Inspection Reports for
Adair Village
1801 N GAINES DR, CLINTON, MO, 64735-1127
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
160% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
36% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Date: Feb 21, 2025
Visit Reason
The inspection was conducted due to complaints regarding medication administration documentation, resident safety related to falls, nutritional care, respiratory care, and nurse aide training compliance.
Complaint Details
The complaint investigation revealed failures in medication administration documentation, resident safety protocols for transfers and brief changing, nutritional supplement administration, oxygen therapy documentation, and nurse aide training compliance.
Findings
The facility failed to document medication administration for three residents, failed to provide two-staff assistance for a resident resulting in a fall and fracture, failed to document administration of dietary supplements for one resident with weight loss, failed to document oxygen administration/checks for one resident, and employed nurse aides who had not completed CNA training and certification within four months of hire.
Deficiencies (5)
Failure to document administering medications per physician orders for three residents.
Failure to provide two-staff assistance as required for one resident, resulting in a fall and fracture.
Failure to document administration of dietary supplements per physician order for one resident with weight loss.
Failure to document oxygen administration/checks every shift per physician orders for one resident.
Failure to ensure nurse aides completed CNA training and certification within four months of hire.
Report Facts
Facility census: 43
Weight loss: 12.6
Medication administration documentation failures: 20
Oxygen administration documentation failures: 9
Nurse aides not certified within 4 months: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA C | Nurse Assistant | Named in fall incident involving Resident #1 where two-staff assistance was not provided |
| NA D | Nurse Assistant | Named as uncertified nurse aide working beyond 4 months without CNA certification |
| NA E | Nurse Assistant | Named as uncertified nurse aide working beyond 4 months without CNA certification |
| CMT F | Certified Medication Technician | Provided statements regarding medication administration and oxygen therapy documentation |
| LPN D | Licensed Practical Nurse | Provided statements regarding medication administration and resident care requirements |
| PT G | Physical Therapist | Provided statements regarding resident transfer requirements |
| Administrator | Provided statements regarding facility policies and staff expectations | |
| Regional Nurse Consultant | Provided statements regarding resident care requirements | |
| Resident's Physician | Provided statements regarding resident transfer safety | |
| CNA Instructor | Provided statements regarding CNA training timelines | |
| Dietary Manager | Provided statements regarding nutritional care and supplement administration |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Date: Feb 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration, accident hazards, nutrition/hydration status, respiratory care, and nurse aide training at Adair Village nursing facility.
Complaint Details
The complaint investigation substantiated multiple deficiencies related to medication administration errors, accident hazards, nutrition and hydration maintenance, respiratory care, and nurse aide training compliance.
Findings
The facility failed to ensure proper medication administration documentation for multiple residents, maintain a safe environment to prevent accidents, provide adequate nutrition and hydration, ensure respiratory care per standards, and comply with nurse aide training requirements. Several deficiencies were cited with varying severity levels.
Deficiencies (5)
F684 Quality of care: Facility failed to ensure all residents received care and treatment per professional standards when nursing staff failed to document administering medications for three residents. Facility census was 43.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to keep residents free from accident hazards when staff failed to provide care with two trained staff for one resident, resulting in a fall and fracture. Facility census was 43.
F692 Nutrition/Hydration Status Maintenance: Facility failed to maintain acceptable nutritional status and document dietary interventions for one resident with significant weight loss. Facility census was 43.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility failed to provide respiratory care per standards when staff failed to ensure documentation of oxygen administration/checks every shift for one resident. Facility census was 43.
F728 Facility Hiring and Use of Nurse Aide: Facility failed to have a system in place to ensure nurse aides completed required training and competency evaluation within four months of hire. Facility census was 43.
Report Facts
Facility census: 43
Deficiency severity Level 3: 2
Deficiency severity Level 2: 3
Inspection Report
Routine
Census: 34
Deficiencies: 3
Date: Aug 28, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards, focusing on wound care, accident prevention, and pain management for Resident #1.
