Deficiencies (last 6 years)
Deficiencies (over 6 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
58% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Jan 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged sexual abuse of a resident by a Certified Medication Aide (CMA A).
Complaint Details
The complaint investigation was substantiated based on interviews and record review showing failure to suspend the alleged staff and incomplete investigation documentation.
Findings
The facility failed to implement its abuse policy to ensure resident safety when staff allowed CMA A to work during the investigation of a reported sexual abuse allegation. The investigation lacked documentation of suspension of the alleged staff and proper follow-up actions.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to implement written policies prohibiting abuse and ensuring reporting to authorities, as staff allowed CMA A to work during an investigation of sexual abuse allegations.
Report Facts
Facility census: 34
Inspection Report
Life Safety
Census: 49
Deficiencies: 5
Date: Mar 6, 2024
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with fire hazard regulations and safety requirements at the assisted living facility.
Findings
The facility failed to maintain fire safety standards including the absence of carbon monoxide detectors, improper storage of combustible materials, lack of current sprinkler system certification, use of non-fire-resistant wastebaskets, and unsafe electrical wiring. These deficiencies affected all 49 residents present during the inspection.
Deficiencies (5)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements. The facility failed to keep the building free of fire hazards, including absence of carbon monoxide detectors. This deficiency affected all 49 residents.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to ensure storage of unnecessary combustible materials was prohibited, with paint buckets stored in the furnace room. This deficiency affected all 49 residents.
19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. The facility failed to maintain the sprinkler system certification with no current annual report available. This deficiency affected all 49 residents.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility used non-approved wastebaskets that were not metal or fire-resistant. This deficiency affected all 49 residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to maintain electrical wiring safely, with multiple unapproved extension cords and multi-plug adapters in resident rooms. This deficiency affected all 49 residents.
Report Facts
Facility census: 49
Deficiencies cited: 5
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 2
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to assess compliance with kitchen cleanliness and sanitation regulations at Mill Creek Village Assisted Living by Missouri Department of Health and Senior Services.
Findings
The facility failed to maintain kitchen equipment in a clean and sanitary manner, with observed debris and grease buildup on cooking surfaces and dishwashing machines. Interviews revealed inconsistent deep cleaning practices and staffing challenges affecting kitchen sanitation.
Deficiencies (2)
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: The food-contact surfaces of grills, griddles, microwaves, and cooking equipment were not cleaned daily and had encrusted grease and soil buildup.
19 CSR 30-87.030(83) Dishwashing Machine Clean Daily/As Needed: Dishwashing machines were not thoroughly cleaned daily, showing debris buildup and lime deposits.
Report Facts
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tolly Fuller | LAN LNHA | Signed the inspection report |
| Director of Nursing | Interviewed regarding kitchen cleaning schedule and practices | |
| Assistant Dietary Manager | Interviewed regarding cleaning schedules and deep cleaning practices | |
| Dietary Manager | Interviewed regarding staffing and cleaning schedules | |
| Administrator | Interviewed regarding dietary staff and cleaning practices |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
The inspection was conducted to assess compliance with hazardous area requirements related to fire safety in an assisted living facility.
Findings
The facility failed to ensure the kitchen was separated from the remainder of the facility by a minimum of smoke stop partitions, which could allow smoke and toxic gases to pass from the kitchen to the dining room.
Deficiencies (1)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements were not met. The kitchen was not separated from the rest of the facility by smoke stop partitions, risking smoke and toxic gases passing to the dining room.
Report Facts
Facility census: 43
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Date: Nov 21, 2019
Visit Reason
Annual inspection conducted on 11/21/2019 to assess compliance with medication administration and food safety regulations at Mill Creek Village Assisted Living.
Findings
The facility failed to ensure proper documentation of medication administration, including missing signatures and incomplete records for as-needed medications. Food safety violations were also noted, including improper food storage, unsealed and undated food items, and lack of working thermometers in refrigerators and freezers.
Deficiencies (2)
19 CSR 30-86.047(47)(G) Medication Administration: Facility staff failed to document medication administration on the Medication Administration Record and did not record results of as-needed medications. The facility census was 40.
19 CSR 30-87.030(13) Food-Protected, Temp. Need to Contact DHSS: Facility staff failed to protect food from potential contamination, including unsealed and undated food items and lack of working thermometers in refrigerators and freezers.
Report Facts
Facility census: 40
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 1
Date: Aug 23, 2018
Visit Reason
The inspection was conducted to assess compliance with food protection regulations related to temperature control and contamination prevention in the facility's kitchens.
Findings
The inspection found multiple instances of unsealed, undated, and open food items with debris present on bottles and in freezers, indicating failure to protect food from potential contamination. Staff interviews revealed inconsistent food storage practices and lack of proper labeling.
Deficiencies (1)
19 CSR 30-87.030(13) Food-Protected, Temp, Nced to Contact DHSS. Facility staff failed to protect food from potential contamination by storing multiple food items unsealed, undated, and with debris present. The facility census was 40.
Report Facts
Facility census: 40
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