Adair Village

Inspectors wroteBased on observation, interview and record review the facility failed to implement interventions to promote optimal food intake for one resident who the facility identified at risk for weight loss (Resident #2). The resident experienced a severe weight loss of 21.7 pounds or 15.78 % body weight in three months. The facility failed to follow their policy to fully inform the physician, involve the Dietary Manager (DM), and notify the consultant Registered Dietitian (RD) for an assessment related to the weight loss, failed to assess or identify reasons for the weight loss or develop and implement interventions to prevent further weight loss including the provision of assistance and encouragement during meals. The facility census was 57. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Residents #3 and #5) who remained in the facility. The facility census was 57. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident or resident's representative received written notice of transfer and/or discharge when the facility failed to have a process in place to routinely provide transfer letters and notice of bed hold for three sampled residents (Resident #57, #25, #7) transferred to the hospital. The facility census was 57. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of medication errors greater than 5% when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration and failed to follow manufacturer's administration instructions for three residents (Resident #8, #44, #4). Three medication errors occurred out of 26 opportunities resulting in an error rate of 11.54%. The facility census was 57. Review of the facility policy titled Administering Medications, dated April 2019, showed the following:-Medications are administered in a safe and timely manner, and as prescribed;-Medications are administered in accordance with prescriber orders, including any required time frames. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free of significant medication errors when staff failed to prime insulin pens (hormone to help regulate the amount of glucose (type of sugar) in the blood) prior to administration and follow the manufacturer's instructions for administration for three residents during five different observations (Residents #8, #44 and #4). The facility census was 57. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a baseline care plan within 48 hours of admission for one resident (Residents #60). The facility census was 57. Review of the facility's policy titled Baseline Care Plans, dated March 2022, showed the following:-A baseline plan of care (gives initial instructions on necessary care until a comprehensive care plan (extremely detailed note that provides information on a patient's past medical history AND current medical history) is established) to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission;-The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient medical documentation to support a new mental health diagnosis of schizophrenia for one resident (Resident #4). The facility census was 57. Review of the facility policy titled Psychotropic Medication Use, dated February 2025, showed the following: -Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or representative and includes determining adequate indication for use, establishing appropriate dose, adequate monitoring of efficacy and adverse consequences, and determining appropriateness of gradual dose reductions;-When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to obtain an order for dialysis and routine assessment and monitoring of the dialysis site for one resident who received dialysis (Resident #60). The facility census was 57. The facility did not provide a policy related to dialysis. Review of the facility's undated form titled Dialysis Communication Record, showed the following:-Vital Signs: blood pressure, pulse, respiration, temperature, weight;-Vital signs completed prior to dialysis as ordered by physician, Yes or No;-Shunt site (a surgically created connection between an artery and a vein);-Nurse Signature;-Time left for dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO, microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during personal cares for a resident who had a catheter (thin tube that remains in the bladder for continuous urine drainage, often held in place by a small balloon and connected to a collection bag) and failed to complete proper hand hygiene during personal cares for one resident (Resident #9). The census was 57. [...]