Findings
The facility failed to provide appropriate wound care, failed to ensure safe resident transfers preventing injury, and failed to provide timely and documented pain management for Resident #1. Documentation and physician orders were incomplete or missing for wounds, bruising was not properly assessed or reported, and pain medication was delayed and not documented.
Deficiencies (3)
Failed to identify, assess, document, monitor, obtain orders for treatment of, and notify the physician of wounds for one resident.
Failed to ensure residents were free from accident hazards by failing to transfer one resident in a safe manner and failing to follow-up on possible injury from the transfer.
Failed to provide effective pain management by not administering requested pain medication timely, failing to assess pain level, failing to document administration, and failing to follow-up on pain medication effectiveness.
Report Facts
Census: 34
Wound measurements: 5
Wound measurements: 6
Pain rating: 5
Pain medication delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Discussed wound care expectations and pain medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided wound care treatments and assisted with resident transfer |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Discussed bruising assessment and resident complaints |
| Certified Nursing Assistant A | Certified Nursing Assistant (CNA) | Involved in resident transfer related to bruising |
| Certified Nursing Assistant C | Certified Nursing Assistant (CNA) | Reported pain medication request to nurse |
| Registered Nurse G | Registered Nurse (RN) | Discussed skin assessments and pain medication procedures |
| Social Services Director | Social Services Director (SSD) | Discussed care plan updates and wound documentation |
| Physical Therapist D | Physical Therapist (PT) | Discussed resident's pain and transfer issues |
| Certified Medication Tech H | Certified Medication Technician (CMT) | Discussed pain medication administration process |
| Administrator | Facility Administrator | Discussed expectations for reporting bruising and pain management |
| Resident's Physician | Physician | Discussed wound care orders and pain management expectations |
| Regional Nurse Consultant | Regional Nurse Consultant | Discussed wound care and pain management protocols |
| Director of Regional Consulting | Director of Regional Consulting | Discussed bruise assessment and follow-up expectations |
Inspection Report
Routine
Census: 34
Deficiencies: 3
Date: Aug 28, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with federal regulations related to quality of care, accident hazards, and pain management at Adair Village nursing facility.
Findings
The facility was found deficient in quality of care, failing to provide adequate wound care and pain management, and in ensuring residents were free from accident hazards. Documentation and adherence to physician orders and facility protocols were inadequate.
Deficiencies (3)
F684 Quality of care deficiency due to failure to identify, assess, document, monitor, and obtain physician orders for treatment of wounds for one resident. The facility did not provide a wound protocol book signed by the physician or medical director.
F689 Failure to ensure residents were free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents, including failure to transfer one resident safely and follow up on possible injury.
F697 Pain management deficiency due to failure to provide effective pain management, timely administration of pain medication, and proper documentation of pain assessments and medication effectiveness for one resident.
Report Facts
Resident census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed regarding wound care and bruising documentation |
| Assistant Director of Nursing | ADON | Interviewed regarding wound care and pain management |
| Registered Nurse G | RN | Interviewed regarding wound care and pain management documentation |
| Certified Nursing Assistant A | CNA | Interviewed regarding resident transfer and bruising |
| Licensed Practical Nurse B | LPN | Interviewed regarding bruising and resident care |
| Physical Therapist D | PT | Interviewed regarding resident bruising and pain |
| Certified Medication Tech H | CMT | Interviewed regarding pain medication administration |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 2
Date: Mar 19, 2024
Visit Reason
The document is a Plan of Correction submitted by Adair Village following a state survey conducted on 03/19/2024. The plan addresses deficiencies related to abuse/neglect policies and infection prevention and control.
Findings
The facility failed to implement required background checks and registry verifications for new hires prior to employment, and did not maintain an effective infection control program, including timely tuberculosis screening for staff. The facility census was 27 at the time of inspection.
Deficiencies (2)
F607: The facility failed to develop and implement policies to prevent abuse, neglect, and misappropriation of residents by not completing required background and registry checks prior to hiring staff. This included failures to complete Family Care Safety Registry, Employee Disqualification List, and Nurse Aide Registry checks for multiple staff members.
