Inspection Reports for
Warrensburg Manor Health Care Center
400 Care Center Dr, Warrensburg, MO 64093, United States, MO, 64093
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
49% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 6
Date: Sep 19, 2024
Visit Reason
The inspection was a re-inspection to verify correction of previously cited deficiencies related to resident assessments, care plans, accident hazards, nursing staffing, and oxygen equipment storage at Warrensburg Manor Care Center.
Findings
The facility failed to meet requirements for comprehensive resident assessments, care plans, accident prevention, nursing staffing, and oxygen equipment storage. Deficiencies were cited for incomplete assessments, inadequate care plans, failure to investigate falls properly, insufficient RN coverage, and improper oxygen equipment handling.
Deficiencies (6)
F636: The facility failed to conduct comprehensive assessments of residents' functional capacity and ensure accurate Minimum Data Set (MDS) assessments for sampled residents.
F656: The facility failed to develop and implement comprehensive, person-centered care plans for residents, including nutritional status and edema management.
F689: The facility failed to ensure a safe environment free of accident hazards and adequate supervision to prevent falls for a sampled resident.
F695: The facility failed to ensure proper respiratory care and tracheostomy suctioning, including storage and handling of oxygen equipment for sampled residents.
F727: The facility failed to ensure services of a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, and failed to have a full-time Director of Nursing (DON) onsite.
F921: The facility failed to provide a safe, functional, sanitary, and comfortable environment, including secure storage of cleaning chemicals and laundry supplies.
Report Facts
Facility census: 43
Sampled residents: 14
RN hours required: 8
RN hours worked: 8
Inspection Report
Routine
Census: 43
Deficiencies: 6
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, incomplete care plans especially related to nutritional status and edema management, inadequate fall investigation and follow-up, improper storage and maintenance of oxygen equipment, failure to maintain required RN staffing and Director of Nursing (DON) coverage, and unsafe storage of cleaning chemicals in a resident's room.
Deficiencies (6)
Failure to ensure accurate MDS assessments and update care plans for residents with swallowing, choking, and weight loss issues.
Failure to develop and implement a complete care plan addressing all resident needs including nutritional status and edema management.
Failure to complete thorough fall investigation, update fall care plan with interventions, and monitor effectiveness for a resident who fell and sustained head injury.
Failure to ensure oxygen equipment was stored properly in plastic bags when not in use, tubing and humidifier bottles were not changed timely, and oxygen tubing was improperly coiled around equipment for three residents.
Failure to maintain RN staffing eight hours per day, seven days per week and to have a full-time Director of Nursing onsite as required.
Failure to ensure safe and secure storage of cleaning chemicals including bleach and laundry soap in a resident's room.
Report Facts
Facility census: 43
Weight loss: 13
RN hours missing: 4
Interim DON hours: 52
Oxygen tubing date: 8
Oxygen tubing date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Provided information on MDS assessments and oxygen equipment maintenance |
| Certified Nursing Assistant E | CNA | Interviewed regarding resident feeding, oxygen equipment storage, and fall precautions |
| Director of Nursing | DON | Provided expectations for MDS accuracy, care plan updates, fall investigations, and oxygen equipment maintenance |
| Assistant Director of Nursing | ADON | Discussed fall follow-up procedures and oxygen equipment maintenance |
| Certified Medication Technician B | CMT | Reported on facility DON staffing and resident care |
| Interim Director of Nursing | Interim DON | Discussed staffing coverage and care plan expectations |
| Administrator | Administrator | Discussed staffing challenges and PBJ reporting |
| Housekeeper A | Housekeeper | Reported awareness of cleaning chemicals in resident room |
| Laundry Aid A | Laundry Aid | Interviewed about laundry soap and bleach in resident room |
Inspection Report
Life Safety
Census: 43
Capacity: 81
Deficiencies: 3
Date: Sep 17, 2024
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services on 09/17/2024 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with emergency lighting, hazardous area enclosures, and fire-rated door requirements. Deficiencies had the potential to affect all 43 residents present at the facility during the inspection.
