Inspection Reports for
Wilson’s Creek Nursing &Amp; Rehab
3403 WEST MT VERNON, SPRINGFIELD, MO, 65802-5241
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
74% occupied
Based on a December 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 128
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to infection prevention and control at Wilson's Creek Nursing & Rehab following a survey completed on 12/07/2023.
Findings
The facility failed to maintain an effective infection control program, specifically in administering the second step of a two-step tuberculosis (TB) skin test within recommended guidelines for five staff members. The facility also did not meet the annual review requirement of its infection prevention and control program.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain an effective infection control program when staff did not follow manufacturer guidelines for administering the second step of a two-step TB skin test for five staff members. The facility also failed to conduct an annual review of its infection prevention and control program as required.
A4031 Communicable Disease-Employees: The facility did not develop and implement policies ensuring employees diagnosed with communicable diseases do not expose residents, referencing the F880 deficiency for details.
Report Facts
Facility census: 128
Number of staff with TB test issues: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Personnel record reviewed showing TB skin test administration dates |
| LPN B | Licensed Practical Nurse | Personnel record reviewed showing TB skin test administration dates |
| Housekeeper C | Housekeeper | Personnel record reviewed showing TB skin test administration dates |
| CNA D | Certified Nurse Aide | Personnel record reviewed showing TB skin test administration dates |
| DA E | Dietary Aide | Personnel record reviewed showing TB skin test administration dates |
Inspection Report
Life Safety
Census: 128
Capacity: 172
Deficiencies: 6
Date: Dec 6, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Missouri Department of Health on 12/06/23 to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including emergency lighting, hazardous area enclosures, fire alarm system installation, sprinkler system maintenance, smoke barrier construction, and gas equipment storage. These deficiencies had the potential to affect all 128 residents.
Deficiencies (6)
K291 Emergency Lighting: The facility failed to provide emergency lighting at the emergency generator transfer switch as required by NFPA 110 Standard. This deficient practice could affect all 128 residents.
K321 Hazardous Areas - Enclosure: The facility failed to separate hazardous areas with fire barriers and failed to ensure self-closing doors functioned properly, including kitchen doors held open improperly. This could affect all 128 residents.
K341 Fire Alarm System - Installation: The facility failed to provide smoke automatic detection at the fire alarm control panel in the Therapy Room, violating NFPA 101 requirements. This could affect all 128 residents.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system by not completing required quarterly tests and inspections of the dry sprinkler system for the third quarter of 2023 and fourth quarter of 2022.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers due to unsealed penetrations and lack of inspection of dampers, and failed to provide documentation of four-year damper inspections. This could affect all 128 residents.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to meet oxygen storage requirements by storing combustible materials within five feet of oxygen cylinders and failing to mark empty and full cylinders properly. The facility census was 128.
Report Facts
Facility census: 128
Total licensed capacity: 172
Stored E-cylinders: 50
Inspection Report
Routine
Census: 128
Deficiencies: 8
Date: Nov 30, 2023
Visit Reason
Routine inspection of Wilson's Creek Nursing & Rehab to assess compliance with regulatory requirements including bed hold policies, PASARR screening, fall prevention, medication regimen reviews, psychotropic medication monitoring, medication administration, and kitchen sanitation.
Findings
The facility failed to provide written bed hold notices at transfer, complete required PASARR screenings and incorporate recommendations, properly investigate falls, complete timely medication regimen reviews, monitor psychotropic medication side effects and behaviors, maintain medication error rates below 5%, and maintain kitchen cleanliness and food safety standards.
Deficiencies (8)
F 0625: Facility failed to provide written bed hold notice at time of transfer for two sampled residents, violating bed hold policy requirements.
F 0644: Facility failed to complete a Level 2 PASARR screening for one resident and failed to incorporate Level 2 PASARR recommendations into another resident's care plan.
F 0645: Facility failed to complete a Level 1 PASARR screening for one resident as required prior to admission.
