Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
26% occupied
Based on a June 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Life Safety
Census: 19
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
The inspection was a fire safety inspection conducted to assess the sprinkler system maintenance and the building's substantial construction and maintenance in accordance with fire safety regulations.
Findings
The facility failed to maintain the sprinkler system properly, with multiple sprinkler head escutcheon rings missing or loose. Additionally, the building showed signs of poor maintenance including unsealed dryer pipes, drywall seams separating, and exposed drywall screws, which could compromise fire safety.
Deficiencies (2)
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: The facility failed to maintain the sprinkler system as required, with multiple sprinkler head escutcheon rings missing or loose in various locations.
19 CSR 30-86.032(2) Substantially Constructed & Maintained: The building was not maintained in good repair, showing unsealed dryer pipes, drywall seams separating, and exposed drywall screws that could permit fire entry to the attic.
Report Facts
Facility census: 19
Inspection Report
Plan of Correction
Census: 24
Deficiencies: 2
Date: Jan 26, 2022
Visit Reason
The document is a plan of correction submitted in response to deficiencies cited during a survey conducted on 01/26/2022 at Ashland Villa-Assisted Living by Ameri.
Findings
Deficiencies included failure to maintain personnel records with physician statements for staff and incomplete resident records missing admission information and emergency contact details.
Deficiencies (2)
19 CSR 30-86.047(20)(I) Personnel Record-physician statement. Facility staff failed to ensure four of seven staff had a written physician statement indicating capability to work in a long-term care facility.
19 CSR 30-86.047(58)(A) Resident Record Admission Info. Facility staff failed to ensure resident records were complete for two of three sampled residents, missing personal inventory, emergency contact address, and history and physical documentation.
Report Facts
Facility census: 24
Staff missing physician statements: 4
Sampled residents with incomplete records: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary L. Clunigan | LNHA | Signed the plan of correction as the facility representative |
Inspection Report
Plan of Correction
Census: 26
Capacity: 72
Deficiencies: 1
Date: Nov 1, 2019
Visit Reason
The inspection was conducted to assess compliance with medication administration regulations and to identify deficiencies in the facility's medication system.
Findings
The facility failed to implement a safe and effective medication administration system, with missing documentation for medication administration on specific dates and staff confusion about medication location and notification procedures.
Deficiencies (1)
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to implement a safe and effective medication administration system as evidenced by missing documentation for medication administration on October 26, 27, and 28, 2019, and staff uncertainty about medication location and notification.
Report Facts
Facility census: 26
Total capacity: 72
Medication dosage: 12.5
Medication count: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joni Unger | Administrator | Named as administrator in plan of correction and signature |
Inspection Report
Plan of Correction
Census: 24
Capacity: 72
Deficiencies: 1
Date: Aug 21, 2019
Visit Reason
The inspection was conducted to identify deficiencies related to food protection, temperature control, and labeling in the facility's food storage and handling practices.
Findings
The facility failed to seal, date, and label opened, prepackaged food properly, risking contamination. Several observations showed undated and unlabeled food items in refrigerators and freezers, violating food safety regulations.
Deficiencies (1)
19 CSR 30-87.030(13) Food-Protected, Temp. Need to Contact DHSS. Facility staff failed to seal, date, and label opened, prepackaged food, risking contamination and improper food storage.
Report Facts
Facility census: 24
Facility capacity: 72
Inspection Report
Plan of Correction
Census: 25
Deficiencies: 1
Date: Aug 12, 2019
Visit Reason
The inspection was conducted to evaluate compliance with fire drill requirements and emergency preparedness regulations.
Findings
The facility failed to conduct the required quarterly fire drills on each shift as mandated. Fire drills were missing for several months, and the facility lacked a maintenance director during that period.
Deficiencies (1)
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to conduct one fire drill every three months on each shift. Fire drills were missing for multiple months between August 2018 and July 2019.
Report Facts
Residents present during inspection: 25
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