Inspection Reports for
Wilson’s Creek Nursing &Amp; Rehab
3403 WEST MT VERNON, SPRINGFIELD, MO, 65802-5241
Back to Facility Profile13 Reports
Inspection Report — Dec 7, 2023
Routine
Date: Dec 7, 2023
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal deficiency for infection prevention and control concerning improper timing of two-step TB skin testing for staff, and one Missouri licensure deficiency for communicable disease-employee screening that refers to the federal finding.
Deficiencies (1)
19 CSR 30-85.042(27) Communicable Disease-Employees: Please refer to F880.
Report Facts
employees affected: 5
Inspection Report — Aug 28, 2023
Complaint Investigation
Date: Aug 28, 2023
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Federal CMS-2567 health survey and accompanying Missouri Department of Health and Senior Services State Form were included; the file documents a complaint investigation. The complaint referenced is MO000223585.
Complaint Details
Complaint MO000223585; the facility investigation (8/31/2023) concluded the abuse allegation was unsubstantiated and family of Resident #1 denied abuse concerns, as noted in facility records.
Findings
Six deficiencies were cited: three federal health deficiencies addressing resident abuse, failure to report alleged abuse, and failure to investigate/prevent alleged abuse; and three Missouri licensure deficiencies addressing protective oversight, abuse/neglect policies, and reporting requirements.
Deficiencies (3)
19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: See the deficiency cited at F600.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Please refer to F609. Please refer to F610.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Please refer to F609.
Report Facts
residents sampled: 6
residents affected: 1
Inspection Report — Jul 21, 2022
Complaint Investigation
Date: Jul 21, 2022
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CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form; complaint investigation (Complaint MO00204277).
Findings
Two deficiencies were cited: one federal quality-of-care deficiency involving failure to assess and notify the provider about a resident's neurological change after a fall, and one Missouri state nursing care deficiency referencing the federal finding. Main topics are neurological assessment after a fall and failure to notify the provider.
Deficiencies (1)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Please refer to F684.
Inspection Report — Jul 20, 2021
Life Safety
Date: Jul 20, 2021
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Federal Life Safety survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Eleven deficiencies were cited: six federal Life Safety (K) deficiencies addressing building construction and ceiling penetrations, egress/exit doors, fire alarm testing and maintenance, corridor doors, smoke barrier construction, and gas/oxygen storage; and five Missouri state citations addressing oxygen storage, fire alarm testing/maintenance, smoke section walls/doors, door devices, and substantial building construction/maintenance that refer to the federal findings.
Deficiencies (5)
19 CSR 30-85.022(6) Oxygen Storage: Please refer to K923.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Please refer to K345.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Please refer to K372.
19 CSR 30-85.022(30) Door Devices: Please refer to K222.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Please refer to K161 and K363.
Report Facts
oxygen_canisters_total: 44
oxygen_canisters_with_plastic_ring: 25
Inspection Report — Jul 20, 2021
Complaint Investigation
Date: Jul 20, 2021
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This file contains a CMS-2567 federal health survey and a Missouri Department of Health and Senior Services State Form licensure survey; Missouri complaint numbers MO00185115 and MO00188326 are cited in the record. The survey type is not otherwise stated.
Complaint Details
Complaint numbers cited: MO00185115 and MO00188326; the record does not state whether the allegations were substantiated.
Findings
There are 7 federal health survey deficiencies involving the facility environment/homelike conditions, resident abuse/neglect concerns, nutrition/hydration and meal assistance, medication administration errors, food procurement/handling, infection prevention and sanitation. There are 13 Missouri State Form licensure deficiencies that reference and cross‑cite the federal findings and address medication systems, oversight/voluntary leave, nursing care, mealtime assistance, infection control/communicable disease, odor elimination, floor surfaces, cleanable fixtures/vent covers, kitchen waste containers, lavatory/fixtures, clothing/hair restraints and food protection.
Deficiencies (13)
19 CSR 30-85.042(47) Safe/Effective Medication System: Please refer to F759.
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Please refer to F600.
19 CSR 30-85.042(67) Nursing Care per Res Condition: Please see F692.
19 CSR 30-85.042(72) Mealtime Assistance/Supervision: Please refer to F692.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: Please refer to F880.
