Inspection Reports for
Adair Village
1801 N GAINES DR, CLINTON, MO, 64735-1127
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
43 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy 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
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
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
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
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
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
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 |
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