Visit Reason
Routine state inspection of Troy Manor nursing home covering multiple regulatory compliance areas including resident care, safety, nutrition, infection control, and staffing.
Findings
The facility was cited for multiple deficiencies including failure to notify responsible parties of resident condition changes, failure to prevent and investigate resident-to-resident sexual abuse, failure to report abuse allegations timely, inadequate care planning, medication administration errors, insufficient personal care and hygiene assistance, inadequate restorative therapy, insufficient staffing levels, food service issues including improper food temperatures and portion sizes, infection control lapses during COVID-19, and failure to allow hospice access.
Deficiencies (17)
Failure to notify resident's family and physician of condition changes for Resident #13.
Failure to prevent and investigate sexual abuse involving multiple residents including Resident #33 and Resident #51.
Failure to report allegations of abuse and sexual abuse to state agency within required timeframes.
Failure to provide written notice of transfer to resident or representative and ombudsman for hospital transfers.
Failure to notify residents and representatives of bed hold policy and duration at time of hospital transfer.
Failure to develop and implement comprehensive care plans addressing specific resident needs including dialysis access, urostomy care, sexual behaviors, and restorative therapy.
Failure to provide adequate personal care and hygiene assistance including showers, shaving, nail care, and timely response to call lights for multiple residents.
Failure to provide restorative therapy as ordered due to staffing shortages and restorative aide being pulled to floor duties.
Failure to provide sufficient nursing staff to meet resident needs including personal care, restorative therapy, and timely call light response.
Medication administration errors including failure to discontinue expired orders, failure to administer ordered eye drops, and breaking extended release tablets.
Failure to provide nourishing, palatable, and appropriate diet options consistent with resident preferences including vegetarian diet and alternate meal choices.
Failure to maintain food safety including improper food temperatures, uncovered food items, unclean food preparation equipment, and poor kitchen sanitation.
Failure to maintain covered garbage dumpsters and proper waste disposal.
Failure to allow hospice providers access to provide care and failure to establish new hospice contracts during COVID-19 pandemic.
Failure to maintain infection control program including incomplete COVID-19 symptom surveillance, failure to isolate symptomatic residents, improper PPE use, and failure to maintain social distancing.
Failure to provide appropriate perineal care and hand hygiene by staff during incontinent care.
Failure to assess and monitor bed rails and mattresses for entrapment risks and failure to complete entrapment assessments.
Report Facts
Medication administration opportunities: 27
Resident census: 111
Weight loss: 18.9
Showers received: 5
Showers scheduled: 8
Showers received: 5
Showers scheduled: 12
Showers received: 4
Showers scheduled: 12
Showers received: 3
Showers scheduled: 12
Showers received: 2
Showers scheduled: 12
Showers received: 3
Showers scheduled: 12
Restorative therapy sessions: 4
Restorative therapy sessions: 1
Restorative therapy sessions: 15
Restorative therapy sessions: 0
Restorative therapy sessions: 0
Restorative therapy sessions: 0
Staffing levels: 3
Staffing levels: 2
Staffing levels: 11
Staffing levels: 2
Staffing levels: 2
Staffing levels: 9
Staffing levels: 8
In-service education hours: 12
In-service education hours: 0
Medication administration error rate: 11.11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN K | Licensed Practical Nurse | Named in medication administration and staffing findings. |
| CNA H | Certified Nurse Assistant | Named in personal care and food service findings. |
| CMT I | Certified Medication Technician | Named in medication administration and food service findings. |
| LPN C | Licensed Practical Nurse | Named in medication administration and elopement findings. |
| LPN V | Licensed Practical Nurse | Named in resident-to-resident sexual abuse findings. |
| CMT U | Certified Medication Technician | Named in resident-to-resident sexual abuse findings. |
| DON | Director of Nursing | Named in multiple findings including staffing, infection control, medication, and abuse. |
| Administrator | Facility Administrator | Named in multiple findings including hospice, staffing, infection control, and abuse. |
| Dietary Staff DD | Dietary Staff | Named in food service and sanitation findings. |
| Dietary Staff EE | Dietary Staff | Named in food service and sanitation findings. |
| Dietary Manager | Dietary Manager | Named in food service and sanitation findings. |
| CNA JJ | Certified Nurse Assistant | Named in infection control and elopement findings. |
| CNA SS | Certified Nurse Assistant | Named in infection control and elopement findings. |
| LPN I | Licensed Practical Nurse | Named in staff to resident abuse allegation. |
| CNA MM | Certified Nurse Assistant | Named in staff to resident abuse allegation. |
| CNA NN | Certified Nurse Assistant | Named in staff to resident abuse allegation. |