Inspectors wroteBased on interviews and record review, the facility failed to keep residents free from accident hazards when staff failed to provide care with two staff as trained and care planned for one resident (Resident #1) resulting in a fall and fracture. The facility census was 43. Review of the facility policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to ensure nurses aides (NA) completed their training, competencies, and testing in a timely manner when two NA's failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification within four months of hire and continued to work providing care to residents. The facility census was 43. Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Nurse aides must undergo a state-approved training program; -A nurse aide is any individual providing nursing or nursing-related services to residents in a facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all residents received care and treatment in accordance with professional standards of practice when facility nursing staff failed to document administering medications per physician orders for three residents (Resident #1, Resident #2, and Resident #3). The facility census was 43. Review of the policy titled, Clinical Administering Medications, revised April 2019 showed the following: -Medications are administered in accordance with prescriber orders, including any required time frame; -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before or after meal orders) for liberal medication passes; -For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record (MAR) may be flagged. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all residents received recommended interventions to help maintain acceptable parameters of nutritional status when staff failed to document administering a dietary supplement per physician's order for one resident (Resident #4). The facility census was 43. Review of the facility's policy titled, Weight Assessment and Intervention, revised March 2022, showed the following: -Residents are weighed upon admission and at intervals established by the interdisciplinary team; -Weights are recorded in each unit's weight record chart and in the individual's medical record; -The threshold for significant unplanned and undesired weight loss will be based on the following criteria; [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure documentation of oxygen administration/checks every shift per physician orders for one resident (Resident #1). The facility census was 43. Review of the facility policy titled, Oxygen Administration, revised October 2010, showed the following: -Purpose was to provide guidelines for safe oxygen administration; -Verify there is a physician's order for the procedure. Review physician's orders or facility protocol for oxygen administration; -Review the resident's care plan to assess for any special needs of the resident; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide effective pain management consistent with professional standards of practice when staff failed to administer requested pain medication timely, failed to assess the resident's pain level, failed document the administration of pain medication, and failed to follow-up with the resident regarding the effectiveness of the pain mediation for one resident (Resident #1) who displayed physical verbal signs of pain. The facility census was 34. Review of the facility's policy titled Medication and Treatment Orders. dated July 2016, showed the following information: -Drug and biological orders must be recorded on the physian's order sheet in the resident's chart; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care per standards of practice when staff failed to identify, assess, document, monitor, obtain orders for treatment of, and notify the physician of wounds for one resident (Resident #1). The census was 34. Review of the facility's policy titled Wound and Skin Care Protocols and Procedures, dated June 2021, showed the following: -The facility would include the orders on the physician's order sheet (POS); -May use facility skin and wound care protocols. Each resident's personal physician must approve of orders at the time of admission and then sign the order sheets monthly; -Each individual resident required treatment and specific telephone orders would be written based on protocols. -If a wound was not making progress, it was important to attempt to reduce the bioburden and manage infection. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were as free from accident hazards as possible when staff failed to transfer one resident (Resident #1) in a safe manner and failed to follow-up on possible injury from the transfer. The facility census was 34. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following: -The purpose of the procedure was to promote cleanliness, promote comfort, and to observe the condition of the resident's skin; -Staff should observe the skin for any rashes, reddened areas, and swelling and document all assessment data including reddened areas, and sores on the resident's skin. 2. Review of Resident #1's face sheet (brief look at resident information) showed the following information: -admission date of 07/11/24; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain appropriate infection control practices to prevent the risk of contamination and spread of infection while transporting clean laundry uncovered throughout the facility. This had the potential to affect 26 of 27 residents in the facility. Review of the facility's policy titled, Policy and Procedure Regarding Laundry and Bedding Soiled, issued 09/22 and reviewed 03/14/24, showed clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. 1. During an observation and interview on 03/12/24, at 2:55 P.M., Laundry Aide (LA) 2 was observed pushing a clothes cart down the hallway. LA2 said that he/she delivered the clothes to the residents. When asked should the clothes be covered, LA2 did not respond. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate steps had been put into place to prevent accidents when the staff failed to document fall investigations were complete and included a root cause analysis for three of four residents (Residents #8, #21, and #12) reviewed for falls of 18 sampled residents. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Review of the facility's policy titled, Fall Risk Assessment, dated 03/18, showed staff staff will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan. 1. Review of Resident #8's Face Sheet, showed the following: -admission date of 12/27/23; -Diagnoses included atrial fibrillation (irregular heart rhythm) and major depressive disorder. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained when staff failed to ensure catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bags were kept in a privacy bag for two residents (Resident #16 and #23) reviewed for catheter care out of 18 sampled residents. 1. Review of Resident #16's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 07/06/23 with readmission date of 02/21/24; -Diagnoses included chronic kidney disease, cellulitis of groin, and retention of urine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize all resident's right to self-determination when the facility failed to provide showers as scheduled, care planned, and preferred for one resident (Resident #4) of 18 sampled residents. Review of the facility's policy titled, Activities of Daily Living (ADL)s, Supporting, dated March 2018, showed the following: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out services of daily living; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident representative of a change in condition for one of three residents (Resident #21) reviewed for change in condition. The facility failed to inform the resident's representative of a urinary tract infection (UTI) and upper respiratory infection (URI) which required the administration of antibiotics. Review of the facility's policy titled, Change in Resident's Condition or Status, dated 02/21, showed the following: -The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. Review of the resident's Face Sheet, provided by medical records, revealed Resident #21 was admitted to the facility on [DATE] with a diagnoses that included dementia. [...]