19 CSR 30-87.020(11) No Deodorizers/Sprays to Eliminate Odors: Please refer to F584.
19 CSR 30-87.020(12) Floor Surfaces: Please refer to F584.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: Please refer to F921.
19 CSR 30-87.020(31) Kitchen Waste Containers Covered: Please refer to F812.
19 CSR 30-87.020(45) Lavatory/Fixtures Clean/Good Repair: Please refer to F584.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Please refer to F812.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Please refer to F812.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: Please refer to F921.
Report Facts
residents affected: 12
medication error rate (percent): 8
Inspection Report — May 10, 2021
Complaint Investigation
Date: May 10, 2021
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure survey; the file documents a complaint investigation citing MO00185028.
Complaint Details
MO00185028; substantiation not indicated in the record.
Findings
Two deficiencies were cited: one federal health deficiency for resident respect/dignity involving staff verbal and physical handling of residents, and one Missouri state dignity/privacy citation that references the federal finding.
Deficiencies (1)
19 CSR 30-88.010(29) Dignity/Privacy: See the deficiency cited at F557.
Inspection Report — Mar 9, 2021
Complaint Investigation
Date: Mar 9, 2021
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Federal health survey (CMS-2567) with an accompanying Missouri State Form; complaint investigation MO00182399 is cited.
Complaint Details
MO00182399; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal health citation for failure to ensure freedom from abuse and neglect, and one Missouri licensure citation for protective oversight/voluntary leave (Class II referencing the federal finding).
Deficiencies (1)
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Please see F600.
Report Facts
residents affected: 1
Inspection Report — Oct 31, 2019
Life Safety
Date: Oct 31, 2019
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CMS-2567 Life Safety Code survey (K-tags) and Missouri Department of Health and Senior Services State Form; life safety survey.
Findings
Five deficiencies were cited in this file: three federal K-tag life safety deficiencies addressing exit discharge, sprinkler system maintenance/testing, and smoke barrier doors, and two Missouri state deficiencies (both Class II) regarding sprinkler system testing/maintenance and smoke section walls/doors.
Deficiencies (2)
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Please refer to K-353.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Please refer to K-374.
Inspection Report — Oct 31, 2019
Routine
Date: Oct 31, 2019
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
The file contains 3 federal health deficiencies addressing resident rights/dignity, posting of survey results/advocate information, and food procurement/food safety, and 4 Missouri state deficiencies addressing thawing potentially hazardous foods, nonfood contact surfaces cleaning, inspection reports posted, and dignity/privacy.
Deficiencies (4)
19 CSR 30-87.030(33) Thawing Potentially Hazardous Foods: See the deficiency cited at F812.
19 CSR 30-87.030(54) Nonfood Contact Surfaces, Cleaning: Please refer to F812.
19 CSR 30-88.010(2) Noncompliance/Inspection Reports Posted: Please refer to F577.
19 CSR 30-88.010(29) Dignity/Privacy: Please refer to F550.
Inspection Report — Nov 5, 2018
Routine
Date: Nov 5, 2018
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure pages; the survey type is not stated.
Findings
3 deficiencies: one federal ventilation deficiency and two Missouri state deficiencies involving employee communicable disease screening (TB testing) and insufficient ventilation.
Deficiencies (2)
19 CSR 30-85.042(27) Communicable Disease-Employees: Based on interview and record review, the facility failed to ensure newly hired employees were properly screened for tuberculosis; two of eight sampled employees did not receive TB skin testing in a timely manner and staff did not document administration of the second step of the TB skin test.
19 CSR 30-87.020(8) Sufficient Ventilation: See the deficiency cited at F-923.
Report Facts
employees sampled: 8
employees affected: 2
resident bathrooms without functioning exhaust vents: 11
Inspection Report — Nov 5, 2018
Life Safety
Date: Nov 5, 2018
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CMS-2567 life safety survey (annual recertification stated on the CMS-2567) and a Missouri Department of Health and Senior Services State Form (state licensure).
Findings
Two deficiencies were cited: one federal life-safety deficiency regarding smoke barrier/corridor doors failing to operate properly, and one Missouri state licensure deficiency for building construction/maintenance which references the life-safety finding.