F 0689: Facility failed to ensure safe turning and repositioning of a resident, failed to complete fall investigations, and failed to conduct root cause analysis for falls.
F 0756: Facility failed to ensure monthly medication regimen reviews were completed timely for five sampled residents.
F 0758: Facility failed to monitor side effects and target behaviors for three residents receiving psychotropic medications and failed to obtain informed consent for these medications.
F 0759: Facility failed to maintain medication error rates below 5%, with three errors in 30 opportunities involving improper medication preparation and administration.
F 0812: Facility failed to maintain kitchen cleanliness and repair, improperly handled leftovers, failed to date opened foods, and served foods at unsafe temperatures.
Report Facts
Facility census: 128
Medication error rate: 10
Medication regimen review delay: 3
Temperature of gravy: 117
Refrigerator temperature: 48
Mixed fruit temperature: 50
Apple sauce temperature: 45.5
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 3
Date: Aug 28, 2023
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse by a Certified Nursing Assistant (CNA A) toward a resident (Resident #1).
Complaint Details
The complaint investigation was triggered by an allegation that CNA A verbally abused Resident #1 by cursing and threatening to laugh if the resident fell again. The allegation was deemed unsubstantiated after investigation, but counseling was provided for inappropriate conduct. The facility failed to report the allegation to the State Survey Agency within the required two-hour timeframe.
Findings
The facility failed to protect a resident from verbal abuse by a staff member who cursed at the resident. Additionally, the facility failed to timely report the allegation of abuse to the State Survey Agency within the required two-hour timeframe and failed to take appropriate protective actions by allowing the accused staff member to continue working independently before being sent home.
Deficiencies (3)
F 0600: The facility failed to protect a resident from verbal abuse when CNA A cursed at Resident #1, saying if the resident fell again, the CNA would laugh at them. Multiple staff witnessed and reported the incident.
F 0609: The facility failed to report the allegation of verbal abuse to the State Survey Agency within the required two-hour timeframe after the incident involving CNA A and Resident #1.
F 0610: The facility failed to take appropriate protective actions by allowing CNA A, accused of verbal abuse, to continue working independently with residents before being moved to a different hall and eventually sent home.
Report Facts
Facility census: 127
Residents sampled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Accused of verbally abusing Resident #1 by cursing and threatening to laugh if the resident fell again |
| RN F | Registered Nurse | Reported the incident to the Assistant Director of Nursing and intervened during the incident |
| RN G | Registered Nurse | Overheard CNA A's comments and intervened by telling CNA A to stop speaking to the resident that way |
| ADON | Assistant Director of Nursing | Spoke with CNA A about inappropriate comments and moved CNA A to a different hall |
| DON | Director of Nursing | Received reports of the incident and was responsible for reporting allegations to the State Survey Agency |
Inspection Report
Plan of Correction
Census: 120
Deficiencies: 2
Date: Jul 21, 2022
Visit Reason
The inspection was conducted to investigate a complaint regarding quality of care related to neurological assessments and condition changes of a resident after a fall.
Complaint Details
Complaint MO00204277 was investigated and substantiated as evidenced by the deficiencies cited.
Findings
The facility failed to properly assess and notify the provider of a resident's neurological condition changes after a fall. Documentation and staff interviews revealed inconsistent neurochecks and failure to notify the physician of abnormal findings.
Deficiencies (2)
F684 Quality of care: The facility failed to address one resident's neurological condition changes after a fall and did not notify the provider of abnormal neurological assessments.
A4075 Nursing care per resident condition: The facility did not provide personal attention and nursing care consistent with the resident's condition as evidenced by the deficiency in F684.