F880: The facility failed to maintain an effective infection prevention and control program, including failure to ensure timely two-step tuberculosis testing and documentation for staff members, risking transmission of communicable diseases.
Report Facts
Facility census: 27
Number of staff files reviewed: 8
Plan of Correction completion date: Completion dates listed as 4/22/2024 for corrective actions
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Personnel file reviewed showing missing registry checks and background checks |
| NA B | Nurse Aide | Personnel file reviewed showing missing registry checks |
| LPN C | Licensed Practical Nurse | Personnel file reviewed showing missing registry checks |
| HK D | Housekeeper | Personnel file reviewed showing missing registry checks |
| Business Office Manager | Interviewed regarding missing registry checks and TB testing | |
| Administrator | Interviewed regarding missing registry checks and TB testing | |
| Director of Nursing | Interviewed regarding TB testing procedures and documentation | |
| Infection Preventionist | Interviewed regarding TB testing procedures and documentation |
Inspection Report
Life Safety
Census: 27
Capacity: 27
Deficiencies: 9
Date: Mar 19, 2024
Visit Reason
A Life Safety Code survey was conducted on 03/19/2024 to assess compliance with Medicare/Medicaid participation requirements and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including egress door locking arrangements, vertical openings enclosure, hazardous areas enclosure, fire alarm system installation and maintenance, sprinkler system maintenance, corridor doors, smoke barrier construction, and HVAC compliance. Deficiencies had the potential to affect residents and staff.
Deficiencies (9)
K222 Egress Doors: Doors in required means of egress were equipped with delay egress locking that did not meet NFPA 101 requirements, affecting all 27 residents.
K311 Vertical Openings - Enclosure: Facility failed to ensure linen chutes were maintained with self-latching doors, affecting all 27 residents.
K321 Hazardous Areas - Enclosure: Facility failed to ensure three hazardous storage areas had self-closing doors, potentially affecting four residents.
K341 Fire Alarm System - Installation: One of 50 photo electric smoke detectors was improperly installed less than 36 inches from air diffusers, potentially affecting four residents.
K345 Fire Alarm System - Testing and Maintenance: Facility failed to maintain fire alarm system per NFPA 101, potentially affecting all 27 residents.
K353 Sprinkler System - Maintenance and Testing: Facility failed to maintain sprinkler system coverage in therapy room, potentially affecting all 27 residents.
K363 Corridor Doors: Corridor doors failed to resist smoke and latch properly, potentially affecting five staff on a vacant floor.
K372 Subdivision of Building Spaces - Smoke Barrier: Facility failed to ensure smoke/fire barrier walls were protected, potentially affecting 10 residents and staff on two floors.
K521 HVAC: Facility failed to maintain three smoke dampers at smoke barrier walls, potentially affecting all 27 residents.
Report Facts
Deficiencies cited: 9
Residents affected: 27
Exit doors with delayed egress devices: 13
Photo electric smoke detectors: 50
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident care, specifically focusing on the provision of scheduled showers and assistance with activities of daily living for residents.
Findings
The facility failed to provide showers as scheduled, care planned, and preferred for two residents (Resident #4 and Resident #11) out of 18 sampled residents, resulting in minimal harm or potential for actual harm. Multiple interviews and record reviews confirmed missed showers over several months due to staffing and plumbing issues.
Deficiencies (2)
Failed to recognize resident's right to self-determination by not providing showers as scheduled and preferred for Resident #4.
Failed to ensure dependent residents maintained good grooming when staff failed to provide showers as scheduled and needed for Resident #11.
Report Facts
Missed showers: 3
Missed showers: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Interviewed regarding reasons for missed showers for Resident #4. |
| LPN2 | Licensed Practical Nurse | Interviewed about Resident #4's complaints of missed showers. |
| CNA2 | Certified Nurse Aide | Interviewed about shower schedules and challenges for Residents #4 and #11. |
| RN1 | Registered Nurse | Interviewed about monitoring resident showers and missing shower sheets for Resident #11. |
| Regional Nurse Consultant | Interviewed about expectations for shower frequency. |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities of daily living, change in condition notifications, PASARR screening, fall prevention, catheter care, medication use, infection control, and other aspects of nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, failure to provide showers as scheduled, failure to notify resident representatives of changes in condition, lack of PASARR screening documentation, incomplete care plans for activities and pacemaker care, inadequate fall investigations, improper catheter bag handling, failure to document rationale for antipsychotic medication use, and failure to maintain infection control during laundry transport.
