Inspection Results
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Facility failed to meet the following Requirement(s):Corrected DateLevel of HarmResidents Affected
Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/III 7/7/2021   
The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II 7/7/2021   
All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. II/III 7/7/2021   
The administrator/manager shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II 7/7/2021   
Records shall be maintained upon receipt and disposition of all controlled substances and shall be maintained separately from other records, for two (2) years. II/III (C) Receipt records shall include the date, source of supply, resident name and prescription number when applicable, medication name and strength, quantity and signature of the supplier and receiver. Administration records shall include the date, time, resident name, medication name, dose administered and the initials of the individual administering. The signature and initials of each medication staff documenting on the medication administration record must be signed in the signature area of the medication record. II/III 7/7/2021   
A pharmacist or registered nurse shall review the medication regimen of each resident. This shall be done at least every three (3) months in a residential care facility. The review shall be performed in the facility and shall include, but shall not be limited to, indication for use, dose, possible medication interactions and medication/food interactions, contraindications, adverse reactions and a review of the medication system utilized by the facility. Irregularities and concerns shall be reported in writing to the resident ' s physician and to the administrator/manager. If after thirty (30) days, there is no action taken by a resident ' s physician and significant concerns continue regarding a resident ' s or residents ' medication order(s), the administrator/manager shall contact or recontact the physician to determine if he or she received the information and if there are any new instructions. II/III 7/7/2021   
Medications that are not in current use shall be disposed of as follows: (F) All other medications, including all controlled substances and all expired or otherwise unusable medications, shall be destroyed within thirty (30) days as follows: II/III 2. A record of medication destroyed shall be maintained and shall include the resident ' s name, date, medication name and strength, quantity, prescription number, and signatures of the individuals destroying the medications; and II/III 7/7/2021   
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 7/7/2021   
Menus shall be planned in advance and shall be readily available for personnel involved in food purchase and preparation. Food shall be served as planned although substitutes of equal nutritional value and complementary to the remainder of the meal can be made if recorded. III 7/7/2021   
Lavatories, soap dispensers, hand-drying devices and all related fixtures shall be kept clean and in good repair. III 7/7/2021   
At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45��F) or below or one hundred forty degrees Fahrenheit (140��F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III 7/7/2021