Report Facts
Deficiencies cited: 2
Facility census: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented resident's neurological assessments and noted failure to notify physician |
| Director of Nursing | Director of Nursing | Documented X-ray results and participated in corrective action plan |
| CNA B | Certified Nurse Aide | Observed resident condition and reported findings |
Inspection Report
Plan of Correction
Census: 127
Deficiencies: 1
Date: Mar 31, 2022
Visit Reason
The inspection was conducted to assess compliance with COVID-19 vaccination requirements for facility staff, including policies, procedures, and exemptions.
Findings
The facility failed to ensure 100% of staff were fully vaccinated for COVID-19 or granted a qualifying exemption. One staff member had a medical exemption not recognized by CDC guidelines.
Deficiencies (1)
F 888 COVID-19 Vaccination of facility staff. The facility failed to ensure all staff were fully vaccinated or had a qualifying exemption as required by federal regulations.
Report Facts
Facility census: 127
Total staff: 102
Staff with completed vaccination: 85
Staff with granted exemption: 17
Contracted staff: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Staff member with medical exemption not recognized by CDC |
Inspection Report
Routine
Census: 133
Deficiencies: 7
Date: Jul 20, 2021
Visit Reason
Routine inspection of Wilson's Creek Nursing & Rehab to assess compliance with health, safety, and regulatory standards.
Findings
The facility was found deficient in maintaining a clean and homelike environment, preventing abuse, providing adequate nutrition, ensuring medication administration accuracy, maintaining food safety and sanitation, and enforcing proper infection control practices including mask usage.
Deficiencies (7)
F 0584: The facility failed to maintain a clean, comfortable environment with persistent urine odors on the special care unit, stained bathroom floor tiles, and a non-functioning hot water faucet in a resident's room.
F 0600: A staff member verbally abused a resident by using curse words, causing emotional harm.
F 0692: The facility failed to consistently provide nutritional interventions and supplements for a resident with a history of weight loss.
F 0759: Medication error rate exceeded 5% due to failure to administer fast-acting insulin within appropriate time frames before meals for two residents.
F 0812: Dietary staff failed to wear beard nets, left trash cans uncovered, and stored leftover food uncovered in the walk-in freezer.
F 0880: Staff failed to wear masks properly around residents during COVID-19 outbreak, exposing residents and staff to infection risk.
F 0921: Dietary staff failed to clean metal wire shelves and intake vents in the kitchen, leading to accumulation of lint and dirt.
Report Facts
Medication error rate: 8
Facility census: 133
Weight loss: 8.59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Q | Certified Nurse Aide | Named in verbal abuse finding for using curse words toward Resident #107. |
| RN F | Registered Nurse | Interviewed regarding urine odors and medication administration. |
| CMT T | Certified Medication Technician | Observed wearing mask improperly and pushing unmasked resident. |
| Housekeeping Staff A | Observed wearing mask improperly and failing to follow infection control protocols. | |
| Dietary Manager O | Dietary Manager | Interviewed about food safety and cleaning practices. |
Inspection Report
Annual Inspection
Census: 133
Deficiencies: 7
Date: Jul 20, 2021
Visit Reason
Annual inspection survey conducted at Wilson's Creek Nursing & Rehab to assess compliance with federal and state regulations.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, freedom from abuse and neglect, nutrition and hydration status maintenance, medication error rates, infection prevention and control, food safety, and other regulatory requirements. Multiple observations and interviews documented issues such as urine odors and stains in the Special Care Unit, verbal abuse by staff, inadequate nutrition and hydration interventions, medication errors exceeding acceptable rates, and lapses in infection control and food safety practices.
Deficiencies (7)
F584 Safe Environment. The facility failed to maintain a clean, comfortable, and homelike environment with urine odors and stains in the Special Care Unit and a non-working hot water faucet in a resident's room.
F600 Free from Abuse and Neglect. A Certified Nurse Aide used curse words toward a resident, constituting verbal abuse.
F692 Nutrition/Hydration Status Maintenance. The facility failed to provide adequate nutritional interventions and hydration for a resident with weight loss and cognitive impairment.