Deficiencies (10)
Failure to ensure catheter bags were kept in privacy bags for residents #16 and #23.
Failure to provide showers as scheduled for resident #4.
Failure to notify resident representative of change in condition for resident #21.
Failure to ensure PASARR screening was completed for resident #3.
Failure to develop comprehensive care plans for activities for residents #21 and #22 and pacemaker care plan for resident #21.
Failure to provide showers as scheduled for resident #11.
Failure to document fall investigations and root cause analysis for residents #8, #21, and #12.
Failure to ensure catheter bags were kept off the floor for residents #16 and #23.
Failure to document diagnosis and rationale for antipsychotic medication use for resident #22.
Failure to maintain infection control by transporting clean laundry uncovered.
Report Facts
Residents sampled: 18
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Confirmed catheter bag on floor for Resident #23 and discussed shower monitoring |
| LPN 1 | Licensed Practical Nurse | Discussed shower scheduling and antipsychotic medication use |
| LPN 2 | Licensed Practical Nurse | Acknowledged resident complaints about missed showers |
| CNA 2 | Certified Nurse Aide | Discussed shower scheduling and observed resident grooming |
| Regional Nurse Consultant | Provided expectations on catheter bag handling, shower frequency, notification of condition changes, care planning, fall investigations, and medication monitoring | |
| Social Services/Minimum Data Set Staff | Confirmed lack of PASARR documentation for Resident #3 | |
| Director of Nursing | DON | Confirmed expectations for PASARR, care plans, and fall investigations |
| Administrator | Confirmed expectations for PASARR, care plans, fall investigations, and infection control | |
| Pharm D | Pharmacist | Discussed antipsychotic medication use and diagnosis for Resident #22 |
| Activities Coordinator | AC | Discussed activities care plans and resident preferences |
| Laundry Aide 1 | LA1 | Discussed laundry transport practices |
| Laundry Aide 2 | LA2 | Observed transporting uncovered clean clothes |
Inspection Report
Recertification And Complaint Investigation
Census: 27
Deficiencies: 10
Date: Mar 14, 2024
Visit Reason
A recertification and complaint investigation was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health, and Senior Services.
Complaint Details
The investigation included a complaint component related to resident dignity, catheter care, shower provision, notification of changes, PASARR screening, care planning, fall prevention, catheter care, psychotropic medication use, and infection control. The facility was found not in substantial compliance.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to resident rights, self-determination, notification of changes, PASARR screening, comprehensive care plans, accident prevention, catheter care, psychotropic drug use, and infection control.
Deficiencies (10)
F550 Resident Rights/Exercise of Rights. The facility failed to ensure residents' dignity and privacy, including failure to provide privacy bags for catheter care for two residents.
F561 Self-Determination. The facility failed to recognize residents' rights to self-determination, including failure to provide showers as scheduled for one resident.
F580 Notification of Changes. The facility failed to promptly notify the resident representative of a change in condition for one resident.
F645 PASARR Screening for MD & ID. The facility failed to ensure a Level I PASARR screening was completed prior to admission for one resident with a mental disorder.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to develop comprehensive person-centered care plans with measurable goals for two residents.
F677 ADL Care Provided for Dependent Residents. The facility failed to provide showers as scheduled and maintain good grooming for one resident.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to ensure adequate fall prevention measures for three residents, placing them at risk for unmet care needs.
F690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide appropriate catheter care and prevent infections for two residents.
F758 Free from Unnec Psychotropic Meds/PRN Use. The facility failed to document rationale for psychotropic drug use and monitor side effects for five residents.
F880 Infection Prevention & Control. The facility failed to maintain infection control practices, including proper handling of linens and laundry, affecting 26 of 27 residents.