Deficiencies (3)
K291 Emergency Lighting: Emergency lighting was not properly hardwired to the lighting circuit, as emergency lights were plugged into electrical outlets. This deficient practice could affect all 43 residents.
K321 Hazardous Areas - Enclosure: Hazardous areas were not properly separated from other areas by fire barriers or automatic fire extinguishing systems as required by NFPA 101. This deficiency could affect all 43 residents.
K324 Cooking Facilities: The kitchen door was not a fire-rated door assembly and was secured in the open position, failing to meet fire rating requirements. This deficiency could affect all 43 residents.
Report Facts
Occupied beds: 43
Total beds: 81
Residents potentially affected: 44
Residents potentially affected: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified emergency lighting and fire door conditions during interviews and observations | |
| Administrator | Signed the inspection report and plan of correction |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Aug 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #2 was found in Resident #1's room with his/her hand under Resident #1's shirt, touching his/her breast, raising concerns of resident-to-resident sexual abuse.
Complaint Details
The investigation was triggered by a complaint regarding Resident #2's inappropriate sexual behavior towards Resident #1. The complaint was substantiated based on observations, interviews, and record reviews confirming the incident and ongoing risk.
Findings
The facility failed to ensure Resident #1 was free from resident-to-resident abuse. Resident #2, who had a history of sexually inappropriate behavior, entered Resident #1's room multiple times despite staff interventions. The bathroom door between the rooms was found unlocked, allowing Resident #2 access. Staff placed Resident #2 on 1:1 observation and moved him/her to a different room. Family members and staff interviews confirmed awareness of Resident #2's behaviors and the facility's attempts to manage the risk.
Deficiencies (1)
Failure to protect Resident #1 from resident-to-resident sexual abuse by Resident #2.
Report Facts
Residents present: 50
Sampled residents: 7
Brief Interview for Mental Status (BIMS) score: 0
Brief Interview for Mental Status (BIMS) score: 3
Date of incident: Jul 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) A | Discovered Resident #2 in Resident #1's room and reported the event | |
| Certified Nursing Assistant (CNA) B | Provided 1:1 observation of Resident #2 and reported inappropriate remarks | |
| Licensed Practical Nurse (LPN) A | Provided statement about the incident and staff interventions | |
| Social Worker | Interviewed regarding Resident #2's admission and behavior | |
| MDS Coordinator A | Discussed referral and admission process for Resident #2 | |
| Administrator | Provided overview of facility response and monitoring of Resident #2 |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Date: Aug 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect involving two residents at Warrensburg Manor Care Center.
Complaint Details
The complaint investigation was substantiated. Resident #2 was found to have entered Resident #1's room and touched Resident #1 inappropriately. The facility's investigation confirmed the incident and identified failures in protective oversight and policy implementation.
Findings
The facility failed to ensure one resident was free from abuse by another resident, specifically non-consensual sexual contact. The investigation revealed multiple instances where Resident #2 was found with his/her hand under Resident #1's shirt, touching the breast, violating the resident's rights to be free from abuse and neglect.
Deficiencies (3)
F600 Freedom from Abuse and Neglect: The facility failed to prevent Resident #2 from entering Resident #1's room and touching Resident #1 inappropriately, violating the resident's right to be free from abuse.
A4074 Protective Oversight, Voluntary Leave: The facility did not have adequate procedures for protective oversight and supervision for residents on voluntary leave.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, including reporting requirements.
Report Facts
Facility census: 50
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Feb 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding the treatment of residents by an agency Licensed Practical Nurse (LPN) who was allegedly inconsiderate, raised his/her voice, and was argumentative with residents.
Complaint Details
The complaint involved Agency LPN A being inconsiderate, raising his/her voice, and being argumentative with residents, including Resident #1 who has severe cognitive impairment and Resident #18 with bipolar disorder. Multiple staff and residents witnessed the behavior. Agency LPN A was asked to leave the facility and placed on leave pending investigation.
