Volante of Chesterfield

Service plan deficiencies: Resident's service plan lacked specific instructions for fall prevention and toileting assistance, and had not been updated for several months despite a major incident.

Inadequate supervision: A resident fell and broke his hip; staff could not confirm when the resident was last checked prior to being discovered on the floor.

Water temperature regulation: Hot water temperatures in multiple resident rooms (10, 15, 17, 19, 23, 28, 51, 55) were not within the required 105 to 120 degrees Fahrenheit range.

Failure to notify the department of a change in administrator within five business days.

Failure to maintain an organized program for protection/supervision: Three residents had bedrails attached without specific service plan instructions or staff training; bedrail slats were large enough to pose an entrapment risk.

Inadequate care: Staff failed to document necessary care (repositioning/ADLs) for a resident, with several days showing no staff initials or markings on care logs.

No designated supervisor on duty and facility was short staffed during evening hours.

Late administration of resident medications.