Report Facts
Survey Census: 27
Sample Size: 18
Deficiency Severity Counts: 8
Deficiency Severity Counts: 1
Deficiency Severity Counts: 1
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Oct 25, 2023
Visit Reason
The inspection was conducted in response to allegations of abuse involving a resident at Adair Village. The investigation focused on the facility's failure to timely report and properly handle the alleged abuse.
Complaint Details
Complaint # M000225994 involved allegations of resident abuse by a staff member hitting the resident. The complaint was substantiated as the facility failed to timely report the abuse to the Missouri Department of Health and Senior Services within the required 2-hour timeframe.
Findings
The facility failed to timely report an allegation of resident abuse involving a staff member hitting a resident. The investigation revealed the resident had injuries and the facility did not notify the state survey agency within the required timeframe.
Deficiencies (2)
F609: The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than 2 hours after the allegation when abuse was involved. The facility did not timely report an allegation of staff hitting a resident to the state survey agency.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds. This deficiency is linked to F609.
Report Facts
Facility census: 31
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Oct 25, 2023
Visit Reason
The inspection was conducted due to an allegation of staff to resident abuse reported by a resident at the facility.
Complaint Details
Complaint # MO00225994. The complaint involved an allegation of staff to resident abuse. The facility did not notify the state survey agency within two hours as required, reporting over four hours after the allegation was made.
Findings
The facility failed to timely report the allegation of abuse to the state survey agency within the required two-hour timeframe. The resident alleged a staff member hit him/her, but no visible injuries were found upon assessment. The facility initiated an investigation and notified the resident's physician and next of kin.
Deficiencies (1)
Failed to timely report an allegation of staff to resident abuse to the state survey agency within the required timeframe.
Report Facts
Residents Affected: 31
Time to report allegation: 4
Reporting timeframe: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented resident's allegation and assessment during the incident |
| CNA B | Certified Nurse Assistant | Worked the night of the incident and assisted with resident |
| Director of Nursing | Director of Nursing (DON) | Assessed resident, initiated investigation, and reported allegation to state agency |
| Administrator | Facility Administrator | Provided instructions on reporting abuse and confirmed training on abuse reporting |
Inspection Report
Plan of Correction
Census: 25
Deficiencies: 2
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to assess compliance with quality of care standards related to wound care and skin integrity for residents at Adair Village.
Findings
The facility failed to monitor all resident wounds per standards of practice, with incomplete weekly wound assessments documented for two residents. Staff did not document comprehensive wound assessments including site, stage, size, appearance, drainage, and odor as required.
Deficiencies (2)
F684 Quality of care: The facility failed to monitor all resident wounds per standards of practice, with incomplete weekly wound assessments for two residents. Staff did not document comprehensive wound assessments including site, stage, size, appearance, drainage, and odor.
A4075 Nursing care per resident condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as referenced to F684.
Report Facts
Facility census: 25
Inspection Report
Routine
Census: 25
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with wound care standards, specifically monitoring the documentation and assessment of resident wounds.
Findings
The facility failed to document weekly comprehensive wound assessments for wounds of two residents, potentially causing a delay in identifying wound decline. Staff did not complete comprehensive wound assessments including site, stage, size, appearance, drainage, and odor as required by facility policy.
Deficiencies (1)
Failure to document weekly comprehensive wound assessments for wounds of two residents.
Report Facts
Facility census: 25
Wound size: 4.6
Wound size: 0.2
Wound size: 12.4
Wound size: 0.2
Wound length: 1
Wound width: 0.5
Wound bed granulation tissue percentage: 50
Wound bed eschar percentage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Interviewed regarding wound care assessments and documentation |
| DON | Director of Nursing | Interviewed regarding wound assessment responsibilities and practices |
| Administrator | Interviewed regarding wound assessment documentation and facility policy compliance |
Inspection Report
Annual Inspection
Census: 17
Deficiencies: 5
Date: Apr 7, 2022
Visit Reason
Annual inspection survey conducted at Westwood Living Center to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including failure to complete required background checks for new hires, inadequate respiratory care procedures for residents requiring oxygen, incomplete documentation and safety assessments related to bed rails, and food safety violations related to sanitation and labeling. The facility submitted a plan of correction addressing these deficiencies.
