Inspection Reports for
Mari De Villa Retirement Center, Inc
13900 CLAYTON RD, TOWN AND COUNTRY, MO, 63017-8406
Back to Facility Profile6 Reports
Inspection Report — May 11, 2026
Routine
Date: May 11, 2026
Visit Reason
Missouri Department of Health and Senior Services State Form survey; the survey type is not stated.
Findings
Sixteen state licensure deficiencies were cited covering fire alarm and smoke detection, sprinkler installation and maintenance, door locking/delayed-egress, fire drill frequency, electrical wiring/GFCI and panel access, criminal background checks and Employee Disqualification List, employee/resident TB testing and infection control, medication self-administration and medication orders/assessments, nursing care/wound care/mechanical lift practices, kitchen and food-contact sanitation, resident rights/grievance procedures, and dignity/privacy issues.
Deficiencies (16)
19 CSR 30-85.022(10)(I) Smoke Detectors-Interconnected to FA System: Based on observation and interview, several spaces open to corridors, including the employee dining room and a converted sitting area, lacked smoke detectors interconnected to the facility's complete fire alarm system.
19 CSR 30-85.022(11)(B) No Complete Sprinkler System Prior to 8/28/07 Sprinkler System: The facility failed to ensure the building was fully equipped with a complete sprinkler system as a closet/utility area in the East building did not have a sprinkler installed.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: The facility failed to maintain sprinkler heads free of debris and obstructions and to ensure sprinkler components were unobstructed and clean, with multiple sprinkler heads observed with foreign substance or dust.
19 CSR 30-85.022(16) Door Locks: Delayed-egress/double delayed-egress exit doors did not reliably unlock and release when the fire alarm was activated, as the locking devices on the Waterford hall doors remained locked during alarm activation.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: The facility failed to ensure required fire drills were conducted on each shift quarterly; review showed missing drills across multiple quarters and shifts.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: The facility failed to maintain electrical wiring and equipment, with multiple outlets lacking GFCI protection, exposed wiring and junction boxes, unsecured/light fixtures, and electrical panels accessible or obstructed.
19 CSR 30-85.042(17) Criminal Background Check Request: The facility failed to ensure criminal background checks and Employee Disqualification List screenings were completed and documented for new hires prior to employment; record review found incomplete or missing CBC/EDL documentation in employee files.
19 CSR 30-85.042(27) Communicable Disease-Employees: The facility failed to ensure required TB screening for employees, including administration and documentation of the two-step tuberculin skin test and related records for staff as required by policy and regulation.
19 CSR 30-85.042(50) Self-Administration of Medication: The facility failed to ensure residents had documented assessments and physician orders permitting self-administration; medications were observed at bedside without appropriate orders or documentation.
19 CSR 30-85.042(66) Nursing Care per Res Condition: The facility failed to follow acceptable nursing practices, including unsafe mechanical lift transfers where a resident was left unattended in a lift, incomplete wound treatment documentation, and failure to provide an ordered mechanical soft diet.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: The facility failed to administer and document the two-step TB test series for residents as required; several residents lacked the second step or proper TB screening documentation.
19 CSR 30-87.020(12) Floor Surfaces: The facility failed to ensure kitchen floors and food-preparation floor surfaces were clean and maintained; observations showed food debris and buildup under the milk/coffee station and deep fryer.
19 CSR 30-87.030(63) Food-Contact Surfaces Washed/Rinsed/Sanitized: The facility failed to ensure food-contact appliances and surfaces were cleaned and free from food debris, with refrigerators and ovens noted with food debris and crumbs.
19 CSR 30-88.010(7) Res Rights/Rules Posted, Alz Unit Info: The facility failed to ensure the State Survey Agency/elder abuse hotline contact information was posted in a conspicuous location accessible to residents and families.
19 CSR 30-88.010(20) Exercise Rights/Voice Grievances: The facility failed to maintain an effective grievance process and accessible grievance procedures, and did not ensure grievances were properly documented and resolved (resident reports of missing personal property and lack of grievance log/process).
19 CSR 30-88.010(29) Dignity/Privacy: The facility failed to protect resident dignity and privacy during care, including incidents where residents were provided perineal care or turned with bare buttocks exposed to an open window and window blinds left open during care.
Report Facts
employee files reviewed: 8
residents with missing/ incomplete two-step TB testing: 7
sample size for nursing care review: 13
Inspection Report — May 5, 2025
Follow-Up
Date: May 5, 2025
Visit Reason
Missouri Department of Health and Senior Services State Form licensure survey with an initial survey completed 2025-05-05 and a follow-up/revisit completed 2025-07-30.