| CMT H | Certified Medication Technician | Named in medication administration and infection control findings. |
| LPN J | Licensed Practical Nurse | Named in medication administration and staffing findings. |
| LPN R | Licensed Practical Nurse | Named in resident-to-resident sexual abuse and medication administration findings. |
| CNA T | Certified Nurse Assistant | Named in personal care and restorative therapy findings. |
| CNA UU | Certified Nurse Assistant | Named in personal care and staffing findings. |
| CNA PP | Certified Nurse Assistant | Named in personal care and infection control findings. |
| CNA F | Certified Nurse Assistant | Named in personal care and infection control findings. |
| LPN M | Licensed Practical Nurse | Named in infection control findings. |
| RN N | Registered Nurse | Named in infection control findings. |
| RN VV | Registered Nurse | Named in elopement findings. |
| LPN CC | Licensed Practical Nurse | Named in elopement findings. |
| CNA JJ | Certified Nurse Assistant | Named in elopement findings. |
| Housekeeper RR | Housekeeper | Named in elopement findings. |
| RN WW | Registered Nurse | Named in hospice findings. |
| HR Staff | Human Resources Staff | Named in CNA in-service training findings. |
| Corporate RN | Corporate Registered Nurse | Named in CNA in-service training findings. |
Inspection Report
Life Safety
Census: 111
Capacity: 130
Deficiencies: 14
Date: Oct 28, 2020
Visit Reason
The inspection was conducted as part of an emergency preparedness and life safety code investigation at Troy Manor nursing facility.
Findings
The facility was found deficient in emergency preparedness training and testing, fire safety code compliance including building construction, fire doors, emergency lighting, sprinkler system maintenance, and fire drills. Several deficiencies had the potential to affect residents and staff in multiple smoke compartments.
Deficiencies (14)
E036 Emergency Preparedness Training and Testing: The facility failed to ensure staff were trained on the emergency preparedness plan upon implementation and annually thereafter.
K161 Building Construction Type and Height: The facility failed to maintain the barrier between the first floor and attic with a one-hour fire resistance rating due to unsealed gaps around conduits and wires.
K222 Egress Doors: The facility failed to ensure one designated emergency exit door with delayed egress locking hardware opened freely and had appropriate signage.
K291 Emergency Lighting: The facility failed to conduct annual 90-minute functional testing of battery-powered emergency lighting throughout the facility.
K321 Hazardous Areas - Enclosure: The facility failed to ensure hazardous areas were protected by self-closing or automatic-closing doors, affecting 20 residents.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler system repairs and inspections were completed and documented, including monthly and quarterly inspections.
K363 Corridor Doors: The facility failed to maintain corridor doors to resist smoke passage and ensure positive latching hardware.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier walls and dampers, allowing unsealed openings and untested dampers.
K374 Doors - Smoke Barrier: The facility failed to maintain smoke barrier doors with proper self-closing and latching, and allowed a 1 inch gap between paired doors.
K741 Smoking Regulations: The facility failed to maintain two designated smoking areas and provide functional self-closing containers for cigarette disposal.
K918 Electrical Systems - Essential Electric System: The facility failed to test and maintain the emergency generator monthly and maintain documentation.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure proper use and inspection of extension cords and electrical receptacles.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to adequately secure oxygen cylinders and separate empty cylinders from full ones.
K932 Features of Fire Protection - Other: The facility failed to maintain areas behind dryers free of lint buildup and debris, creating a fire hazard.
Report Facts
Facility Capacity: 130
Census: 111
Battery-powered emergency lighting units: 10
Fire drills frequency: 4
Fire drills conducted: 1
Smoke compartments: 9
Residents potentially affected: 111
Inspection Report
Complaint Investigation
Census: 111
Capacity: 111
Deficiencies: 10
Date: Oct 20, 2020
Visit Reason
The inspection was conducted due to complaints alleging failure to properly notify the physician of a resident's condition change and allegations of abuse and neglect involving multiple residents.
Complaint Details
The complaint investigation was substantiated. The facility was found deficient in multiple areas related to failure to notify physicians, abuse and neglect prevention, investigation and reporting, resident rights, care planning, restorative services, environment safety, nutrition, and bed rail use.
Findings
The facility failed to notify the physician timely about a resident's condition change and did not properly investigate and prevent abuse and neglect incidents involving residents. The facility also failed to implement adequate care plans and monitoring for affected residents.
Deficiencies (10)
F 580: The facility failed to notify the physician timely of a resident's condition change, resulting in delayed treatment and monitoring.
