Deficiencies (last 5 years)
Deficiencies (over 5 years)
14.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
97 residents
Based on a May 2025 inspection.
Occupancy 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
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
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
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
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
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
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
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 |
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