Inspectors wroteBased on record review, interviews, and record review, the facility failed to ensure that one resident (Resident #3) of 18 sampled residents had a Level I Preadmission Screening Resident Review (PASARR) prior to admission into the facility. This failure had the potential for residents with a mental disorder to go unidentified and not receive specialized services. Review of facility's policy titled, admission Criteria, dated 03/19, showed the following: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process; -The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive plan of care directing measurable goals and person-centered approaches for all residents when the facility failed to develop an activities care plan for the two residents (Residents #21 and #22) and failed to develop a pacemaker care plan for one resident (Resident #21). A sample of 18 residents was selected for review. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 03/22, showed the following: -A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all dependent residents maintained good grooming when staff failed to provide showers as scheduled and needed for one resident (Resident #11) dependent on staff for shower of 18 sampled residents. Review of the facility's policy titled, Activities of Daily Living (ADL)s, Supporting, dated March 2018, showed the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out services of daily living (ADLs); -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all resident's with catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) received treatment to prevent possible infections when the catheter bags of two residents (Resident #16 and #23) were observed on the floor of 18 sampled residents. Review of the facility policy, Catheter Care, Urinary, dated 08/22, showed the following: -The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections; -Use aseptic technique when handling or manipulating the drainage system; -Be sure the catheter tubing and drainage bag are kept off the floor 1. Review of Resident #16's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to failed to document a diagnosis and rationale for the use of an antipsychotic medication for one of five residents (Resident #22) reviewed for unnecessary medications. A sample of 18 residents was selected. These failures placed residents at risk for unrecognized side effects and a diminished quality of life. Review of the facility's policy titled, Antipsychotic Medication Use, dated 03/22, showed the following: -Residents will not receive medications that are not clinically indicated to treat a specific condition; -Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely report an allegation of staff to resident abuse, when one resident (Resident #1) alleged a staff member hit him/her, to the state survey agency (SSA - Department of Health and Senior Services (DHSS)) . The facility census was 31. Review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, showed the following: -If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual; [...]

Inspectors wroteBased on interview and record review, the facility failed monitor all resident wounds per standards of practice when facility staff failed to document weekly comprehensive wound assessments for wounds of two residents (Resident #1 and Resident #2) potentially causing a delay in identification of a decline in a wound. The facility census was 25. Record review of the facility's policy titled, Wound and Skin Care Protocols and Procedures, dated June 2021, showed the following: -The purpose is to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown; -The wound care protocols are written to treat stages of wounds. Not all wounds are from pressure and not all wounds can be staged. The protocols will serve as a reference for selecting appropriate dressings based on the wound assessment; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to keep food safe from potential contamination when food contact surfaces had a buildup of grease, lint, and hair and staff did not date or label stored food after opening. The facility census was 17. Record review of the 2013 Missouri Food Code showed the following information: -Physical facilities shall be cleaned as often as necessary to keep them in sanitary condition; -Clean and sanitize work surfaces, including cutting boards and food-contact equipment, between uses and consistent with applicable code. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information: -Food contact surfaces and utensils shall be clean to the sight and touch. Record review of the facility policy titled Sanitization, revised 2008, showed the following information: [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a sanitary environment when staff failed to keep non-contact food surfaces the kitchen area clean and free of debris. The facility census was 17. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information: -Non food-contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris. Record review of the facility policy titled Sanitization, revised 2008, showed the following information: -All kitchen areas shall be kept clean; -All equipment, food contact surfaces shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions; [...]

Inspectors wroteBased on record review and interview, the facility failed to complete criminal background checks (CBC), employee disqualification list (EDL) checks, and/or Nurse Aide (NA) registry (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) for a federal indicator prior to starting employment and continued resident contact for four staff (Business Office Manager (BOM) A, Certified Nursing Assistant (CNA) B, Housekeeping (HK) C, and HK D). The facility census was 17. Record review of the facility's policy titled Abuse Prevention Program, revised September 2021, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a procedure in place to ensure staff changed oxygen equipment per professional standards and failed to care plan the need to change oxygen equipment for three residents (Resident #6, #10, and #11) and failed to obtained a physician's order to change oxygen equipment for one resident (Resident #10). The facility census was 17. Record review of the facility's (undated) policy, titled Protocol for Care and Cleaning of Oxygen Concentrator, showed the following information: -Oxygen concentrators require regular cleaning and proper maintenance to be able to work efficiently and to maximize the expected service life; -Educate the staff on proper cleaning and care of the oxygen concentrator; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a a risk/benefit review and document alternatives attempted prior to current bed rail use and/or periodic assessments for the use of current side rails (grab bars) for five residents (Resident #7, #67, #11, #12, #16); failed to obtain informed consent for the use of bed rails for two residents (Resident #7 and Resident #16); and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Residents #7, #11, #12, and #16) ), and failed to address the use bed rails in the residents' care plans for five residents (Resident #7, #67, #11, #12, #16). The facility census was 17. Record review of the facility's policy, titled, Assistive Devices and Equipment, dated January 2020, showed the following information: [...]