F 600: The facility failed to prevent abuse and neglect, including sexual abuse, of multiple residents and did not properly investigate or report incidents.
F 604: The facility failed to ensure residents' rights to be free from abuse, neglect, and exploitation, including failure to protect from physical and sexual abuse.
F 609: The facility failed to report alleged abuse and neglect incidents timely and failed to conduct thorough investigations.
F 623: The facility failed to provide proper notice before transfer or discharge of residents, including failure to notify the resident representative and ombudsman.
F 656: The facility failed to develop and implement comprehensive care plans addressing residents' physical, mental, and psychosocial needs.
F 688: The facility failed to ensure residents received restorative nursing services and appropriate physical therapy to maintain mobility and prevent decline.
F 689: The facility failed to maintain a safe environment, including failure to prevent resident elopement and wandering, and inadequate supervision.
F 692: The facility failed to provide adequate nutrition and hydration to residents, including failure to monitor weight loss and provide appropriate dietary interventions.
F 700: The facility failed to ensure bed rails were properly assessed and used according to manufacturer specifications and resident needs.
Report Facts
Facility census: 111
Deficiency tags cited: 10
Inspection Report
Plan of Correction
Census: 7
Deficiencies: 1
Date: Feb 10, 2020
Visit Reason
The inspection was conducted to assess compliance with fire safety regulations regarding wastebasket requirements.
Findings
The facility failed to ensure all trash cans were solid metal or UL- or FM-fire resistant rated. Wastebaskets in several resident rooms were unapproved and not fire resistant.
Deficiencies (1)
19 CSR 30-86.022(15)(A) Wastebaskets must be metal or UL/FM-fire-resistant rated. The facility used non-approved trash cans in resident rooms 607, 610, 609, 611, and 618.
Report Facts
Facility census: 7
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 2
Date: Oct 22, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to pressure ulcer prevention and treatment at Troy Manor nursing facility.
Complaint Details
The visit was complaint-related, triggered by concerns about pressure ulcer care. The deficiencies were substantiated as the facility failed to prevent and treat pressure ulcers adequately.
Findings
The facility failed to prevent and properly treat pressure ulcers in a resident, resulting in deterioration of wounds and hospitalization. Documentation and treatment orders were incomplete or not followed, and the resident's care plan lacked interventions for pressure ulcer prevention.
Deficiencies (2)
F686 Skin Integrity: The facility failed to ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards, resulting in wound deterioration and hospitalization.
A4082 Pressure Sore Prevention/Treatment: The facility did not keep residents free from avoidable pressure sores and failed to provide adequate treatment for existing sores.
Report Facts
Facility census: 107
Braden Scale score: 10
Pressure ulcer measurements: Multiple wound measurements detailed in centimeters (e.g., 8cm x 10cm, 4.5cm x 0.5cm)
Antibiotic dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Yost | Administrator | Signed the report and plan of correction |
| Santyl | Debriding agent (not a person but referenced in treatment) | Recommended by MDS coordinator for wound care |
| LPN B | Licensed Practical Nurse | Reported resident's wound deterioration and medication administration issues |
| LPN C | Licensed Practical Nurse | Described procedures for verbal/telephone treatment orders and documentation |
| Director of Nursing | Discussed resident's wound status and care plan | |
| Wound Care Plus Nurse Practitioner | Provided assessment and treatment orders for resident's wounds |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Date: Jun 20, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident at Troy Manor.
Complaint Details
Complaint # MO156455 regarding a resident elopement incident where the resident left the facility without staff knowledge and was found approximately 1.3 miles away. The complaint was substantiated based on investigation findings.
Findings
The facility failed to provide adequate supervision and protective oversight for a resident at risk of elopement, resulting in the resident leaving the premises without staff knowledge. The investigation revealed lapses in staff awareness and response, including failure to conduct timely face-to-face checks and incomplete elopement prevention measures.
Deficiencies (2)
F689: The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision to prevent resident elopement. Staff did not conduct thorough searches or timely face-to-face checks, and the resident left the facility without staff knowledge.
A4073: The facility did not meet the requirement for protective oversight and supervision for residents on voluntary leave, lacking procedures to inquire about the resident's whereabouts and estimated length of absence.
Report Facts
Facility census: 109
Inspection Report
Plan of Correction
Census: 99
Deficiencies: 2
Date: Apr 4, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to mental and psychosocial treatment and nursing care conditions at Troy Manor nursing facility.
Findings
The facility failed to ensure appropriate person-centered care and individualized treatment for residents with mental disorders, including failure to update care plans to address exhibited behaviors and wandering. There was evidence of resident altercations and inadequate supervision and documentation related to these behaviors.