Findings
The facility failed to ensure two sampled residents were treated with dignity and respect. Agency LPN A was reported to have raised his/her voice and been argumentative with residents, including incidents involving Resident #1 and Resident #18. The facility investigated, obtained witness statements, and removed Agency LPN A from the facility.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Report Facts
Residents affected: 2
Facility census: 53
Sampled residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency LPN A | Licensed Practical Nurse | Named in findings related to disrespectful and argumentative behavior toward residents. |
| Certified Nurses Aide B | Certified Nurses Aide | Provided witness statement regarding Agency LPN A's behavior. |
| Certified Medication Technician B | Certified Medication Technician | Witnessed and reported interactions between Agency LPN A and Resident #1. |
| Housekeeping Supervisor | Reported Resident #1's upset state and Agency LPN A's behavior to the Administrator. | |
| Administrator | Facility Administrator | Conducted investigation and removed Agency LPN A from the facility. |
| Director of Nursing | Director of Nursing | Provided interview regarding expectations for documentation and staff orientation. |
| Agency Human Resources | Human Resources | Verified information and placed Agency LPN A on leave pending investigation. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 9
Date: Feb 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding resident dignity and respect, infection control practices, care plan comprehensiveness, medication storage, hospice services, vaccination offerings, and facility maintenance issues.
Complaint Details
The complaint investigation was triggered by allegations of resident mistreatment, infection control breaches during an outbreak, inadequate care planning, medication storage issues, hospice service coordination failures, vaccination offering deficiencies, and facility maintenance problems.
Findings
The facility failed to ensure residents were treated with dignity and respect by staff, maintain infection control practices during an outbreak, develop comprehensive care plans reflecting current resident status including hospice care, monitor and reconcile medications in the Cubex system, offer vaccinations to all residents, and maintain facility equipment such as windows and vending machine areas.
Deficiencies (9)
Failed to ensure two sampled residents were treated with dignity and respect by an agency LPN who raised his/her voice and was argumentative.
Failed to maintain Resident #31's wheelchair clean and free of hair clumps; failed to prevent storage of contaminated trash in shower rooms; failed to maintain shower room and ceiling fans in good repair.
Failed to develop comprehensive, individualized care plans reflecting current health status for six sampled residents, including lack of hospice care plans and fall prevention interventions.
Failed to ensure safe medication storage system and monitoring of Cubex medication dispensing system.
Failed to maintain kitchen and dry good storage areas free of dust and grime, maintain faucet to prevent leaking, and maintain floors and refrigerator gasket in good repair.
Failed to ensure physician's orders for hospice services were transcribed onto the physician's order sheet including service provider, services provided, and frequency for four sampled residents.
Failed to implement infection prevention and control program including outbreak management, transmission based precautions, hand hygiene, PPE use, signage, visitor notification, and monitoring during a gastrointestinal illness outbreak affecting multiple residents.
Failed to ensure windows in rooms of two sampled residents operated properly for resident convenience and failed to maintain area under vending machine free of dust and grime.
Failed to offer influenza and pneumococcal vaccinations to one sampled resident and one supplemental resident, and failed to document vaccination status.