Deficiencies (1)
19 CSR 30-85.032(2) Substantially Constructed/Maintained: See the deficiency cited at K363.
Inspection Report — Jan 12, 2018
Routine
Date: Jan 12, 2018
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 4 federal deficiencies addressing resident-to-resident abuse (failure to protect, report, and investigate) and food service sanitation, and 4 Missouri State Form deficiencies addressing food protection/ice storage and abuse policy/reporting.
Deficiencies (4)
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Please refer to F812.
19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap: Please refer to F812.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Please refer to F600 and F610.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Please refer to F609.
Report Facts
residents selected for review: 32
interviewable residents asked: 9
staff members asked: 5
Inspection Report — Jan 12, 2018
Life Safety
Date: Jan 12, 2018
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Federal Life Safety survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 3 federal life safety deficiencies related to a smoke barrier not being sealed, deficiencies in fire drill practices, and electrical outlet/equipment hazards, and 2 Missouri state licensure deficiencies referencing smoke section walls/doors and electrical wiring/equipment.
Deficiencies (2)
19 CSR 30-85.022(29) Smoke Section Walls/Doors: See the deficiency cited at K-372.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Please refer to K-919.
24 CMS Surveys
Inspection Report — Dec 7, 2023
Routine
Date: Dec 7, 2023
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal deficiency for infection prevention and control concerning improper timing of two-step TB skin testing for staff, and one Missouri licensure deficiency for communicable disease-employee screening that refers to the federal finding.
Deficiencies (1)
F880 Infection Prevention & Control: Based on observation and record review, the facility failed to maintain an effective infection control program when staff failed to follow manufacturer guidelines and facility policy by administering the second step of a required two-step tuberculosis (TB) skin test outside recommended timing for five staff members.
Report Facts
employees affected: 5
Inspection Report — Dec 6, 2023
Life Safety
Date: Dec 6, 2023
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CMS-2567 Life Safety (K-tag) survey (Life Safety Code Survey stated in the initial comments). The file contains only the federal Life Safety portion.
Findings
Six life safety deficiencies were cited regarding emergency lighting at the generator transfer switch, hazardous area door closures, fire alarm smoke detection at the fire alarm control panel, sprinkler system maintenance and testing, smoke barrier penetrations and damper inspection, and oxygen cylinder storage.
Deficiencies (6)
K291 Emergency Lighting: The facility failed to ensure emergency lighting was provided at the emergency generator transfer switch; the deficient practice had the potential to affect all 128 residents.
K321 Hazardous Areas - Enclosure: The facility failed to separate hazardous areas from other parts of the facility when two self-closing doors failed to self-close and latch, and doors were being held open with devices not tied to the fire alarm system; the deficient practice had the potential to affect all 128 residents.
K341 Fire Alarm System - Installation: The facility failed to provide smoke automatic detection at the fire alarm control unit/panel so the panel was not monitored for smoke detection; the deficient practice had the potential to affect all 128 residents.
K353 Sprinkler System - Maintenance and Testing: Based on record review and interview, the facility failed to maintain required sprinkler inspection and testing records and failed to complete all required quarterly tests and inspections for the dry sprinkler system.
K372 Subdivision of Building Spaces - Smoke Barrie: The facility failed to maintain smoke barriers (unsealed penetrations and missing access panels for dampers) and to provide documentation of four-year testing of smoke dampers; the deficient practice had the potential to affect all 128 residents.
K923 Gas Equipment - Cylinder and Container Storag: The facility failed to meet oxygen storage requirements of NFPA 99 when combustible materials were stored within five feet of oxygen cylinders and empty/full cylinders were not identified or segregated; this had the potential to affect staff and residents in the smoke compartment.
Report Facts
oxygen cylinders stored: 50
Inspection Report — Nov 30, 2023
Routine
Date: Nov 30, 2023
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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
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 — Aug 28, 2023
Complaint Investigation
Date: Aug 28, 2023
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Federal CMS-2567 health survey and accompanying Missouri Department of Health and Senior Services State Form were included; the file documents a complaint investigation. The complaint referenced is MO000223585.
Complaint Details
Complaint MO000223585; the facility investigation (8/31/2023) concluded the abuse allegation was unsubstantiated and family of Resident #1 denied abuse concerns, as noted in facility records.
