Inspection Results
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Facility failed to meet the following Requirement(s):Corrected DateLevel of HarmResidents Affected
Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. I/II 1. For a facility whose plans were approved on or before December 31, 1987, or a facility licensed for twenty (20) or fewer beds, one (1) of the required exits from a multi-story facility shall be an outside stairway or an enclosed stairway that is separated by one- (1-) hour rated construction from each floor with an exit leading directly to the outside at grade level. Existing plaster or gypsum board of at least one-half inch (1/2") thickness may be considered equivalent to one- (1-) hour rated construction. The other required exit may be an interior stairway leading through corridors or passageways to outside or to a two- (2-) hour rated horizontal exit as defined by paragraph 3.3.61 of the 2000 edition NFPA 101. Neither of the required exits shall lead through a furnace or boiler room. Neither of the required exits shall be through a resident ' s bedroom, unless the bedroom door cannot be locked. I/II 3/12/2022   
All personnel shall be able physically and emotionally to work in a long-term care facility. I/II 3/12/2022   
The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II 3/12/2022   
Residents admitted or readmitted to the facility shall have an admission physical examination by a licensed physician. Documentation should be obtained prior to admission but shall be on file not later than ten (10) days after admission and shall contain information regarding the resident ' s current medical status and any special orders or procedures which should be followed. If the resident is admitted directly from a hospital or another long-term care facility and is accompanied on admission by a report which reflects his/her current medical status, an admission physical will not be required. II/III 3/12/2022   
Medication Orders. (C) Telephone and other verbal orders shall be received only by a licensed nurse, medication technician, level I medication aide or pharmacist and shall be immediately reduced to writing and signed by that individual. If a telephone or other verbal order is given to a medication technician or level I medication aide, an initial dosage shall not be administered until the order has been reviewed by telephone, facsimile or in person by a licensed nurse or pharmacist. II 3/12/2022   
The facility shall maintain a record in the facility for each resident which shall include the following: (B) A review monthly or more frequently, if indicated, of the resident ' s general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III 3/12/2022   
Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/III 3/12/2022   
Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III 3/12/2022   
Each resident shall be permitted to retain and use personal clothing and possessions as space permits. Personal possessions may include furniture and decorations in accordance with the facility's policies and shall not create a fire hazard. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to the resident during his or her stay in the facility, which are to be returned to the resident or responsible party upon discharge, transfer, or death. II/III 3/12/2022