Report Facts
Facility census: 53
Residents affected by dignity deficiency: 2
Residents affected by wheelchair and environment deficiency: 40
Sampled residents with care plan deficiencies: 6
Residents affected by medication storage deficiency: 53
Residents affected by infection control deficiency: 28
Residents affected by hospice order deficiency: 4
Residents affected by vaccination deficiency: 2
Residents affected by window and vending machine deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency Licensed Practical Nurse A | Agency LPN | Named in findings related to resident mistreatment and verbal altercations with residents #1 and #18 |
| Certified Nurses Aide B | CNA | Witness statement regarding Agency LPN A's behavior |
| Certified Medication Technician B | CMT | Witness to Agency LPN A's behavior and resident interactions |
| Housekeeping Supervisor | Provided observations and statements regarding environmental cleanliness and resident concerns | |
| Administrator | Involved in investigation and removal of Agency LPN A; provided statements on facility policies and outbreak management | |
| Director of Nursing | DON | Provided statements on care plan responsibilities, infection control, and medication storage |
| Agency Human Resources | HR | Verified investigation and leave status of Agency LPN A |
| Certified Medication Technician D | CMT | Provided statements on resident behaviors and infection control |
| Licensed Practical Nurse B | LPN | Provided statements on care plans and Cubex system |
| MDS Coordinator | Responsible for care plan monitoring and updating | |
| Infection Control Preventionist | Provided statements on outbreak management and infection control policies | |
| Certified Nursing Assistant D | CNA | Provided statements on infection control practices and resident care |
| Certified Nursing Assistant A | CNA | Observed providing care without proper hand hygiene and PPE |
| Certified Medication Technician C | CMT | Provided statements on infection control and visitor precautions |
| Certified Nursing Assistant E | CNA | Observed providing care without proper hand hygiene and PPE |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 4
Date: Mar 31, 2021
Visit Reason
The inspection was conducted to investigate complaints related to falls and respiratory care at Warrensburg Manor Care Center.
Complaint Details
The visit was complaint-related focusing on falls and respiratory care issues. The complaint was substantiated based on findings of inadequate fall investigation and respiratory care.
Findings
The facility failed to ensure a comprehensive fall investigation process and proper respiratory care including CPAP machine management. Deficiencies were found in documentation, supervision, and infection control related to falls and respiratory care.
Deficiencies (4)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure a comprehensive fall investigation process including documentation of root cause and follow-up actions for sampled residents. The facility census was 47 residents.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure proper cleaning and storage of a resident's CPAP machine and mask. The facility census was 47 residents.
F755 Pharmacy Services: The facility failed to ensure shift change narcotic counts were completed and signed by both oncoming and off-going nursing staff. The facility census was 47 residents.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program including hand hygiene and standard precautions to prevent communicable diseases.
Report Facts
Facility census: 47
Sampled residents for fall investigation: 12
Narcotic count discrepancies: 24
Narcotic count discrepancies: 10
Narcotic count discrepancies: 15
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 31, 2021
Visit Reason
The inspection was conducted to investigate complaints related to resident falls, injury prevention, respiratory care, pharmaceutical services, and infection control practices at Warrensburg Manor Care Center.
Complaint Details
The investigation was complaint-driven focusing on falls, respiratory care, pharmaceutical services, and infection control.
Findings
The facility was found deficient in conducting comprehensive fall investigations including root cause analysis and documentation of interventions for fall prevention. Improper cleaning and storage of a resident's CPAP mask was observed. The facility failed to ensure shift change narcotic counts were consistently completed and signed. Infection control practices were inadequate, including improper glove use and hand hygiene during resident care.
Deficiencies (4)
Failed to ensure comprehensive fall investigation process including root cause analysis and documentation of interventions for fall prevention for sampled residents.
Failed to ensure proper cleaning and storage of a resident's CPAP mask when not in use.
Failed to ensure shift change narcotic counts were completed and signed by both oncoming and off-going nursing staff.
Failed to ensure proper infection control practices including hand hygiene and glove use during resident care.