Deficiencies (5)
F607: The facility failed to complete criminal background checks, employee disqualification list checks, and nurse aide registry checks for several staff prior to employment.
F695: The facility failed to ensure proper respiratory and tracheostomy care, including lack of procedures for changing oxygen equipment and failure to obtain physician orders for oxygen changes for multiple residents.
F700: The facility failed to complete risk/benefit assessments, obtain informed consent, and properly document use and safety checks of bed rails for multiple residents.
F812: The facility failed to keep food safe from contamination, including grease buildup, unlabeled and expired food items, and inadequate cleaning of kitchen equipment and surfaces.
F921: The facility failed to maintain a sanitary environment in the kitchen and dining areas, including failure to keep non-food contact surfaces clean and free of debris.
Report Facts
Facility census: 17
Completion date for plan of correction: May 20, 2022
Inspection Report
Routine
Census: 17
Deficiencies: 5
Date: Apr 7, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete required background checks for new employees, inadequate respiratory care procedures for oxygen equipment, improper use and assessment of bed rails and grab bars, and unsanitary conditions in the kitchen including food contamination risks and poor cleaning practices.
Deficiencies (5)
Failed to complete criminal background checks, employee disqualification list checks, and nurse aide registry checks for four staff prior to employment.
Failed to have procedures ensuring oxygen equipment was changed per professional standards and failed to care plan or obtain physician orders for oxygen equipment changes for three residents.
Failed to complete risk/benefit review, document alternatives, obtain informed consent, perform safety checks, and address bed rail use in care plans for multiple residents.
Failed to keep food safe from contamination due to buildup of grease, lint, hair on food contact surfaces and failure to date or label stored food after opening.
Failed to maintain a sanitary kitchen environment with accumulation of dust, dirt, food residue, and grime on non-food contact surfaces including baseboards, refrigerator wheels, ceiling vents, and ice machine.
Report Facts
Facility census: 17
Number of staff missing background checks: 4
Number of residents affected by oxygen equipment deficiencies: 3
Number of residents affected by bed rail deficiencies: 5
Number of residents affected by food safety deficiencies: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding background checks and oxygen equipment procedures |
| Administrator | Facility Administrator | Interviewed regarding background checks and oxygen equipment procedures |
| Certified Nursing Assistant E | Certified Nursing Assistant | Interviewed about oxygen tubing change procedures |
| Licensed Practical Nurse F | Licensed Practical Nurse | Interviewed about oxygen tubing change procedures and bed rail assessments |
| Head Cook G | Head Cook | Interviewed about kitchen cleaning practices and conditions |
| Dietary Aide H | Dietary Aide | Interviewed about food labeling and cleaning responsibilities |
| Dietary Manager | Dietary Manager | Interviewed about kitchen cleaning schedules and staff responsibilities |
| Maintenance Director | Maintenance Director | Interviewed about installation and maintenance of bed rails and assist bars |
Inspection Report
Life Safety
Census: 17
Capacity: 120
Deficiencies: 3
Date: Apr 6, 2022
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety regulations and related provisions.
Findings
The facility failed to prohibit locks on patient sleeping room doors and storage under stairways used as exit pathways. Additionally, the sprinkler system was incomplete with missing sprinkler heads in the walk-in freezer and refrigeration units.
Deficiencies (3)
K221 Patient Sleeping Room Doors: Locks on patient sleeping room doors are not permitted unless they do not restrict egress or are permitted for clinical or safety needs. The facility failed to prohibit locks on a corridor door leading to a resident room.
K225 Stairways and Smokeproof Enclosures: The facility failed to prohibit storage underneath and around two stairways used as exit pathways, potentially impeding egress during emergencies.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain a complete sprinkler system as sprinkler heads were removed and not replaced in the walk-in freezer and refrigeration units.
