Inspection Reports for
Avenir at Maple Grove
2407 KENTUCKY ST, LOUISIANA, MO, 63353-2503
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
64% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to repeated resident complaints about food being served cold during meals.
Complaint Details
The investigation was complaint-driven based on resident reports of cold food served in the dining room and resident rooms. The complaints were substantiated by observations, interviews, and record reviews.
Findings
The facility failed to provide food items at safe and appetizing temperatures, with multiple residents reporting cold food at all meals. Observations confirmed food temperatures below safe levels and incomplete food temperature recording logs.
Deficiencies (1)
F 0804: The facility failed to ensure food and drink were served at safe and appetizing temperatures. Observations showed multiple food items served cold, and dietary temperature logs were incomplete for several days.
Report Facts
Residents affected: 5
Food temperature readings: 106
Food temperature readings: 84
Food temperature readings: 95
Food temperature readings: 80
Census: 58
Missing temperature logs: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary [NAME] A | Cook | Interviewed; stated unawareness of resident complaints and responsibility to check food temperatures. |
| Certified Nurse Assistant (CNA) B | Certified Nurse Assistant | Interviewed; reported residents complained about cold food. |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Interviewed; reported frequent resident complaints about cold food and staff instructions to deliver one resident's tray first. |
| Facility Activity Director | Activity Director | Interviewed; responsible for Resident Council meetings and reported resident complaints to dietary manager and administrator. |
| Administrator | Facility Administrator | Interviewed; aware of complaints and new steam table acquisition; unaware of missing temperature logs. |
Inspection Report
Routine
Census: 49
Deficiencies: 2
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding maintenance of the physical environment and adequacy of nursing staff to meet residents' needs.
Findings
The facility failed to maintain walls, ceilings, sink counters, chairs, and parking lot in good repair, creating potential hazards. Additionally, the facility did not have sufficient nursing staff on duty per the facility assessment to meet residents' needs, with documented shortages of licensed nurses and nurse aides on multiple shifts.
Deficiencies (2)
F 0584: The facility failed to maintain walls, ceilings, sink counters, and dining room/TV room chairs in good repair, and the parking lot had large potholes and uneven surfaces creating hazards.
F 0725: The facility failed to provide sufficient nursing staff every day to meet residents' needs, including having a licensed nurse in charge on each shift, resulting in staffing shortages documented on multiple days.
Report Facts
Facility census: 49
Damaged chairs: 18
Potholes size: 2
Potholes size: 3
Potholes depth: 3
Parking lot depression size: 4
Parking lot depression size: 6
Parking lot depression depth: 4
Licensed nurses required per facility assessment: 2
Certified nurse aides required per facility assessment: 4
Inspection Report
Routine
Census: 49
Deficiencies: 13
Date: Apr 30, 2025
Visit Reason
Routine inspection of Avenir at Maple Grove nursing home to assess compliance with resident rights, facility maintenance, care planning, infection control, staffing, dietary services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to honor resident choice in waking times, inadequate maintenance of facility environment, inaccurate resident assessments, incomplete care plans, insufficient assistance with activities of daily living, failure to provide continuous oxygen therapy as ordered, inadequate staffing levels, dietary management deficiencies, improper food service practices, failure to implement enhanced barrier precautions for infection control, incomplete antibiotic stewardship, and lack of documentation of COVID-19 vaccination education and status for staff.
Deficiencies (13)
F 0561: The facility failed to ensure residents' right to choose schedules and make choices about their life, including waking times, for two residents. Staff routinely woke residents early for breakfast against care plan preferences.
F 0584: The facility failed to maintain walls, ceilings, sink counters, dining room and TV room chairs in good repair and failed to maintain parking lot and driveway free of damage and potholes.
F 0641: The facility failed to accurately code Minimum Data Set assessments for two residents, miscoding catheter use and insulin medication.
F 0657: The facility failed to update and revise comprehensive care plans for three residents to reflect current risks, care needs, and interventions including skin breakdown, mobility, wound care, and behavioral issues.
F 0677: The facility failed to provide necessary care and services to maintain good personal hygiene and prevent body odor for three residents dependent on staff for activities of daily living, including failure to provide peri care after incontinence and oral care.
F 0695: The facility failed to provide continuous oxygen therapy as ordered for one resident, including failure to provide portable oxygen tanks and monitor oxygen saturation levels.
F 0725: The facility failed to provide sufficient nursing staff per facility assessment, including frequent shifts with only one licensed nurse when two were required and insufficient nurse aide staffing.