Deficiencies (2)
F742 Treatment/Services Mental/Psychosocial Concerns: The facility failed to ensure residents with mental disorders received appropriate treatment and individualized care to address exhibited behaviors and psychosocial well-being. Care plans were not updated to include interventions for wandering, verbal and physical altercations, or behaviors related to dementia.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiencies cited under F742.
Report Facts
Facility census: 99
Inspection Report
Plan of Correction
Census: 104
Deficiencies: 2
Date: Feb 21, 2019
Visit Reason
The inspection was conducted to investigate and document deficiencies related to quality of care, specifically bowel monitoring and medication administration, and to review the facility's plan of correction.
Complaint Details
Complaint #MO152982 was investigated as part of the inspection.
Findings
The facility failed to provide necessary care and services to two residents, including inadequate monitoring and documentation of bowel movements and medication administration. The resident developed a fecal impaction requiring emergency treatment, and staff failed to follow policies for bowel monitoring and medication administration.
Deficiencies (2)
F684 Quality of care: The facility failed to monitor and document bowel movements and administer medications appropriately for two residents, resulting in a fecal impaction and emergency treatment for one resident.
F684 The facility lacked a policy on bowel monitoring and failed to follow professional standards for assessing and treating residents with bowel and medication needs.
Report Facts
Facility census: 104
Inspection Report
Plan of Correction
Census: 8
Deficiencies: 1
Date: Feb 4, 2019
Visit Reason
The inspection was conducted to assess fire safety compliance related to the separation of two levels of long-term care within the facility.
Findings
The facility failed to ensure that the two levels of long-term care were separated by a one-hour fire-resistant construction as required. The doors separating the levels did not provide the required one-hour fire separation due to removed latches.
Deficiencies (1)
19 CSR 30-86.022(10)(L) Multilevel/2 Business, Const. & Fire Safety: The facility failed to ensure the two levels of long-term care were separated by a one-hour fire-resistant construction. Doors separating the levels lacked latches, compromising fire safety.
Report Facts
Facility census: 8
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 22
Date: Jan 15, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Troy Manor nursing facility.
Findings
The facility was found to have multiple deficiencies including issues with housekeeping and maintenance, resident care including hygiene and pressure ulcer prevention, infection control, medication administration, and documentation. The facility failed to meet several regulatory requirements and was required to submit a plan of correction.
Deficiencies (22)
F584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, evidenced by persistent urine odor, dirty vents, stained walls, and unclean resident rooms.
F585: The facility failed to establish a grievance policy and procedure ensuring residents' rights to voice grievances and receive timely responses.
F640: The facility failed to complete and transmit Minimum Data Set (MDS) assessments timely and accurately for residents.
F677: The facility failed to provide adequate perineal and oral care to residents, resulting in hygiene deficiencies.
F686: The facility failed to prevent and treat pressure ulcers, including failure to reposition residents and provide appropriate skin care.
F689: The facility failed to prevent accidents and falls by not adequately assessing risks and implementing interventions.
F760: The facility failed to administer insulin according to manufacturer instructions and failed to properly train staff on insulin administration.
F804: The facility failed to serve food at safe and appetizing temperatures and failed to maintain proper food storage and preparation.
F806: The facility failed to provide meals consistent with residents' preferences and dietary needs, including failure to provide adequate vegan meal options.
F809: The facility failed to provide bedtime snacks to residents as per policy and failed to ensure staff passed snacks to residents at bedtime.
F880: The facility failed to maintain an effective infection prevention and control program, including failure to properly sanitize glucometers and ensure hand hygiene.
F924: The facility failed to maintain secure handrails in the hallways, posing a safety risk to residents.
A4029: The facility failed to ensure employees received required tuberculosis testing and documentation.
A4054: The facility failed to maintain a safe and effective medication system.
A4074: The facility failed to provide personal attention and nursing care consistent with residents' conditions and nursing standards.
A4075: The facility failed to maintain residents clean, dry, and odor free.
A4082: The facility failed to prevent pressure sores and provide adequate treatment.
A4085: The facility failed to prevent and control infection and communicable disease.
A5007: The facility failed to provide adequate bedside snacks and nourishment.
A6011: The facility failed to provide appropriate food storage and preparation to maintain food safety.
A6012: The facility failed to maintain clean walls, ceilings, doors, and windows.
A6019: The facility failed to maintain clean and well-maintained light fixtures and vent covers.