Report Facts
Facility capacity: 120
Resident census: 17
Wheelchairs stored: 11
Oxygen canisters stored: 17
Oxygen canisters stored: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Apr 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 4
Date: Aug 2, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Westwood Living Center.
Findings
The facility was found deficient in multiple areas including quality of care related to laboratory testing, medication error rates exceeding 5 percent, improper labeling and storage of insulin medications, and food safety violations related to hand hygiene and food handling.
Deficiencies (4)
F684 Quality of care deficiency due to failure to follow physician orders for Hemoglobin A1c testing for a resident with diabetes. The facility census was 49.
F759 Medication error rates exceeded 5 percent with an error rate of 12 percent affecting three residents. The facility census was 49.
F761 Labeling and storage of drugs and biologicals deficient as insulin medications were not properly labeled with open dates and improperly disposed of. The facility census was 49.
F812 Food procurement, storage, preparation, and serving sanitary violations including failure to perform proper hand hygiene and improper glove use. The facility census was 57.
Report Facts
Medication error rate: 12
Facility census: 49
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Interviewed regarding laboratory test procedures and insulin administration. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding nursing procedures, medication administration, and insulin labeling. |
| Registered Nurse C | Registered Nurse (RN) | Interviewed regarding medication administration and insulin vial dating. |
| Cook F | Observed during food service with improper glove use and hand hygiene. | |
| Dietary Manager | Interviewed regarding food handling and hand hygiene policies. |
Inspection Report
Routine
Census: 49
Deficiencies: 4
Date: Aug 2, 2019
Visit Reason
The inspection was conducted to evaluate compliance with healthcare regulations related to treatment, medication administration, labeling of drugs, and food safety in the facility.
Findings
The facility failed to follow physician orders for laboratory testing, had a medication error rate exceeding 5%, improperly labeled and stored insulin vials, and failed to maintain sanitary food handling practices including inadequate hand hygiene and glove use among staff.
Deficiencies (4)
Failed to obtain physician ordered Hemoglobin A1c tests for a diabetic resident for three months.
Medication error rate of 12% due to three errors out of 25 opportunities affecting three residents.
Failed to properly label insulin medications with open dates and failed to dispose of open vials according to guidelines.
Failed to serve food under sanitary conditions including improper hand hygiene, glove use, and chemical use near food.
Report Facts
Facility census: 49
Medication error rate: 12
Medication error opportunities: 25
Medication errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Interviewed regarding laboratory test tracking and medication administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for following physician orders and medication administration |
| LPN A | Licensed Practical Nurse | Observed administering insulin and interviewed about insulin vial labeling |
| RN C | Registered Nurse | Interviewed about insulin vial labeling and medication administration |
| Administrator | Administrator | Interviewed regarding staff expectations for medication and food handling |
| Dietary Manager | Dietary Manager | Interviewed regarding food handling and hand hygiene practices |
Inspection Report
Life Safety
Census: 49
Capacity: 120
Deficiencies: 6
Date: Aug 1, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, including building construction, fire alarm systems, door locks, and corridor doors.
Findings
The facility failed to maintain the integrity of building construction fire ratings, had locks on patient sleeping room doors that restricted egress, and failed to maintain smoke resistive properties of corridor doors. The facility also failed to complete annual fire department consultation and maintain proper door hardware.
Deficiencies (6)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and shared space above a suspended ceiling. This deficiency affects all residents, staff, and visitors.
K221: The facility failed to prohibit locks on a corridor door leading to a resident room, which could restrict egress in an emergency. This deficiency affects residents in the event of an emergency.
K363: The facility failed to maintain smoke resistive properties of corridor doors by allowing impediments to door closing and installing door latches backwards. This deficiency affects all residents, staff, and visitors.
A2020: The facility failed to complete annual fire department consultation for the previous years, violating fire alarm system inspection requirements.
A2041: Door locks did not meet regulatory requirements; only one lock is permitted on any one door, and the facility failed to comply as evidenced by K221.
A3001: The building was not substantially constructed and maintained in good repair, with violations referenced in K161. This is a Class II deficiency.