F 0801: The facility failed to employ a Dietary Director with required food safety and management training.
F 0803: The facility failed to serve meals according to the diet spreadsheet menu and physician orders, including failure to provide double portions and appropriate food substitutes for residents.
F 0812: The facility failed to ensure food service staff practiced proper hand hygiene and hair restraint usage, failed to label and date food items, failed to remove dented cans, and failed to maintain dishwashing machine sanitizer levels and kitchen cleanliness.
F 0880: The facility failed to implement Enhanced Barrier Precautions for residents with wounds and indwelling devices, failed to post required signage, failed to ensure staff wore appropriate PPE, failed to perform proper hand hygiene during incontinence care, and failed to implement a water management program to reduce Legionella risk.
F 0881: The facility failed to maintain an antibiotic stewardship program and failed to ensure appropriate clinical indications and documentation for antibiotic use for one resident. The facility also failed to track infections by organism and location.
F 0887: The facility failed to provide COVID-19 vaccination education to all staff and failed to maintain documentation of staff vaccination status or refusals.
Report Facts
Facility census: 49
Deficiency count: 13
Oxygen saturation: 87
Oxygen saturation: 92
Oxygen saturation: 84
Food portions: 0.25
Food portions: 0.375
Water temperature: 105.6
Water temperature: 106.1
Water temperature: 101.2
Water temperature: 71.4
Water temperature: 80.2
Food can weight: 6.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Q | Certified Nurse Aide | Named in waking time choice deficiency and resident care refusal |
| CNA S | Certified Nurse Aide | Named in waking time choice deficiency |
| CNA E | Certified Nurse Aide | Named in hygiene care deficiency and improper glove use |
| CNA H | Certified Nurse Aide | Named in hygiene care deficiency and improper glove use |
| LPN N | Licensed Practical Nurse | Named in oxygen therapy deficiency |
| Dietary Manager | Dietary Director | Named in dietary management and food safety training deficiency |
| Dishwasher B | Dishwasher | Named in dishwashing sanitizer deficiency |
| Maintenance Director | Maintenance Director | Named in water management and facility maintenance deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including infection control, staffing, and COVID-19 vaccine education |
| ADON | Assistant Director of Nursing | Named in infection control and staffing deficiencies |
Inspection Report
Routine
Census: 48
Deficiencies: 1
Date: Oct 10, 2023
Visit Reason
The inspection was conducted to evaluate compliance with food safety and preparation standards following resident complaints about food being served at unsafe and unappetizing temperatures.
Findings
The facility failed to maintain food at safe and appetizing temperatures as evidenced by resident complaints, observations of cold food service, and improper food temperature monitoring. The facility's policies on food safety and preparation were not consistently followed.
Deficiencies (1)
F 0804: The facility failed to provide food items at a safe and appetizing temperature, with observations showing cold food and melted ice cream not kept properly chilled. Resident complaints and interviews confirmed ongoing issues with food temperature.
Report Facts
Food temperature: 101.4
Food temperature: 86.9
Facility census: 48
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to protect residents from physical abuse by another resident and to assess compliance with staffing requirements for registered nurses.
Complaint Details
The complaint investigation revealed that on 07/29/2023, Resident #49 struck Resident #4 in the back of the head with a closed fist in the dining room. The facility failed to intervene effectively after earlier aggressive behavior by Resident #49. Resident #49 was sent for psychiatric evaluation and treated for a urinary tract infection. Staff monitoring and interventions were implemented post-incident. The facility also lacked adequate RN staffing and a Director of Nursing in January 2023.
Findings
The facility failed to prevent resident-to-resident physical abuse when Resident #49 struck Resident #4 in the head. The facility also failed to ensure a Director of Nursing was on staff and that a registered nurse worked eight consecutive hours daily in January 2023.
Deficiencies (2)
F 0600: The facility failed to protect residents from physical abuse by another resident, specifically failing to implement interventions immediately after the first indications of aggression.
F 0727: The facility failed to ensure a Director of Nursing was on staff in January 2023 and did not provide registered nurse coverage for eight consecutive hours daily during that month.
Report Facts
Incident date: Jul 29, 2023
BIMS score: 4
RN coverage days missed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #14 | Nurse Aide | Witnessed Resident #49 hitting Resident #4 and provided statements about the incident and subsequent monitoring |
| ADON | Assistant Director of Nursing | Provided witness statements, coordinated response to incident, and reported on monitoring and interventions |
| LPN #5 | Licensed Practical Nurse | Provided statements about Resident #4's behavior and the incident, and staffing coverage |
| Administrator | Facility Administrator | Provided statements regarding awareness of the incident and staffing issues |
| DON | Director of Nursing | Provided statements about the incident and staffing expectations |
Inspection Report
Census: 48
Deficiencies: 7
Date: Aug 10, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care planning participation, abuse prevention, transfer notifications, nursing staff coverage, nurse aide training, food safety, and environmental cleanliness.