Findings
Six deficiencies were cited: three federal health deficiencies addressing resident abuse, failure to report alleged abuse, and failure to investigate/prevent alleged abuse; and three Missouri licensure deficiencies addressing protective oversight, abuse/neglect policies, and reporting requirements.
Deficiencies (3)
F600 Free from Abuse and Neglect: The facility failed to protect a resident from verbal abuse when a CNA cursed at Resident #1; documentation and interviews showed the incident and subsequent facility investigation.
F609 Reporting of Alleged Violations: The facility failed to report an allegation of verbal abuse to the State Survey Agency within the required timeframes when staff reported that a CNA was verbally abusive to a resident.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to take adequate steps to protect residents and to thoroughly investigate and prevent further potential abuse after staff reported that a CNA acted abusively.
Report Facts
residents sampled: 6
residents affected: 1
Inspection Report — Jul 21, 2022
Complaint Investigation
Date: Jul 21, 2022
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CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form; complaint investigation (Complaint MO00204277).
Findings
Two deficiencies were cited: one federal quality-of-care deficiency involving failure to assess and notify the provider about a resident's neurological change after a fall, and one Missouri state nursing care deficiency referencing the federal finding. Main topics are neurological assessment after a fall and failure to notify the provider.
Deficiencies (1)
F 684 Quality of Care: Based on interview and record review, the facility failed to assess and notify the provider about a resident's change in neurological status after a fall, including abnormal hand grip findings.
Inspection Report — Mar 31, 2022
Routine
Date: Mar 31, 2022
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Federal health survey (CMS-2567); the survey type is not stated.
Findings
One federal health deficiency related to staff COVID-19 vaccination practices; the surveyor found the facility failed to ensure all staff were fully vaccinated and that an agency staff member had a medical exemption not recognized by CDC.
Deficiencies (1)
F 888 COVID-19 Vaccination of Facility Staff: Based on interview and record review the facility failed to ensure 100% of staff were fully vaccinated for COVID-19 and one agency staff member (Employee A) had a medical exemption not recognized as a contraindication by CDC.
Report Facts
Total staff: 102
Staff with completed vaccination: 85
Staff with granted exemption (medical or non-medical): 17
Contracted staff (therapy, hospice, quality assurance nurse, beautician, registered dietician): 25
Inspection Report — Jul 20, 2021
Life Safety
Date: Jul 20, 2021
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Federal Life Safety survey (CMS-2567) with accompanying Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
Eleven deficiencies were cited: six federal Life Safety (K) deficiencies addressing building construction and ceiling penetrations, egress/exit doors, fire alarm testing and maintenance, corridor doors, smoke barrier construction, and gas/oxygen storage; and five Missouri state citations addressing oxygen storage, fire alarm testing/maintenance, smoke section walls/doors, door devices, and substantial building construction/maintenance that refer to the federal findings.
Deficiencies (6)
K161 Building Construction Type and Height: The facility failed to maintain the integrity of the building construction when staff failed to maintain the one-hour fire rating of ceilings where there were unsealed penetrations between the attic and areas below and failed to enclose wall studs in the laundry room with drywall or other fire-resistant material, creating openings that could allow smoke to pass between the attic and occupied areas.
K222 Egress Doors: The facility failed to maintain exit egress doors in a manner usable by all residents, staff, and visitors; observations showed exit doors that were stuck/tight and required excessive force or multiple attempts to open, which could delay exit time in a fire.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain the complete fire alarm system when audible alarms or visible strobes did not activate during the annual alarm test, resulting in delayed or absent alarm notifications during testing.
K363 Corridor - Doors: The facility failed to maintain the smoke-resistive properties of corridor doors by allowing unsealed areas and gaps around doors, which could permit smoke to pass from rooms into the exit corridor.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain the smoke-resistive properties of smoke barrier walls (SBW) with observed cutouts, holes and unsealed gaps in the attic area and above the activity area that could allow passage of smoke between compartments.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to keep oxygen canisters separated from combustibles by five feet or more and failed to display signage indicating full or empty oxygen canisters; observations showed numerous canisters stored adjacent to combustibles and lack of required signage.