F759 Medication Error Rates. The facility failed to ensure medication error rates were below 5%, with an 8% error rate observed.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. Dietary staff failed to wear beard nets and maintain food safety standards in the kitchen.
F880 Infection Prevention & Control. The facility failed to maintain an infection prevention program, including improper mask use and inadequate COVID-19 precautions.
F921 Safe/Functional/Sanitary/Comfortable Environment. The facility failed to clean metal wire shelves in the kitchen, allowing buildup of fuzzy lint.
Report Facts
Facility census: 133
Medication error rate: 8
Medication error rate threshold: 5
Resident count for medication error observation: 2
Medication opportunities observed: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Q | Certified Nurse Aide | Named in verbal abuse finding involving use of curse words toward a resident |
| RN F | Registered Nurse | Interviewed regarding urine odors and hot water faucet issues |
| Housekeeping Staff G | Interviewed regarding urine odors and cleaning efforts | |
| Maintenance Director | Interviewed regarding floor replacement and maintenance logs | |
| DON | Director of Nursing | Interviewed regarding staff behavior and medication administration policies |
| CNA P | Certified Nurse Aide | Interviewed regarding verbal abuse and resident interactions |
| CNA R | Certified Nurse Aide | Interviewed regarding staff mask use and resident interactions |
| Housekeeping Staff A | Observed not wearing mask properly and adjusting surveyor's mask | |
| Housekeeping Staff B | Observed mask use and resident room entry | |
| Dietary Manager (DM) O | Dietary Manager | Interviewed regarding food safety and kitchen practices |
| Dietary Supervisor (DS) K | Dietary Supervisor | Interviewed regarding food safety and kitchen practices |
| Certified Medication Technician (CMT) T | Certified Medication Technician | Observed medication administration and mask use |
| Licensed Practical Nurse (LPN) W | Licensed Practical Nurse | Interviewed regarding mask use policies |
Inspection Report
Plan of Correction
Census: 133
Deficiencies: 2
Date: May 10, 2021
Visit Reason
The inspection was conducted to investigate deficiencies related to respect, dignity, and resident rights at Wilson's Creek Nursing & Rehab.
Findings
The facility failed to ensure all residents were treated with respect and dignity, as evidenced by staff using profane language and rude behavior towards residents. Multiple interviews and observations confirmed inappropriate staff conduct and lack of adherence to resident care policies.
Deficiencies (2)
F 557 Respect, Dignity/Right to have Personal Property. The facility failed to ensure all residents were treated with respect and dignity, including use of profane language and rough handling by staff toward residents.
A8030 Dignity/Privacy. The facility did not meet regulations requiring residents to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care.
Report Facts
Facility census: 133
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 12, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 2
Date: Mar 9, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse involving a staff member and a resident at Wilson's Creek Nursing & Rehab.
Complaint Details
The complaint investigation substantiated that a staff member (Housekeeper HK A) engaged in a consensual sexual relationship with Resident #1. Multiple interviews and record reviews confirmed the incident and the facility's failure to prevent the abuse. The staff member was terminated following the incident.
Findings
The facility failed to protect one resident from abuse by a staff member who had a sexual relationship with the resident. The investigation found that the sexual activity was consensual but violated facility policies and regulatory requirements.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation was not met as the facility failed to protect a resident from sexual abuse by a staff member. The facility census was 131 at the time of the incident.
A4073 Protective Oversight, Voluntary Leave was not met as the facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, related to the F600 deficiency.
Report Facts
Facility census: 131
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK A | Housekeeper | Named in sexual abuse finding involving Resident #1 |
| CNA B | Certified Nursing Assistant | Witnessed and reported the incident involving Resident #1 and HK A |
| LPN C | Licensed Practical Nurse | Interviewed Resident #1 and observed the incident |
| RN D | Registered Nurse | Interviewed Resident #1 and involved in investigation |
| HK G | Housekeeping Supervisor | Provided training on abuse and neglect and interviewed during investigation |
| CNA F | Certified Nursing Assistant | Observed incident and reported during investigation |
| CNA E | Certified Nursing Assistant | Interviewed during investigation, denied concerns |
| CNA H | Certified Nursing Assistant | Informed of inappropriate relationship, had training on abuse and neglect |
| Director of Nursing | DON | Interviewed regarding concerns and facility policies |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 22, 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
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 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.