Findings
Eleven state deficiencies were cited, primarily involving fire and life-safety (combustible storage under stairways, portable fire extinguisher placement, sprinkler maintenance, smoke barrier doors, and fire drill documentation), plus wastebasket/chemical storage issues, deficiencies related to written orders/restraints and nursing care assessments, and failures to post electronic monitoring signage. Revisit documentation indicates some restraint/order deficiencies remained uncorrected (past noncompliance).
Deficiencies (11)
19 CSR 30-85.022(2)(D) Combustibles Not Stores Under Stairways: Based on observation and interview, the facility staff failed to prohibit storage underneath two stairways designated as exit pathways.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: Based on observation and interview, the facility failed to ensure portable fire extinguishers were maintained in accordance with requirements and several extinguishers were mounted more than 60 inches above the finished floor.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Based on observation and interview, staff failed to maintain sprinkler heads free of debris and ensure escutcheon plates fit tightly, leaving multiple sprinkler heads loaded with dust, with gaps, paint on deflectors, or signs of corrosion.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Based on observation and interview, the facility failed to ensure smoke barrier doors closed fully and left gaps between the vertical meeting edges on sets of doors.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Based on interview and record review, the facility failed to ensure required fire drills were completed on each shift quarterly, with missing documentation and no night shift drills documented.
19 CSR 30-85.022(40)(A) Wastebaskets, Metal/UL/FM: Based on observation and interview, the facility failed to ensure all trash cans were only metal or UL/FM-approved and had multiple non-UL/FM plastic trash cans in resident rooms and other areas.
19 CSR 30-85.042(45) Written Orders; Restraints: Based on observation, interview and record review, the facility failed to obtain a physician's order for the use of a waist restraint for one sampled resident.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Based on observation, interview and record review, the facility failed to assess residents for risk related to side rails and waist restraints and failed to ensure ordered interventions (for example, an arm sling) were in place for several residents.
19 CSR 30-87.020(5) Toxic Material Storage: Based on observation, interview and record review, poisonous or toxic materials were not secured and were accessible to residents in multiple storage and utility areas.
19 CSR 30-91.010 (8)(A) Notice-posting facility sign: Based on observation, interview and record review, the facility failed to post a notice at the main entrance in large, legible type informing visitors that some resident rooms may be monitored electronically.
19 CSR 30-91.010 (8)(B) Notice-posting resident room sign: Based on observation and record review, the facility failed to ensure residents with electronic monitoring devices had a conspicuous notice posted at the resident's room; the facility identified residents with devices but signage was not posted as required.
Report Facts
sampled residents lacking physician order: 1
sampled residents lacking assessments for restraints: 4
residents identified as confused/disoriented in facility-provided survey: 12
residents with electronic monitoring devices identified: 2
Inspection Report — Oct 14, 2021
Routine
Date: Oct 14, 2021
Visit Reason
Missouri Department of Health and Senior Services State Form (state licensure survey); the survey type is not stated.
Findings
One Missouri State Form deficiency involving nursing care practices and failure to ensure a resident who requested the COVID-19 vaccine received it.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Based on interview and record review the facility failed to ensure current acceptable nursing practices were provided by not having a system in place to ensure one of three sampled residents who requested the COVID-19 vaccine received it (Resident #1).
Report Facts
residents sampled: 3
Inspection Report — Jun 23, 2021
Complaint Investigation
Date: Jun 23, 2021
Visit Reason
Missouri state licensure survey (State Form); complaint investigation (MO00186423).
Complaint Details
MO00186423: complaint investigation cited in the file; the finding indicates the complaint was investigated and substantiated as noted in the deficiency.
Findings
1 state licensure deficiency concerning denial of ombudsman/representative access and failures in arranging or escorting visits related to COVID-19 restrictions and staffing.
Deficiencies (1)
19 CSR 30-85.042(3) Operator/Administrator Responsibilities: Based on interview and record review, the facility failed to ensure state statutes were followed by not allowing an ombudsman representative entrance to the building and access to residents. The facility staff cited being busy and COVID-related restrictions and did not reschedule or escort the representative to see residents.
Inspection Report — Apr 17, 2019
Routine
Date: Apr 17, 2019
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
10 Missouri State Form deficiencies were cited covering oxygen storage, monthly fire alarm testing, sprinkler maintenance, exit obstructions, smoking ashtray disposal, fire drill frequency, electrical inspection certification, employee tuberculosis screening, food storage/labeling and kitchen sanitation, and ice machine air gap.