Report Facts
oxygen_canisters_total: 44
oxygen_canisters_with_plastic_ring: 25
Inspection Report — Jul 20, 2021
Complaint Investigation
Date: Jul 20, 2021
Visit Reason
This file contains a CMS-2567 federal health survey and a Missouri Department of Health and Senior Services State Form licensure survey; Missouri complaint numbers MO00185115 and MO00188326 are cited in the record. The survey type is not otherwise stated.
Complaint Details
Complaint numbers cited: MO00185115 and MO00188326; the record does not state whether the allegations were substantiated.
Findings
There are 7 federal health survey deficiencies involving the facility environment/homelike conditions, resident abuse/neglect concerns, nutrition/hydration and meal assistance, medication administration errors, food procurement/handling, infection prevention and sanitation. There are 13 Missouri State Form licensure deficiencies that reference and cross‑cite the federal findings and address medication systems, oversight/voluntary leave, nursing care, mealtime assistance, infection control/communicable disease, odor elimination, floor surfaces, cleanable fixtures/vent covers, kitchen waste containers, lavatory/fixtures, clothing/hair restraints and food protection.
Deficiencies (7)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a clean, comfortable, homelike environment on the Special Care Unit as evidenced by pervasive urine odors, urine on the floor, stained/soiled floor tiles and a non-working hot water faucet in a resident bathroom.
F600 Free from Abuse and Neglect: Based on record review and interviews, staff used curse words to speak to a resident and the facility failed to ensure residents were free from verbal abuse by staff.
F692 Nutrition/Hydration Status Maintenance: The facility failed to consistently provide required nutritional interventions and assistance for a resident with documented weight loss and did not ensure ordered fortified supplements were available and administered.
F759 Free of Medication Error Rts 5 Prcnt or More: The facility had a medication error rate that exceeded 5% for fast-acting insulin administration for two residents, resulting in an observed error rate of 8%.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to store and prepare food in accordance with professional standards, including uncovered trash receptacles and uncovered food left to cool in the walk-in, and staff not using appropriate hair/beard restraints.
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program and failed to ensure staff consistently wore masks and appropriate PPE, with multiple observations of staff masks worn below nose/mouth and exposed residents and staff.
F921 Safe/Functional/Sanitary/Comfortable Environ: Dietary staff failed to clean metal wire shelving and intake vents were observed with a build-up of lint; overall kitchen/storage sanitation and cleanliness issues were documented.
Report Facts
residents affected: 12
medication error rate (percent): 8
Inspection Report — May 10, 2021
Complaint Investigation
Date: May 10, 2021
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure survey; the file documents a complaint investigation citing MO00185028.
Complaint Details
MO00185028; substantiation not indicated in the record.
Findings
Two deficiencies were cited: one federal health deficiency for resident respect/dignity involving staff verbal and physical handling of residents, and one Missouri state dignity/privacy citation that references the federal finding.
Deficiencies (1)
F 557 Respect, Dignity/Right to have Prsnl Property: Based on record review, observation, and interviews, staff (including a CNA) spoke to residents in a rude manner, used profane language, and handled a resident roughly; multiple residents reported or were observed experiencing disrespectful treatment.
Inspection Report — Apr 12, 2021
Complaint Investigation
Date: Apr 12, 2021
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CMS-2567 federal survey (COVID-19 Focused Infection Control and Emergency Preparedness); the document states this was a complaint investigation.
Findings
No federal health or emergency preparedness deficiencies were cited; the survey found the facility in compliance with COVID-19 infection control and emergency preparedness requirements.
Inspection Report — Mar 9, 2021
Complaint Investigation
Date: Mar 9, 2021
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Federal health survey (CMS-2567) with an accompanying Missouri State Form; complaint investigation MO00182399 is cited.
Complaint Details
MO00182399; substantiation not stated in the document.
Findings
Two deficiencies were cited: one federal health citation for failure to ensure freedom from abuse and neglect, and one Missouri licensure citation for protective oversight/voluntary leave (Class II referencing the federal finding).
Deficiencies (1)
F 600 Free from Abuse and Neglect: Based on interviews and record review, the facility failed to protect one resident (Resident #1) from abuse when one staff member (Housekeeper HK A) had a sexual relationship with the resident.