Complaint Details
This was a complaint investigation related to COVID-19 focused infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 9, 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: Oct 20, 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 infection control practices for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Census: 126
Deficiencies: 3
Date: Oct 31, 2019
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal and state regulations regarding resident rights, food safety, and accessibility of survey results.
Findings
The facility failed to ensure staff treated residents with dignity and respect, failed to post prior survey results in an accessible location, and failed to maintain proper food safety standards including storage and sanitation of food and kitchen equipment.
Deficiencies (3)
F 0550: The facility failed to ensure staff treated two residents with dignity and respect when a staff member spoke to them in a demeaning manner.
F 0577: The facility failed to ensure prior survey results were posted in a readily accessible public location for residents and their representatives.
F 0812: The facility failed to ensure food was stored and served in accordance with professional standards, including undated or uncovered food in refrigerators and unsanitary conditions of cookware drying areas and food storage bins.
Report Facts
Facility census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Named in dignity and respect deficiency for speaking to residents in a demeaning manner | |
| Director of Nursing (DON) | Interviewed regarding staff expectations for resident respect and dignity | |
| Administrator | Interviewed regarding training on resident rights and accessibility of survey results | |
| Dietary Manager (DM) | Interviewed regarding food safety and cleaning practices | |
| Kitchen Supervisor (KS) | Interviewed regarding food thawing and dating procedures |
Inspection Report
Annual Inspection
Census: 126
Deficiencies: 3
Date: Oct 31, 2019
Visit Reason
The inspection was an annual survey of Wilson's Creek Nursing & Rehab to assess compliance with federal and state regulations regarding resident rights, food safety, and posting of survey results.
Findings
The facility was found deficient in treating residents with dignity and respect, posting survey results in an accessible location, and maintaining food safety standards including proper storage, preparation, and sanitation. The facility census was 126 during the inspection.
Deficiencies (3)
F550 Resident Rights: The facility failed to ensure staff treated two residents with dignity and respect, including inappropriate communication by a Licensed Practical Nurse.
F577 Right to Survey Results: The facility failed to post prior survey results in a readily accessible public location for residents and family members.
F812 Food Safety: The facility failed to store and serve food in accordance with professional food safety standards, including uncovered food with grease buildup and unlabeled thawing food.
Report Facts
Facility Census: 126
Inspection Report
Life Safety
Census: 126
Capacity: 172
Deficiencies: 3
Date: Oct 31, 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 ensure that exit discharge surfaces were properly maintained as hard packed all-weather travel surfaces, did not document quarterly sprinkler system tests, and failed to maintain smoke barrier doors properly, allowing them to remain partially open after fire alarm activation.
Deficiencies (3)
K271 Discharge from Exits: The facility failed to ensure exit discharge surfaces were hard packed all-weather travel surfaces, affecting egress paths from multiple emergency exits.
K353 Sprinkler System - Maintenance and Testing: The facility failed to document quarterly sprinkler system tests and did not perform required inspections and tests for the past year.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to maintain smoke barrier doors properly, allowing two sets of doors to remain partially open after fire alarm activation, compromising smoke resistive properties.
Report Facts
Facility capacity: 172
Census: 126
Inspection Report
Annual Inspection
Census: 143
Capacity: 172
Deficiencies: 3
Date: Nov 5, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations, including ventilation and communicable disease control.
Findings
The facility failed to maintain adequate bathroom exhaust ventilation and did not ensure timely tuberculosis skin testing for newly hired employees. Corrective actions and education were initiated to address these deficiencies.
