LEWIS COUNTY NURSING HOME DISTRICT


LEWIS COUNTY NURSING HOME DISTRICT (CCN: 265360) is a Government - County facility located in CANTON, MO (63435). The facility has an overall rating of 2/5, health inspection rating of 2/5, and a staffing rating of 3/5. It offers 118 certified beds and maintains an average of 51.2 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 2.89617 total hours per resident per day. It has been certified since April 18, 1989 and the last listed health inspection was on November 17, 2023, The facility is located in Lewis county and provides senior and nursing home care.

LEWIS COUNTY NURSING HOME DISTRICT Summary


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Provider Name: LEWIS COUNTY NURSING HOME DISTRICT

Address: 17528 STATE HIGHWAY 81, CANTON, MO 63435

Phone: (573) 288-4454

County: Lewis (541)

Ownership Type: Government - County

Certified Beds: 118

Average Residents Per Day: 51.2 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: LEWIS COUNTY NURSING HOME DISTRICT

First Approved Date: April 18, 1989

Affiliated Entity: ()

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 2 ()

Health Inspection Rating: 2 ()

QM Rating: 3 ()

Long Stay QM Rating: 3 ()

Short Stay QM Rating: 4 ()

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.93175, LPN Staff Hours Per Day: 0.5412, RN Staff Hours Per Day: 0.4231, Licensed Staff Hours Per Day: 0.9644

Total Nurse Staff Hours Per Day, per resident: 2.89617

Weekend Nurse Staff Hours: 2.60166, Weekend RN Staff Hours: 0.2894

PT Staff Hours Per Day, per resident: 0.0093

Nurse Staff Turnover: 53.5, Nurse Turnover Note:

RN Turnover: 20.0, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.6843, Case Mix LPN Hours Per Day: 0.6097, Case Mix RN Hours Per Day: 0.2662

Adjusted Nurse Aide Hours Per Day, per resident: 2.33647, Adjusted LPN Hours Per Day: 0.6550, Adjusted RN Hours Per Day: 0.5989

Total Adjusted Nurse Hours Per Day, per resident: 3.56543

Adjusted Weekend Nurse Hours Per Day, per resident: 3.20287

Health Survey Dates and Scores: Cycle 1: 2023-11-17 (Score: 128), Cycle 2: 2021-05-21 (Score: 44), Cycle 3: 2019-04-11 (Score: 8)

Total Weighted Health Score: 80.000

Reported Incidents: 0, Substantiated Complaints: 3

Infection Control Citations:

Fines and Penalties: Number of Fines: 6, Total Fines in Dollars: 31420.75, Payment Denials Number: 0, Total Penalties Number: 6

Location and GPS: 17528 STATE HIGHWAY 81,CANTON,MO,63435 (40.1411, -91.542)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-06-13

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-14

Citation on 2023-11-17

Type: Health, Deficiency: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has no plan of correction on

Citation on 2023-11-17

Type: Health, Deficiency: Protect each resident from the wrongful use of the resident's belongings or money.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Past Non-Compliance on 2023-11-17

Citation on 2023-11-17

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Assess the resident when there is a significant change in condition

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has no plan of correction on

Citation on 2023-11-17

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has no plan of correction on

Citation on 2023-11-17

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has no plan of correction on

Citation on 2023-11-17

Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Have a plan that describes the process for conducting QAPI and QAA activities.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has plan of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Implement a program that monitors antibiotic use.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-17

Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-02-09

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-03-10

Citation on 2021-05-21

Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Health, Deficiency: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Health, Deficiency: Provide activities to meet all resident's needs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Health, Deficiency: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2019-04-11

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-25


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-11-29

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-29

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2023-11-29

Type: Fire Safety, Tag: 0926, Version: New

Description: Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-01-01

Citation on 2021-05-21

Type: Fire Safety, Tag: 0004, Version: New

Description: Develop and maintain an Emergency Preparedness Program (EP).

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0013, Version: New

Description: Develop Emergency Preparedness policies and procedures.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0015, Version: New

Description: Address subsistence needs for staff and patients.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0020, Version: New

Description: Establish policies and procedures including evacuation.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0222, Version: New

Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2021-05-21

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-06-23

Citation on 2019-04-11

Type: Fire Safety, Tag: 0161, Version: New

Description: Use approved construction type or materials.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-25

Citation on 2019-04-11

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-25

Citation on 2019-04-11

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-25

Citation on 2019-04-11

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-25