Report Facts
Facility census: 107
Deficiencies cited: 22
Inspection Report
Life Safety
Census: 107
Capacity: 130
Deficiencies: 12
Date: Jan 15, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including maintaining fire resistance barriers, ensuring proper operation of delayed egress locking hardware, illumination of means of egress, emergency lighting, maintenance of cooking facilities range hood, sprinkler system maintenance, fire drills, electrical system safety, and smoke barrier construction. Multiple deficiencies were identified that could potentially affect residents, staff, and visitors.
Deficiencies (12)
K161: The facility failed to maintain the fire resistance barrier between the first floor and attic with a one-hour rating by not repairing openings in the ceiling around sprinklers and conduits.
K222: The facility failed to ensure one exit door with delayed egress locking hardware released within 15 seconds of pressure, potentially affecting 16 residents.
K281: The facility failed to ensure continuous illumination of the exit discharge at the front entrance, affecting any resident, visitor, or staff using this exit.
K291: The facility failed to ensure emergency lighting in the means of egress was functional, potentially affecting 16 residents and others using the front entrance as an emergency exit.
K324: The facility failed to maintain the kitchen range hood in accordance with NFPA 96, with baffle filters covered with thick layers of dust and debris, potentially affecting 12 residents.
K353: The facility failed to maintain sprinkler heads free of corrosion, dust, and debris, potentially affecting 107 residents in nine smoke compartments.
K355: The facility failed to ensure a 10-pound portable fire extinguisher was present in the kitchen, potentially affecting 12 residents and others in the kitchen area.
K372: The facility failed to maintain smoke barriers with required fire resistance rating and sealed openings, potentially affecting 32 residents and others in multiple smoke compartments.
K711: The facility failed to conduct fire drills under varied and unexpected conditions on two of three shifts, potentially affecting all occupants in nine smoke compartments.
K911: The facility failed to maintain electrical wiring in compliance with National Electrical Code, including unsecured wires and missing outlet covers, potentially affecting 36 residents and others.
K920: The facility failed to ensure electrical wiring was installed and maintained to prevent fire hazards, with items plugged into power strips and extension cords improperly used, potentially affecting 34 residents and others.
K932: The facility failed to maintain laundry dryers free of lint buildup, creating a fire hazard, potentially affecting 19 residents and others in the laundry area.
Report Facts
Facility capacity: 130
Census: 107
Residents potentially affected: 79
Residents potentially affected: 16
Residents potentially affected: 12
Residents potentially affected: 32
Residents potentially affected: 36
Residents potentially affected: 34
Residents potentially affected: 19
Inspection Report
Plan of Correction
Census: 9
Deficiencies: 4
Date: Jan 15, 2019
Visit Reason
The inspection was conducted to identify deficiencies related to emergency lighting, medication administration, resident condition/medication review, and food temperature compliance at Troy Manor.
Findings
The facility failed to ensure emergency lighting was operational, did not administer medications as ordered for residents, failed to provide snacks to prevent weight loss, did not maintain monthly summaries for residents, and served food at unsafe temperatures due to malfunctioning ovens.
Deficiencies (4)
19 CSR 30-86.022(12)(A) Emergency Lighting - locations. The facility failed to ensure emergency lighting at the front entrance was operational, with emergency lights under the main entrance canopy not illuminating when tested.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to administer medications as ordered for one resident and failed to provide snacks to prevent weight loss for another resident.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to ensure three residents had monthly summaries of their condition and general needs completed at least monthly.
19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below. The facility failed to serve food at safe and appetizing temperatures due to two ovens not functioning properly.
Report Facts
Facility census: 9
Deficiencies cited: 4
Inspection Report
Routine
Census: 107
Deficiencies: 12
Date: Jan 7, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including housekeeping, grievance policies, resident care, infection control, medication administration, food service, fall prevention, and life safety.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean environment, inadequate grievance policy implementation, failure to transmit MDS assessments timely, insufficient personal care and hygiene assistance, pressure ulcer care deficiencies, fall prevention and supervision failures, medication administration errors related to insulin pen use, serving food at unsafe temperatures, failure to provide vegan diet as ordered, failure to provide routine bedtime snacks, improper infection control practices, and loose handrails in hallways.
Deficiencies (12)
Facility failed to ensure housekeeping and maintenance services maintained a clean and comfortable environment, including persistent urine and feces odors and mold-like substances on vents.
Facility failed to develop and implement a grievance policy that included all required components and failed to act promptly on grievances.
Facility failed to electronically encode and transmit MDS assessments within required timeframes for five residents.
Facility failed to provide necessary care and services to maintain good personal hygiene, prevent body odor, oral care, and showers for seven residents.
Facility failed to turn and reposition residents at risk for pressure ulcers, failed to provide appropriate pressure ulcer care, and failed to report newly identified pressure ulcers and obtain treatment orders.