Report Facts
Facility census: 47
Controlled drug count opportunities: 85
Un-signed narcotic count opportunities: 24
Narcotic count opportunities not signed by both staff: 10
Narcotic count opportunities missing package count: 15
CPAP mask storage frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided information on fall review process, CPAP mask storage expectations, narcotic count procedures, and infection control expectations. |
| LPN B | Licensed Practical Nurse | Described fall assessment and documentation procedures. |
| Certified Medication Technician B | Certified Medication Technician | Described notification and documentation procedures for resident falls and CPAP mask storage. |
| CNA A | Certified Nursing Assistant | Described fall notification procedures and CPAP mask storage. |
| CNA B | Certified Nursing Assistant | Described fall notification procedures and hand hygiene expectations. |
| CNA C | Certified Nursing Assistant | Observed providing care with improper glove use and hand hygiene. |
| CNA D | Certified Nursing Assistant | Described proper hand hygiene and glove use during resident care. |
| CNA E | Certified Nursing Assistant | Described proper hand hygiene and glove use during resident care. |
| LPN A | Licensed Practical Nurse | Described expectations for hand hygiene and glove use during resident care. |
| Registered Nurse | Registered Nurse (RN) | Described expectations for hand hygiene and glove use during resident care. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
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 relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Follow-Up
Census: 42
Deficiencies: 8
Date: Feb 7, 2019
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies related to food safety, infection control, and employee communicable disease policies at Warrensburg Manor Care Center.
Findings
The facility failed to maintain sanitary kitchen conditions and proper infection control practices, including improper handling of catheter bags and inadequate employee tuberculosis screening. The facility census was 42 residents during the inspection.
Deficiencies (8)
F812 Food safety requirements were not met as the facility failed to maintain sanitary kitchen cutting boards, separate damaged foods, monitor refrigerator temperatures, and ensure proper hand hygiene among staff.
F880 Infection prevention and control program was deficient as the facility failed to maintain a comprehensive infection control program, including proper catheter bag handling and documentation for waterborne pathogen outbreaks.
A4029 The facility failed to develop and implement policies ensuring employees are screened for communicable diseases and did not obtain timely tuberculosis testing for employees.
A4085 Infection control/communicable disease procedures were inadequate to prevent infection spread and ensure timely reporting of communicable diseases.
A7002 Employees did not consistently wash hands and keep fingernails clean and trimmed as required.
A7048 Safe plastic/rubber items for food contact were not maintained according to standards.
A7065 Food-contact surfaces were not washed, rinsed, and sanitized at required intervals.
A7088 Utensils and equipment were not stored properly to prevent contamination.
Report Facts
Facility census: 42
Employees hired since last annual survey: 88
Employees sampled for TB testing: 9
Employees with delayed TB skin test reading: 2
Inspection Report
Life Safety
Census: 42
Capacity: 92
Deficiencies: 5
Date: Feb 7, 2019
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and electrical safety requirements.
Findings
The facility failed to maintain a comprehensive emergency preparedness program including proper federal agency contact information and monitoring measures during power outages. Electrical system deficiencies included failure to maintain complete records for electrical receptacles, broken receptacles, insufficient work area around circuit breaker panels, unsecured surge protectors, and improper use of extension cords and power strips.
Deficiencies (5)
E001: The facility failed to have a comprehensive Emergency Preparedness program including federal agency contact information and measures for monitoring inside temperatures during power outages.
K914: The facility failed to maintain complete records for duplex receptacles in resident rooms and failed to replace broken receptacles in two locations, affecting seven smoke zones.
K918: The facility failed to maintain sufficient work area around circuit breaker panels and provide complete documentation of annual inspections, affecting seven smoke zones.
K920: The facility failed to prevent appliances from being plugged into surge protectors exceeding amperage ratings and failed to secure surge protectors, affecting multiple smoke zones.
A3030/A3037: Electrical wiring and extension cords were not maintained according to NFPA 70 standards, including improper use and placement of extension cords and power strips.
Report Facts
Census: 42
Total Capacity: 92
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Donald | Administrator | Named in relation to emergency preparedness findings and plan of correction |
Inspection Report
Annual Inspection
Census: 41
Capacity: 82
Deficiencies: 16
Date: Apr 6, 2018
Visit Reason
Annual inspection survey conducted at Warrensburg Manor Care Center to assess compliance with federal and state regulations related to resident care, safety, and facility operations.