Deficiencies (10)
19 CSR 30-85.022(6) Oxygen Storage: Based on observation and interview, the facility failed to maintain two of two oxygen storage rooms with a system for identifying full and empty oxygen cylinders and failed to store cylinders in racks.
19 CSR 30-85.022(10)(E) Fire Alarm System, Monthly Activation: Based on interview and record review, the facility failed to test the fire alarm on a monthly basis and had no documentation of monthly alarm tests for several months.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Based on interview and record review and the fire safety tour, the facility failed to maintain sprinkler heads free of corrosion, debris and lint and some heads showed signs of corrosion and foreign material.
19 CSR 30-85.022(12) Exit Requirements: Based on observation and interview, the facility failed to maintain six exit doors in three rooms clear and unobstructed.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: Based on observation and interview, the facility failed to properly dispose of smoking materials in a designated smoking area, including broken or unsafe ashtray receptacles and trash containing cigarette butts.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Based on interview and record review, the facility failed to conduct required quarterly fire drills on each shift for three of four quarters reviewed.
19 CSR 30-85.032(31)(B) Electrical System-Certification Every 2 Years: Based on interview and record review, the facility failed to have documentation of an electrical inspection completed every two years.
19 CSR 30-85.042(27) Communicable Disease-Employees: Based on interview and record review, the facility failed to ensure the two-step PPD was completed for four of ten facility employees sampled who had been hired since 5/1/18.
19 CSR 30-87.030(13) Food Storage and Kitchen Sanitation: Based on observation, interview and record review, the facility failed to ensure food was protected from contamination and failed to discard or date open food items in kitchen storage areas.
19 CSR 30-87.030(4) Ice Store/Dispense, No Contamination, Air Gap: Based on observation and interview, the facility failed to maintain an air gap between the ice machine drain and the floor drain; the deficiency was noted to merit the higher classification due to extent of the violation.
Report Facts
facility employees sampled: 10
facility employees with missing second PPD step: 4
oxygen storage rooms: 2
exit doors obstructed: 6
Inspection Report — Feb 15, 2018
Routine
Date: Feb 15, 2018
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Nine state deficiencies were cited covering fire alarm system interconnection and audible signals, delayed egress door locks and signage, smoke barrier doors not closing, fire drill and emergency preparedness plan deficiencies, unsecured electrical panels, employee tuberculosis screening, inadequate nursing neurological assessments after a fall, and failure to administer tuberculosis (PPD) testing to residents.
Deficiencies (9)
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: The facility failed to maintain the fire alarm system in compliance with NFPA 72; the alarm systems in the East and West buildings were not interconnected through a main panel and audible/strobe signals did not activate in the opposite building during testing.
19 CSR 30-85.022(16) Door Locks: The facility failed to ensure magnetically locked delayed egress doors were equipped with required signage and would open within the required time; several doors lacked the "PUSH UNTIL ALARM SOUNDS. DOOR WILL OPEN IN 15 SECONDS." signage and some doors did not release in the required time when tested.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: The facility failed to ensure doors in smoke barrier walls closed completely upon activation of the fire alarm system; observed gaps between paired doors left openings up to approximately 8 inches and 3/4 inch.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: The facility failed to request an annual consultation from the fire department or state fire marshal for 2017, with the most recent consultation form on file dated 2/19/16.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: The facility failed to conduct the required fire drills on each shift at least quarterly for the last two quarters of 2017, with no evening/night shift drills documented for the third and fourth quarters of 2017.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: The facility failed to ensure electrical panels were secured from unauthorized use as required; multiple electrical panels were found unlocked and accessible to staff, residents and visitors.
19 CSR 30-85.042(27) Communicable Disease-Employees: The facility failed to implement policies and procedures to ensure employees who work ten or more hours per week were appropriately screened for tuberculosis; three of seven facility employees hired since 7/1/17 did not have documented completion of the two-step PPD.
19 CSR 30-85.042(67) Nursing Care per Res Condition: The facility failed to provide thorough neurological assessments and ongoing monitoring following a fall for one of nine sampled residents (Resident #7); neuro-checks and documentation were not completed as expected.
19 CSR 30-85.042(78) Infection Control/Communicable Disease: The facility failed to administer the purified protein derivative (PPD) skin test or conduct an annual tuberculosis screen for nine of nine sampled residents; medical records did not show PPD administration, screening or results.
Report Facts
residents sampled: 9
employees hired since a date: 7
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