Report Facts
residents affected: 1
Inspection Report — Dec 22, 2020
Routine
Date: Dec 22, 2020
Visit Reason
CMS-2567 federal health and emergency preparedness forms; a COVID-19 Focused Infection Control and Emergency Preparedness survey was conducted, as stated in the Initial Comments.
Findings
No deficiencies were cited. The surveyor documented the facility was found in compliance with 42 CFR 483.73 related to E-0024(b)(6) and with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Nov 13, 2020
Complaint Investigation
Date: Nov 13, 2020
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Federal CMS-2567 health and emergency preparedness survey. A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted and the file states it was a complaint investigation.
Findings
No deficiencies were cited on this CMS-2567; the survey covered COVID-19 focused emergency preparedness and infection control.
Inspection Report — Nov 9, 2020
Routine
Date: Nov 9, 2020
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Federal CMS-2567 health survey. The document states a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted on 11/09/2020.
Findings
No deficiencies were cited. The facility was found to be in compliance with the referenced COVID-19 emergency preparedness and infection control requirements.
Inspection Report — Oct 20, 2020
Routine
Date: Oct 20, 2020
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CMS-2567 (federal health) documenting a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey; no complaint or revisit is stated in the file.
Findings
No health or emergency preparedness deficiencies were cited on the CMS-2567; the facility was found in compliance with CMS and CDC recommended practices for COVID-19 and with 42 CFR 483.73.
Inspection Report — Aug 26, 2020
Complaint Investigation
Date: Aug 26, 2020
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Federal CMS-2567 health and emergency preparedness survey (COVID-19 Focused Infection Control Survey); the file states it was conducted as a complaint investigation.
Findings
No health survey deficiencies were cited; the facility was found in compliance with CMS and CDC recommended practices for COVID-19 and with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Jul 20, 2020
Complaint Investigation
Date: Jul 20, 2020
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CMS-2567 federal health survey (COVID-19 Focused Infection Control and Emergency Preparedness survey); the form states this was a complaint investigation.
Findings
No deficiencies were cited on this complaint investigation; the surveyor found the facility in compliance with CMS and CDC recommended practices for COVID-19 and with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — May 27, 2020
Routine
Date: May 27, 2020
Visit Reason
Federal CMS-2567 health survey; the Initial Comments state this was a COVID-19 Focused Emergency Preparedness and Infection Control survey.
Findings
No deficiencies were cited. The Initial Comments state the facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6) and with CMS/CDC recommended practices for COVID-19.
Inspection Report — Oct 31, 2019
Life Safety
Date: Oct 31, 2019
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CMS-2567 Life Safety Code survey (K-tags) and Missouri Department of Health and Senior Services State Form; life safety survey.
Findings
Five deficiencies were cited in this file: three federal K-tag life safety deficiencies addressing exit discharge, sprinkler system maintenance/testing, and smoke barrier doors, and two Missouri state deficiencies (both Class II) regarding sprinkler system testing/maintenance and smoke section walls/doors.
Deficiencies (3)
K271 Discharge from Exits: Based on observation, interview, and record review, the facility failed to ensure exit discharges from designated exits were a hard-packed all-weather travel surface terminating at the public way; several exit sidewalks did not extend to the public way and did not provide a continuous means of egress.
K353 Sprinkler System - Maintenance and Testing: Based on record review and interview, the facility failed to document that required quarterly sprinkler tests and associated inspections were performed, leaving sprinkler testing/maintenance records incomplete.
K374 Subdivision of Building Spaces - Smoke Barrie: Based on observation, interview, and record review, the facility failed to maintain smoke resistant properties by allowing two sets of Smoke Barrier Doors to remain partially open or to have excessive gaps after fire alarm activation, compromising the smoke barrier.
Inspection Report — Oct 31, 2019
Routine
Date: Oct 31, 2019
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Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
The file contains 3 federal health deficiencies addressing resident rights/dignity, posting of survey results/advocate information, and food procurement/food safety, and 4 Missouri state deficiencies addressing thawing potentially hazardous foods, nonfood contact surfaces cleaning, inspection reports posted, and dignity/privacy.