Findings
The facility was found to have multiple deficiencies including unsafe equipment, failure to notify residents and representatives about transfers and discharges, inaccurate assessments, inadequate infection control practices, improper medication storage and labeling, and failure to maintain a safe environment. The facility census was 41 residents with a licensed capacity of 82 beds.
Deficiencies (16)
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to ensure a fall mat in resident room 52 was maintained without rips and the base of a stand-up lift was maintained without cracks, affecting two residents.
F623 Notice Requirements Before Transfer/Discharge. The facility failed to notify residents and representatives in writing of transfers or discharges and failed to provide required notices to the ombudsman for two sampled residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer. The facility failed to notify residents and representatives of the bed-hold policy before transferring or discharging two sampled residents.
F641 Accuracy of Assessments. The facility failed to identify dental issues on admission assessment for one sampled resident and failed to develop a dental care plan.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to develop comprehensive care plans for three sampled residents, including measurable objectives and timeframes.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to safely transfer three sampled residents using a mechanical lift and failed to ensure wheelchair brakes were locked during transfers.
F761 Label/Store Drugs and Biologicals. The facility failed to ensure medications were stored, labeled, and dated correctly in medication carts and rooms for two sampled medications.
F813 Personal Food Policy. The facility failed to produce a policy regarding the use and storage of foods brought in by family and visitors, which had the potential to affect all residents.
F880 Infection Prevention & Control. The facility failed to maintain an effective infection prevention program, including proper hand hygiene, use of gloves, and incontinence care for sampled residents.
A3038 Furniture/Equip, Provide Comfort & Safety. The facility failed to maintain furniture and equipment in good condition and replace broken or damaged items as needed.
A4015 Personnel Informed of Policies/Duties. The facility failed to fully inform personnel of policies and duties.
A4061 Medication Labeling. The facility failed to supply and label all prescription medications according to professional standards and regulations.
A4074 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4085 Infection Control/Communicable Disease. The facility failed to use acceptable infection control procedures and report communicable diseases as required.
A8008 Informed Services/Charges - Alz Disclosure. The facility failed to fully inform residents or representatives of services and charges during admission.
A8018 Emergency Discharges. The facility failed to provide timely written notice of emergency discharges to residents or representatives.
Report Facts
Facility census: 41
Licensed capacity: 82
Number of sampled residents: 12
Number of deficiencies cited: 15
Inspection Report
Life Safety
Census: 41
Capacity: 82
Deficiencies: 8
Date: Apr 6, 2018
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 regulations.
Findings
The facility failed to meet several Life Safety Code requirements including means of egress, ramps and other exits, smoke barrier construction, smoking regulations, and electrical systems maintenance and testing. Deficiencies potentially affected multiple residents and smoke zones.
Deficiencies (8)
K211 Means of Egress - General: The facility failed to ensure two exit doors opened easily during the fire alarm test, affecting at least 30 residents.
K227 Ramps and Other Exits: The facility lacked a handrail at an exit discharge ramp with a 36% slope, potentially affecting at least 10 residents.
K372 Subdivision of Building Spaces - Smoke Barrier: The attic trap door between the center hall and back south hall did not self-close, potentially affecting at least 24 residents.
K741 Smoking Regulations: The facility failed to provide clearly visible signage and self-closing cover devices for designated smoking areas, potentially affecting numerous staff, visitors, and residents.
K914 Electrical Systems - Maintenance and Testing: The facility did not assess electrical receptacles at resident beds in 46 rooms, creating potential electrical injury and fire hazards.
K918 Electrical Systems - Essential Electric System: The facility failed to document annual inspection of circuit breakers and main circuit breakers, affecting all residents.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prevent appliances from being plugged into surge protectors exceeding amperage limits and left surge protectors unsecured in seven locations.
K921 Electrical Equipment - Testing and Maintenance: The facility failed to produce documentation showing assessment and testing of surge protectors, potentially creating electrical hazards.
Report Facts
Facility census: 41
Total licensed capacity: 82
Deficiency count: 8
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