Inspection Reports for
Brentmoor Retirement Community
8600 Delmar Blvd, St. Louis, MO 63124, United States, MO, 63124
Back to Facility Profile8 Reports
Inspection Report — Dec 8, 2025
Routine
Date: Dec 8, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
4 state deficiencies were cited related to fire alarm testing/maintenance, sprinkler system maintenance/testing, electrical wiring inspection/maintenance, and resident room cleanliness/clutter affecting egress.
Deficiencies (4)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview, the facility failed to test and maintain the complete fire alarm system; there was no record of a semi-annual fire alarm inspection and the semi-annual report was not provided.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on record review and interview, the facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13; no annual sprinkler system report was available.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Based on record review and interview, the facility failed to properly maintain the building's electrical wiring; no two-year electrical inspection record was provided.
19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily: Based on observation and interview, the facility failed to ensure rooms are kept neat, orderly and cleaned daily; resident room 213 had an excess amount of belongings lined along the hallway hindering the egress path and preventing required clearance.
Report Facts
residents affected: 16
Inspection Report — Jan 16, 2025
Routine
Date: Jan 16, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Seven state deficiencies were cited addressing staff responsibilities on individual evacuation plans, timely and semi-annual community based assessments (CBAs), development of individualized service plans (ISPs), required resident admission record information, annual resident rights review, and annual advance directive review.
Deficiencies (7)
19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements: Based on interview and record review, the facility failed to provide the responsibilities of specific staff members in an emergency on the Individual Evacuation Plan (IEP) for one resident (Resident #2).
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day: Based on interview and record review, the facility failed to complete a community based assessment (CBA) within five calendar days of admission for two of two sampled residents (Residents #1 and #2).
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually: Based on interview and record review, the facility failed to complete semi-annual community based assessments for two of two sampled residents (Residents #1 and #2).
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: Based on interview and record review, the facility failed to develop individualized service plans that included resident needs, services to be provided, and goals expected by the resident or legal representative for one of two sampled residents (Resident #2).
19 CSR 30-86.047(58)(A) Resident Record Admission Info: Based on interview and record review, the facility failed to maintain a record for each resident that included preferred dentist and funeral director contact information for two of two sampled residents (Residents #1 and #2).
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: Based on interview and record review, the facility failed to review resident rights with residents or their representative annually for two of two sampled residents (Residents #1 and #2).
19 CSR 30-88.010(10) Advance Directive Requirements: Based on interview and record review, the facility failed to review advance directives with residents or their representative annually for two of two sampled residents (Residents #1 and #2).
Report Facts
residents sampled: 2
Inspection Report — Aug 22, 2024
Routine
Date: Aug 22, 2024
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
1 Missouri state licensure deficiency concerning failure to employ a licensed administrator at all times.
Deficiencies (1)
19 CSR 30-86.047(5) Administrator - Licensed: The facility failed to employ a licensed Administrator at all times; the former Administrator was terminated and the Executive Director and a Corporate Staff Member had been acting without a license.
Inspection Report — Jan 2, 2024
Routine
Date: Jan 2, 2024
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
1 Missouri state deficiency (Class II) for failure to report and investigate an allegation of resident abuse affecting Resident #1.
Deficiencies (1)
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Based on interview and record review, the facility failed to report and investigate an allegation of abuse for one of one sampled resident (Resident #1), which had the potential to affect all residents.
Report Facts
residents sampled: 1
Inspection Report — Sep 25, 2023
Routine
Date: Sep 25, 2023
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
13 state deficiencies were cited covering individualized evacuation plans and staff responsibilities, area of refuge signage and two-way communication, tuberculosis screening for residents and staff, personnel/physician statements, development of individualized service plans and documentation of falls, physician order signature requirements, monthly medication recapitulation, backflow/ice machine air gaps, food service hair restraints, annual review of advance directives, and resident personal inventory requirements.
Deficiencies (13)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - In Resident ISP: Based on interview and record review, the facility failed to ensure residents who required more than minimal assistance to safely evacuate had an individual evacuation plan in the residents' individualized service plans for two sampled residents.