Findings
The facility failed to involve residents and their representatives in care planning since March 2020, failed to prevent resident-to-resident abuse, did not notify the ombudsman of a facility-initiated transfer, lacked consistent RN coverage and a Director of Nursing in early 2023, employed uncertified nurse aides beyond four months of hire, served food at unsafe temperatures, and maintained an unclean laundry area.
Deficiencies (7)
F 0553: The facility failed to ensure residents and their responsible parties were invited to participate in care planning for 2 sampled residents since March 2020, affecting all residents.
F 0600: The facility failed to protect a resident from physical abuse by another resident and did not implement interventions immediately after first aggression indications.
F 0623: The facility failed to notify the ombudsman in writing when a resident was transferred or discharged to an acute care facility.
F 0727: The facility failed to ensure a Director of Nursing was on staff and a registered nurse worked eight consecutive hours daily in January 2023.
F 0728: The facility failed to ensure 6 nurse aides completed certification training within four months of hire.
F 0804: The facility failed to provide food at safe and appetizing temperatures, with resident complaints and observations of cold food and liquefied ice cream.
F 0921: The facility failed to maintain a clean laundry environment, with visible debris and unclean floors observed on multiple days.
Report Facts
Facility census: 48
Resident count sampled for care planning: 2
Residents reviewed for abuse prevention: 3
Nurse aides reviewed for certification: 6
Food temperature: 101.4
Food temperature: 86.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #14 | Nurse Aide | Witnessed resident-to-resident abuse incident and provided statements |
| ADON | Assistant Director of Nursing | Provided witness statements and investigation notes on resident abuse incident |
| DON | Director of Nursing | Interviewed regarding care planning, abuse incident, and nursing coverage |
| Administrator | Facility Administrator | Interviewed regarding care planning, abuse incident, transfer notification, and nursing coverage |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding resident abuse incident and nursing coverage |
| NA #15 | Nurse Aide | Interviewed regarding nurse aide certification training |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and service practices |
| Dietary [NAME] A | Dietary Staff | Interviewed regarding food temperature monitoring |
| Housekeeping and Laundry Director | Housekeeping and Laundry Director | Interviewed regarding laundry area cleanliness and cleaning schedules |
| Laundry Aide #1 | Laundry Aide | Interviewed and observed regarding laundry area cleanliness |
Inspection Report
Routine
Census: 51
Deficiencies: 8
Date: Dec 20, 2019
Visit Reason
Routine inspection to assess compliance with regulatory requirements including staff background checks, medication administration, resident care, staffing adequacy, food safety, infection control, and facility-wide assessment.
Findings
The facility had multiple deficiencies including failure to conduct timely nurse aide registry checks for new hires, failure to administer ordered medications timely, inadequate assistance with residents' activities of daily living, insufficient staffing on the special care unit, serving food at unsafe temperatures, poor kitchen hygiene, incomplete facility-wide assessment, and lapses in infection prevention and control practices.
Deficiencies (8)
F 0607: Facility failed to obtain timely nurse aide registry/background screenings for two new employees prior to employment as required by state regulations.
F 0658: Facility failed to follow professional standards for medication administration, resulting in missed doses of ordered medications for two residents.
F 0677: Facility failed to provide adequate personal hygiene care including perineal care, oral hygiene, shaving, and hair care for multiple residents.
F 0741: Facility failed to provide sufficient nursing staff on the behavioral special care unit to meet residents' needs and ensure safety.
F 0804: Facility failed to serve food at safe and appetizing temperatures; observed food temperatures below expected standards.
F 0812: Facility failed to maintain kitchen cleanliness including greasy range hood baffles, dirty ovens, improper storage of scoops, wet trays and plate covers, and incomplete hair covering by kitchen staff.
F 0838: Facility failed to conduct a comprehensive facility-wide assessment addressing staffing, resources, infection control, and emergency preparedness.
F 0880: Facility failed to ensure staff performed proper hand hygiene and infection control practices during resident care, including failure to wash hands after glove removal and touching clean items with soiled gloves, and lacked a Legionella policy.
Report Facts
Facility census: 51
Food temperature: 98
Food temperature: 112
Food temperature: 97
Food temperature: 100
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