Facility failed to consistently implement and modify fall prevention interventions and failed to use appropriate transfer technique with a gait belt.
Facility failed to administer insulin according to manufacturer's recommendations, failing to prime insulin pens before administration.
Facility failed to serve food at safe and appetizing temperatures due to malfunctioning ovens.
Facility failed to provide meals in accordance with a resident's vegan diet preferences.
Facility failed to offer residents a daily bedtime snack and failed to pass snacks to residents' rooms.
Facility failed to ensure staff washed hands when indicated and failed to properly sanitize glucometers between residents.
Facility failed to ensure hallways were equipped with firmly secured handrails on each side.
Report Facts
Facility census: 107
MDS late submissions: 5
Pressure ulcer size: 0.1
Blood sugar level: 241
Blood sugar level: 212
Food temperature: 86
Food temperature: 100
Food temperature: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN S | Licensed Practical Nurse | Named in insulin administration and glucometer sanitization deficiencies |
| CNA G | Certified Nurse Aide | Named in personal care and pressure ulcer care deficiencies |
| CNA H | Certified Nurse Aide | Named in personal care and infection control deficiencies |
| DON | Director of Nursing | Provided interview on multiple deficiencies including falls, medication administration, infection control |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Date: Nov 30, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of physical abuse involving two residents at Troy Manor.
Complaint Details
The complaint investigation substantiated physical abuse by Resident #1 against Resident #2, resulting in injury and unsafe conditions. The facility was found noncompliant with abuse prevention regulations.
Findings
The facility failed to ensure one resident was free from physical abuse when another resident purposely struck him with an electric wheelchair causing injury. The investigation included record reviews, interviews, and observations confirming the abuse incident and unsafe conditions.
Deficiencies (2)
F600 Freedom from Abuse and Neglect: The facility failed to prevent physical abuse when Resident #1 purposely struck Resident #2 with an electric wheelchair causing bruising and injury. Resident #2 required extensive assistance and had behavioral disturbances that were not adequately addressed in the care plan.
A4074 Nursing Care per Resident Condition: The facility did not provide personal attention and nursing care consistent with residents' conditions as evidenced by the abuse incident referenced in F600.
Report Facts
Facility census: 110
Deficiencies cited: 2
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 3
Date: Sep 4, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with safety, cleanliness, and odor control regulations at Troy Manor.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment, particularly due to pervasive urine odors and soiled mattresses in multiple resident rooms and common areas. Cleaning protocols were not adequately followed, resulting in odor issues and unsanitary conditions.
Deficiencies (3)
F 584: The facility failed to maintain a clean, homelike, and odor-free environment on the 300 hall, evidenced by strong urine odors and soiled mattresses in resident rooms and common areas. Cleaning and maintenance procedures were insufficient to eliminate odors and maintain sanitary conditions.
A4094: Staff did not use moisture proof covers as necessary to keep mattresses and pillows clean, dry, and odor free. This regulation was not met as referenced by F 584.
A6011: Deodorizers or sprays were improperly used to cover up odors instead of eliminating the source by cleaning bedpans, commodes, floors, furniture, and equipment with proper ventilation. This regulation was not met as referenced by F 584.
Report Facts
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice Onore | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Plan of Correction
Census: 10
Deficiencies: 1
Date: Jul 12, 2018
Visit Reason
The document is a Plan of Correction related to a deficiency cited during a medication system inspection at Troy Manor on 07/12/2018.
Findings
The facility failed to provide a safe and effective medication control system as evidenced by medication administration errors and lack of verification of medication consumption for multiple residents. The deficiency was classified as Class II and involved ten residents.
Deficiencies (1)
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to provide a safe and effective medication control system for ten residents as evidenced by medication administration errors and lack of verification of medication consumption.
Report Facts
Facility census: 10
Deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 5
Date: Jul 11, 2018
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint MO144494) regarding quality of care related to a resident's leg pain, swelling, and bruising.
Complaint Details
Complaint MO144494 regarding quality of care was substantiated. The facility failed to timely notify the physician and family of the resident's increased pain, swelling, and bruising, and failed to adequately assess and monitor the resident's condition.
Findings
The facility failed to notify the resident's physician and representative timely about a significant change in the resident's condition involving pain, swelling, and bruising of the left leg. Nursing staff did not adequately assess or monitor the resident's condition, resulting in delayed x-ray and notification to family.
Deficiencies (5)
F580 Notification of Changes: The facility failed to promptly notify the resident's physician and representative of a significant change in condition involving pain, swelling, and bruising of the left leg. Staff did not follow the facility's condition change policy or timely communicate changes.