19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements: The facility failed to provide the responsibilities of specific staff members on the Individual Evacuation Plan for one of two sampled residents, as the ISP did not specify which staff member was assigned to the resident.
19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate: The facility failed to evaluate and document the resident's location within the facility and proximity to exits/areas of refuge on the IEP for two sampled residents.
19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements: The facility failed to ensure the area of refuge had required signage, diagrams, and two-way communication devices/instructions for two areas of refuge on the second floor.
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure required annual TB screenings and two-step initial TB tests were completed for two sampled residents and failed to ensure initial/two-step screening was completed for two sampled employees.
19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ: The facility failed to ensure employees had a written statement by a licensed physician or designee indicating the person could work in a long-term care facility for two sampled employees.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: The facility failed to develop individualized service plans documenting residents' needs, goals and interventions for two sampled residents, including documentation of falls and interventions.
19 CSR 30-86.047(47)(B) Physicians Orders Requirements: The facility failed to ensure physician orders were signed by a physician every three months for two sampled residents.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to complete the required monthly medication review/recapitulation for two sampled residents.
19 CSR 30-87.020(28) Backflow Requirements: The facility failed to ensure there was an air gap between the drain pipe of the ice machine and the floor drain for two ice machines.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: The facility failed to ensure proper use of hairnets and beard restraints by kitchen staff during observations.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to review advanced directives annually with two sampled residents as required.
19 CSR 30-88.010(36) Personal Clothing/Possessions: The facility failed to ensure personal inventory lists were completed for two sampled residents.
Report Facts
residents sampled: 2
employees sampled: 2
Inspection Report — Apr 26, 2023
Complaint Investigation
Date: Apr 26, 2023
Visit Reason
Missouri State licensure survey (State Form); a complaint investigation is cited in the file (MO00214755).
Complaint Details
MO00214755; substantiation not stated on the form.
Findings
One state deficiency (Class II) was cited for failure to report alleged resident abuse and deficiencies in reporting/investigation.
Deficiencies (1)
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: The facility failed to report alleged abuse of Resident #1 by a staff member to the Department of Health and Senior Services, despite interviews and documentation indicating the resident had been struck; the incident had the potential to affect all residents.
Inspection Report — Feb 11, 2019
Routine
Date: Feb 11, 2019
Visit Reason
Missouri Department of Health and Senior Services State Form licensure survey; the survey type is not stated.
Findings
2 state licensure deficiencies were cited concerning fire door self-closing hardware and dryer vent/lint creating a fire hazard. One deficiency was labeled Class II and the other Class II*.
Deficiencies (2)
19 CSR 30-86.022(10)(G) Door Devices - Self/Auto closing Protection from Hazards: Based on observation and interview on February 11, 2019, the facility failed to ensure doors providing separation between floors were self-closing; a synchronizer was loosely attached and did not allow the doors to completely close and latch.
19 CSR 30-86.032(2) Substantially Constructed & Maintained: Based on observation and interview on February 11, 2019, the facility failed to maintain the building in good repair; dryer vent pipes above a drop ceiling were poorly connected/sealed and heavy lint accumulation created a flammable fire hazard.
Report Facts
residents affected: 17
residents affected: 17
Inspection Report — Oct 22, 2018
Routine
Date: Oct 22, 2018
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two state licensure deficiencies were cited: one for failure to provide proper care per an individualized service plan related to fall risk documentation and services, and one for failure to meet advance directive/residency and emergency (CPR) policy requirements including lack of staff CPR training.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: Based on observation, interview and record review, the facility failed to provide proper care per the resident's individualized service plan when staff did not document increased fall risk and the services to be provided for one of three sampled residents (Resident #3).
19 CSR 30-88.010(10) Advance Directive Requirements: Based on record review and interview, the facility failed to meet requirements related to advance directives and residency agreements and did not ensure staff were trained or policies ensured initiation of cardiopulmonary resuscitation for residents with a full code status.
Report Facts
residents sampled: 3
residents with full code status: 3
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