Deficiencies (3)
F550 Resident Rights/Exercise of Rights: Based on observation, interview, and record review, the facility failed to ensure staff treated two residents with dignity and respect when a staff member spoke to residents in a demeaning manner.
F577 Right to Survey Results/Advocate Agency Info: The facility failed to ensure the prior survey results were posted in a readily accessible public location; residents reported they did not know where results were kept and the posted notification was small and difficult to see.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: The facility failed to ensure food was stored, prepared, and served in accordance with food safety standards; observations found thawed, undated/unlabeled food, greasy equipment, and unsanitary storage that could lead to contamination.
Inspection Report — Nov 5, 2018
Routine
Date: Nov 5, 2018
Visit Reason
Federal CMS-2567 health survey and Missouri Department of Health and Senior Services State Form licensure pages; the survey type is not stated.
Findings
3 deficiencies: one federal ventilation deficiency and two Missouri state deficiencies involving employee communicable disease screening (TB testing) and insufficient ventilation.
Deficiencies (1)
F923 Ventilation: Based on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation system in proper working condition when 11 residents' bathrooms did not have functioning exhaust vents; the attic fan/motor or belt was not functioning and staff were unaware the system needed monitoring.
Report Facts
employees sampled: 8
employees affected: 2
resident bathrooms without functioning exhaust vents: 11
Inspection Report — Nov 5, 2018
Life Safety
Date: Nov 5, 2018
Visit Reason
CMS-2567 life safety survey (annual recertification stated on the CMS-2567) and a Missouri Department of Health and Senior Services State Form (state licensure).
Findings
Two deficiencies were cited: one federal life-safety deficiency regarding smoke barrier/corridor doors failing to operate properly, and one Missouri state licensure deficiency for building construction/maintenance which references the life-safety finding.
Deficiencies (1)
K363 Corridor - Doors: Based on observation and interview, the facility failed to ensure the smoke barrier doors operated correctly when the fire alarm was activated; some doors did not latch, close, or release properly, potentially allowing smoke to enter adjacent compartments and affecting residents, staff and visitors.
Inspection Report — Jan 12, 2018
Routine
Date: Jan 12, 2018
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 4 federal deficiencies addressing resident-to-resident abuse (failure to protect, report, and investigate) and food service sanitation, and 4 Missouri State Form deficiencies addressing food protection/ice storage and abuse policy/reporting.
Deficiencies (4)
F600 Free from Abuse and Neglect: Based on observation, interview, and record review, the facility failed to protect a resident from abuse when Resident #59 poured a gallon jug of water on Resident #86 and struck Resident #86 with the empty jug.
F609 Reporting of Alleged Violations: Based on observation, interview, and record review, the facility failed to report an allegation of abuse involving Resident #59 and Resident #86 to the appropriate officials as required.
F610 Investigate/Prevent/Correct Alleged Violation: Based on observation, interview, and record review, the facility failed to complete a thorough investigation of the resident-to-resident allegation of abuse between Resident #59 and Resident #86.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Based on observation, interviews, and record review, the facility failed to maintain food contact surfaces and food service equipment in a sanitary manner, including accumulation of a black substance inside the ice machine's plastic ice reflector shield and build-up of grease and lint on range hood extinguishing pipes.
Report Facts
residents selected for review: 32
interviewable residents asked: 9
staff members asked: 5
Inspection Report — Jan 12, 2018
Life Safety
Date: Jan 12, 2018
Visit Reason
Federal Life Safety survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
There are 3 federal life safety deficiencies related to a smoke barrier not being sealed, deficiencies in fire drill practices, and electrical outlet/equipment hazards, and 2 Missouri state licensure deficiencies referencing smoke section walls/doors and electrical wiring/equipment.
Deficiencies (3)
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The smoke barrier wall (SBW) in the attic was not sealed at the top, leaving a 1/2 to 1-inch gap that could allow smoke to pass to unaffected compartments.
K712 Fire Drills: The facility failed to conduct required quarterly fire drills at unexpected times; records showed drills were conducted during the last week of the month.
K919 Electrical Equipment - Other: The facility failed to maintain outlets in resident rooms in a safe manner by allowing items and furniture to place pressure on plugs and outlets, creating a potential for short or fire.
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