F684 Quality of Care: The facility failed to assess and monitor the resident's leg condition following increased complaints of pain, swelling, and bruising. Nursing staff did not document assessments or notify the physician until an x-ray was ordered after a delay.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with their condition and nursing practice. This regulation was not met as evidenced by deficiencies in notification and monitoring.
A4086 Doctor Notification - Change in Condition: Facility staff failed to notify the resident's physician in accordance with emergency treatment policies after a significant change in condition.
A4087 Notify Responsible Party - Change in Condition: Facility staff failed to immediately notify the resident's designated responsible party of the significant change in condition involving pain and bruising.
Report Facts
Facility Census: 103
Deficiency Completion Date: Plan of correction completion date set for 2018-08-07
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse G | Registered Nurse | Interviewed regarding resident's condition and physician notification |
| Certified Nurse Assistant C | Certified Nurse Assistant | Interviewed regarding resident's pain complaints and condition |
| Certified Nurse Assistant H | Certified Nurse Assistant | Interviewed regarding resident's pain complaints and medication |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed regarding medication administration and resident assessment |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding shift work and resident knee assessment |
| Licensed Practical Nurse F | Licensed Practical Nurse | Interviewed regarding resident knee assessment and x-ray orders |
| Director of Nursing | Director of Nursing | Interviewed regarding resident care and facility policies |
Inspection Report
Plan of Correction
Census: 117
Deficiencies: 6
Date: Mar 16, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident safety, care, and facility maintenance at Troy Manor nursing facility.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate resident assessments, comprehensive care plans, incontinence care, frequency of meals and snacks, and infection prevention and control. Multiple specific issues were documented including maintenance problems, care plan deficiencies, and lapses in infection control practices.
Deficiencies (6)
F584 Safe Environment. The facility failed to maintain heating/ventilation units, flooring, walls, ceiling tiles, door frames, handrails, and furniture in good repair. The facility census was 117.
F641 Accuracy of Assessments. The facility failed to ensure comprehensive assessments were accurate and reflected residents' status for two residents in a sample of 24. The facility census was 117.
F657 Comprehensive Care Plans. The facility failed to develop and update care plans consistent with residents' specific conditions, needs, and risks for two residents in a sample of 24. The facility census was 117.
F690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide appropriate incontinence care and catheter care for residents, including infection prevention and catheter maintenance. The facility census was 117.
F809 Frequency of Meals/Snacks at Bedtime. The facility failed to provide three residents with snacks as ordered and documented. The facility census was 117.
F880 Infection Prevention & Control. The facility failed to establish and maintain an infection prevention and control program, including hand hygiene, glove use, and cleaning of soiled linens and surfaces. The facility census was 117.
Report Facts
Facility census: 117
Sampled residents: 24
Residents with catheter: 8
Residents with UTIs: 3
Residents with missed snacks: 3
Inspection Report
Life Safety
Census: 117
Capacity: 130
Deficiencies: 10
Date: Mar 16, 2018
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and building construction regulations.
Findings
The facility failed to meet several provisions of the 2012 edition of the Life Safety Code, including maintaining fire barriers, delayed egress locking doors, emergency lighting, sprinkler system maintenance, corridor door closures, and smoke barrier construction. Multiple unsealed penetrations and deficiencies in fire safety systems were observed, potentially affecting residents and staff.
Deficiencies (10)
K161: The facility failed to maintain the barrier between the first floor and attic with a fire resistance rating of at least one hour due to unsealed penetrations in ceilings and walls.
K222: The facility failed to ensure delayed egress locking doors opened freely and consistently in emergencies, affecting approximately 20 residents.
K291: The facility failed to install and maintain emergency lighting in accordance with NFPA 7.9, potentially affecting 61 residents and others.
K353: The facility failed to maintain the sprinkler system, including corrosion on sprinkler heads and lack of quarterly inspection documentation, affecting all residents.
K363: Corridor doors failed to resist smoke passage and did not positively latch, affecting 69 residents.
K372: The facility failed to maintain smoke barriers, including unsealed penetrations and missing fire-rated products, potentially affecting 50 residents.
K741: The facility failed to maintain designated smoking areas to prevent fire hazards by not ensuring proper disposal of cigarette butts and ashes.
K911: The facility failed to maintain electrical wiring in compliance with the National Electrical Code, affecting approximately 90 residents.
K920: The facility failed to ensure electrical equipment and extension cords were used safely, affecting 108 residents.
K923: The facility failed to properly secure oxygen storage tanks and prevent confusion between full and empty cylinders, affecting 31 residents.