Deficiencies (3)
F 923 Ventilation: The facility failed to maintain the residents' bathroom exhaust ventilation system in proper working condition, with 11 residents' bathrooms lacking functioning exhaust vents.
A4029 Communicable Disease-Employees: The facility failed to ensure all newly hired employees were properly screened for tuberculosis, with two of eight sampled employees not receiving timely TB skin tests.
A6008 Sufficient Ventilation: The facility did not maintain ventilation systems to prevent excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes as required.
Report Facts
Facility census: 143
Facility capacity: 172
Employees sampled for TB testing: 8
Employees not tested timely: 2
Residents' bathrooms without functioning exhaust vents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in tuberculosis skin test deficiency |
| Social Service B | Social Service Employee | Named in tuberculosis skin test deficiency |
| Director of Nursing | Director of Nursing | Responsible for administering TB tests and education on communicable disease policies |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding ventilation system issues and follow-up checks |
Inspection Report
Annual Inspection
Census: 143
Capacity: 172
Deficiencies: 2
Date: Nov 5, 2018
Visit Reason
Annual recertification survey to assess compliance with Life Safety Code and other regulatory requirements.
Findings
The facility failed to ensure smoke barrier doors operated correctly during fire alarm activation, posing a risk to residents and staff. No emergency preparedness deficiencies were cited.
Deficiencies (2)
K363 Corridor doors did not close and latch completely, allowing smoke to enter different compartments. The facility failed to ensure smoke barrier doors operated correctly during fire alarm activation.
A3001 The building is not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2).
Report Facts
Facility capacity: 172
Resident census: 143
Inspection Report
Annual Inspection
Census: 151
Capacity: 151
Deficiencies: 4
Date: Jan 12, 2018
Visit Reason
Annual survey conducted from 01/04/2018 to 01/12/2018 to assess compliance with federal regulations including abuse prevention and food safety.
Findings
The facility was found not in compliance with requirements related to abuse prevention, reporting of alleged violations, and food safety. Deficiencies included failure to protect residents from abuse, failure to report allegations timely, and failure to maintain sanitary food contact surfaces.
Deficiencies (4)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to protect a resident from abuse when Resident #59 attempted to barricade in Resident #86's room, emptied a gallon jug of water on Resident #86, and hit Resident #86 with the empty jug.
F609 Reporting of Alleged Violations: The facility failed to report an allegation of abuse involving Resident #59 and Resident #86 within required timeframes and did not complete a thorough investigation.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate allegations of abuse and ensure corrective actions were taken.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain food contact surfaces in a clean sanitary manner, including a black substance buildup on the ice machine's plastic ice reflector shield and grease and lint buildup on range hood extinguishing system pipes.
Report Facts
Facility census: 151
Deficiency sample size: 30
Dates of incident: Dec 29, 2017
Dates of follow-up: Jan 10, 2018
Dates of correction: Jan 25, 2018
Inspection Report
Life Safety
Census: 151
Capacity: 172
Deficiencies: 3
Date: Jan 12, 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 maintain the smoke barrier wall in the attic, conduct quarterly fire drills at unexpected times, and maintain electrical outlets in resident rooms safely. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (3)
K372: The facility failed to maintain the smoke barrier wall in the attic, allowing a gap between the gypsum board and roof deck that could permit smoke passage.
K712: The facility failed to conduct quarterly fire drills at unexpected times, potentially delaying staff response to actual emergencies.
K919: The facility failed to maintain electrical outlets in resident rooms safely by allowing items to place pressure on plugs, risking fire hazards.
Report Facts
Deficiencies cited: 3
Facility capacity: 172
Census: 151
Document
Deficiencies: 0
Visit Reason
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Findings
No findings or content are available due to lack of readable text.
Document
Deficiencies: 0
Visit Reason
The document does not contain any information regarding an inspection or regulatory visit.
Findings
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