Report Facts
Facility capacity: 120
Resident census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenny Deal | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Annual Inspection
Census: 56
Capacity: 120
Deficiencies: 9
Date: Jul 16, 2018
Visit Reason
Annual recertification survey to assess compliance with life safety code and fire safety regulations at Westwood Living Center.
Findings
The facility failed to maintain an environment free from fire hazards, including issues with fire safety equipment, emergency exits, smoke barrier doors, elevators, and emergency power systems. Deficiencies were identified that could affect residents, staff, and visitors in the event of an emergency.
Deficiencies (9)
K100: The facility failed to maintain an environment free from fire hazards by allowing a room with fuel-filled water heaters to become filled with dried leaves. This posed a fire risk to residents, staff, and visitors.
K211: The facility failed to maintain exits free and clear of obstructions, including an emergency exit door that remained impassable due to a stuck door and a metal chair blocking the discharge area.
K222: The facility failed to ensure delayed egress magnetic locking devices on exit doors released properly after three seconds of continuous pressure, potentially impeding emergency egress.
K271: The facility failed to maintain hard paths to safety from emergency exits, with broken cement and uneven sidewalks posing obstacles to evacuation.
K324: The facility failed to maintain fire protective properties of the kitchen exhaust hood, including failure to perform required hydrostatic testing and absence of grease drip trays and collection devices.
K374: The facility failed to ensure smoke barrier doors closed completely and resisted smoke passage during fire alarm tests, with gaps observed between doors.
K531: The facility failed to conduct required annual elevator inspections, missing inspection dates and failing to maintain records, risking elevator safety during emergencies.
K711: The facility failed to ensure staff relocated residents past smoke barrier doors during fire drills, risking resident safety during evacuations.
K918: The facility failed to maintain and test the emergency generator properly, including lack of remote manual stop button, missing annual fuel quality tests, and incomplete documentation.
Report Facts
Facility capacity: 120
Census: 56
Date of alleged compliance: Multiple deficiencies have a compliance date of August 27, 2018.
Inspection Report
Annual Inspection
Census: 56
Capacity: 120
Deficiencies: 9
Date: Jul 16, 2018
Visit Reason
Annual inspection of Westwood Living Center to assess compliance with Medicare and Medicaid regulations, including review of resident care, safety, infection control, and facility environment.
Findings
The facility had multiple deficiencies including failure to provide required Medicare notices, breaches of resident privacy, unsafe environment conditions such as unclean air conditioning units, inadequate pressure ulcer prevention and treatment, improper medication administration, and failure to maintain a safe call system. The facility census was 56 with a total capacity of 120 beds.
Deficiencies (9)
F582 Medicare/Medicaid Coverage/Liability Notice. The facility failed to provide required Skilled Nursing Facility Advance Beneficiary Notices or denial letters for three residents. The facility census was 56.
F583 Personal Privacy/Confidentiality of Records. Staff failed to ensure privacy during toileting and wound observation for sampled residents, leaving doors open and residents exposed.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain clean air conditioning units with dust, debris, and dead insects in resident dining and rooms. The facility census was 56.
F686 Skin Integrity/Pressure Ulcers. The facility failed to routinely assess wounds and follow infection control procedures for pressure ulcers in two residents. Documentation and treatment were incomplete.
F700 Bedrails. The facility failed to assess risks and benefits of side rail use and lacked policy on bed rail use for residents. The facility census was 56.
F760 Residents are Free of Significant Medication Errors. The facility failed to perform accurate blood glucose testing and insulin administration according to physician orders for multiple residents.
F812 Food Procurement/Store/Prepare/Serve-Sanitary. Non-refrigerated foods were stored improperly with rodent droppings and contamination risks. The facility census was 56 residents.
F880 Infection Prevention & Control. The facility failed to maintain proper hand hygiene, isolation precautions, and infection control practices for multiple residents, including those with infections.
F919 Resident Call System. The facility failed to provide an adequate call system in all toilet rooms, limiting residents' ability to summon staff assistance. The facility capacity is 120 with a census of 56.
Report Facts
Facility census: 56
Facility total capacity: 120
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