Report Facts
Facility capacity: 130
Census: 117
Residents potentially affected: 71
Residents potentially affected: 20
Residents potentially affected: 61
Residents potentially affected: 69
Residents potentially affected: 50
Residents potentially affected: 90
Residents potentially affected: 108
Residents potentially affected: 31
Inspection Report
Plan of Correction
Census: 8
Deficiencies: 6
Date: Mar 16, 2018
Visit Reason
The document is a Plan of Correction submitted by Troy Manor following a state inspection conducted on 03/16/2018. It addresses deficiencies identified during the inspection related to fire safety, emergency lighting, electrical wiring, medication system, resident condition/medication review, and resident rights.
Findings
The facility failed to maintain attic smoke barriers, emergency lighting, and electrical wiring in compliance with regulations. Medication administration and documentation were deficient for multiple residents. Resident rights were not reviewed annually for some residents. The facility census was eight residents at the time of inspection.
Deficiencies (6)
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements: The facility failed to maintain attic smoke barriers to ensure they were complete from outside wall to outside wall and from floor to roof deck.
19 CSR 30-86.022(12)(B) Emergency Lighting - Power Source: The facility failed to install and maintain emergency lighting in accordance with NFPA 7.9. Emergency lights near resident rooms did not illuminate when tested.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to maintain electrical wiring in compliance with the National Electrical Code by not protecting wire splices appropriately and leaving uncovered junction boxes in attic spaces.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure a safe and effective medication system for multiple residents, including unattended medications, failure to verify consumption, improper storage, and incomplete documentation.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to maintain monthly summaries of residents' conditions and medication reviews for three sampled residents.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to ensure resident rights were reviewed annually for two residents.
Report Facts
Facility census: 8
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Interviewed regarding medication administration and insulin storage |
| Director of Nursing | Director of Nursing | Interviewed regarding resident monthly summaries and medication audits |
| Assistant Director of Nursing | Assistant Director of Nursing | Mentioned in relation to resident monthly summaries |
| Certified Medication Technician B | Certified Medication Technician | Observed preparing and administering medications with noted deficiencies |
| Social Services Director | Social Services Director | Interviewed regarding resident rights review |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding attic inspections and emergency lighting checks |
| Administrator | Administrator | Provided statements about medication training and plan of correction approval |
Inspection Report
Plan of Correction
Census: 8
Deficiencies: 1
Date: Mar 6, 2018
Visit Reason
The inspection visit was conducted as part of the fire safety portion of the licensure inspection to verify compliance with sprinkler system certification requirements.
Findings
The facility failed to provide written certification of the sprinkler system inspection completed annually by an approved qualified service representative as required by NFPA 25, 1998 edition. The facility census at the time of inspection was eight residents.
Deficiencies (1)
19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections. The facility failed to provide written certification of the sprinkler system inspection at least annually by an approved qualified service representative as required by NFPA 25, 1998 edition.
Report Facts
Facility census: 8
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 2
Date: Jan 19, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate protective oversight and supervision of residents, specifically related to elopement risks and incidents.
Complaint Details
The complaint investigation was substantiated, finding that the facility failed to provide adequate supervision and protective oversight to residents at risk for elopement, resulting in actual elopement incidents.
Findings
The facility failed to provide adequate protective oversight to two residents who eloped from the facility. The investigation revealed multiple incidents of residents leaving the facility without staff knowledge, inadequate staff response, and deficiencies in elopement risk assessment and monitoring procedures.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision to prevent elopements by two residents. Resident #3 left the facility unnoticed and walked approximately 0.1 miles to a community church parking lot in cold temperatures, and Resident #6 left twice in one day without staff awareness.
A4073 Protective Oversight, Voluntary Leave: The facility did not provide twenty-four hour protective oversight and supervision for residents on voluntary leave, failing to inquire about the resident's whereabouts and length of absence.
Report Facts
Facility census: 112
Elopement risk score: 5
Elopement risk score: 4
Elopement risk score: 0
Temperature: 10
Temperature: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Informed charge nurse about resident elopement and involved in corrective actions |
| LPN C | Licensed Practical Nurse | Reported resident confusion and elopement behavior |
| CNA B | Certified Nurse Aide | Assisted resident back to locked unit and reported elopement incident |
| LPN H | Licensed Practical Nurse | Reported lack of knowledge about residents at risk for elopement |
| LPN J | Licensed Practical Nurse | Discussed residents at risk for elopement and facility procedures |
| LPN A | Licensed Practical Nurse | Charge nurse during elopement incident and provided resident care |
| CNA E | Certified Nurse Aide | Reported resident elopement risk and assisted resident |
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