10 Reports
Inspection Report — Mar 10, 2026
Complaint Investigation
Date: Mar 10, 2026
Visit Reason
Missouri Department of Health and Senior Services State Form licensure survey; a complaint number (MO00260853) is referenced in the file.
Complaint Details
Complaint number MO00260853 is referenced in the file; whether the complaint was substantiated is not stated.
Findings
Fifteen state deficiencies were cited covering oxygen storage signage, hot water temperature control, missing physician statements in personnel records, incomplete community-based assessments and significant-change assessments, multiple individualized service plan (ISP) problems (reviews, signatures and documentation of changes), protective oversight and kitchenette safety, medication administration (insulin technique by a LIMA), incomplete resident admission/record information and advanced directive documentation, dementia training deficits, and cleanliness of nonfood-contact surfaces and kitchenettes.
Deficiencies (15)
19 CSR 30-86.022(17) Oxygen Storage Requirements: The facility failed to ensure a resident's room was labeled with a sign indicating oxygen was stored and an oxygen concentrator was observed in resident room 226 without any sign on the door.
19 CSR 30-86.032(34) Hot Water 105-120 Degrees F: The facility failed to ensure plumbing fixture water temperatures were maintained between 105°F and 120°F, with multiple measured temperatures above 120°F and several fixtures measuring in excess of 120°F.
19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ: The facility failed to ensure employees had a physician's statement in their personnel files indicating they could work in long-term care for three of four sampled employees.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually: The facility failed to ensure semiannual community-based assessments (CBAs) were fully completed, with sections left blank for four of four sampled residents.
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change: The facility failed to complete a community-based assessment for a resident after a significant change in condition (Resident #6) and did not update the CBA as required.
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: The facility failed to ensure individualized service plans were reviewed when residents had changes in condition, falls, or new needs for four of four sampled residents and two additional residents.
19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures: The facility failed to ensure resident individualized service plans were signed by a facility representative and the resident or the resident's responsible party for four of four sampled residents.
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight when residents had access to a kitchenette equipped with a working stove/oven that was open and accessible, creating potential safety risks to residents.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure a Level One Medication Aide (LIMA) performed insulin injection technique correctly (did not hold the needle in the resident's abdomen the required amount of time) during a medication pass for one resident.
19 CSR 30-86.047(58)(A) Resident Record Admission Info: The facility failed to maintain required admission information, specifically documentation of preferred funeral director/home, for two of four sampled residents.
19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr: The facility failed to ensure direct care employees had documentation of the required three hours of Alzheimer/dementia training for two of two sampled direct care employees.
19 CSR 30-86.047(63)(B) Dementia Training-Non-Direct Care Staff, 1 hr: The facility failed to ensure non-direct care employees had documentation of the required one hour of dementia training for one of two sampled non-direct care employees.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: The facility failed to ensure nonfood-contact surfaces in the memory care kitchenette were clean, with cabinets, handles, freezer and microwave surfaces observed covered in food residue and sticky substances.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to review resident rights with residents or their representatives upon admission and annually for four of four sampled residents.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to review and document residents' advanced directives with residents or their representatives upon admission and annually for four of four sampled residents, and some advanced directive documentation and signatures were missing.
Report Facts
residents sampled: 4
Inspection Report — Dec 9, 2025
Routine
Date: Dec 9, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three state licensure deficiencies were cited addressing blocked/obstructed exit operation, use of non-fire-resistant trash/wastebaskets throughout resident and public areas, and improper storage of portable oxygen cylinders.
Deficiencies (3)
19 CSR 30-86.022(7)(A) Exits-2 per Floor-Remote/Unobstructed: Based on observation and interview, the facility failed to maintain unobstructed exits remote from each other; an exterior exit door at the base of the stairs on the Willow wing was sticking and required excessive force to open.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Based on observation and interview, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were used for trash; numerous non-metal/non-UL-FM-rated wastebaskets were in use in resident rooms and public/common areas.
19 CSR 30-86.022(17) Oxygen Storage Requirements: Based on observation and interview, the facility failed to store portable oxygen cylinders in accordance with NFPA 99 (1999); four oxygen cylinders were observed standing upright and not secured in an approved rack in the wellness office.
Report Facts
residents affected: 51
portable oxygen cylinders observed: 4
Inspection Report — Apr 28, 2025
Routine
Date: Apr 28, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eight Missouri state licensure deficiencies were cited covering area-of-refuge signage, proper care per individualized service plan and dietary errors, appropriate action and notification to physicians, safe medication administration, following physician orders, resident admission record completeness, handwashing/food handling, and clean clothing/hair restraints.
Deficiencies (8)
19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements: Based on observation and interview, the facility failed to ensure a sign was placed outside the entrance to the Area of Refuge that stated "AREA OF REFUGE IN CASE OF FIRE" and displayed the international symbol of accessibility for two of two AOR.
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 as defined in the individualized service plan for one resident, including serving regular pizza and non-pureed oatmeal contrary to the resident's prescribed pureed diet which resulted in aspiration and hospitalization.
19 CSR 30-86.047(37) Appropriate Action & Notification: Based on interview and record review, the facility failed to notify the resident's physician when a resident went to the hospital on 4/10/25 for shortness of breath for one of four sampled residents.
19 CSR 30-86.047(46) Safe & Effective Medication System: Based on observation and interview, the facility failed to provide a safe and effective medication system when a Level One Medication Aide did not hold the inner canthus while instilling eye drops for a resident, causing medication to stream down the resident's cheek.
19 CSR 30-86.047(47)(A) Physicians Orders Followed: Based on interview and record review, the facility failed to follow physician orders when staff did not provide a resident with the diet prescribed by the resident's physician for one of four sampled residents.
19 CSR 30-86.047(58)(A) Resident Record Admission Info: Based on interview and record review, the facility failed to maintain resident admission records that included preferred dentist and preferred funeral home information for four of four sampled residents (Residents #1, #3, #4 and #2).
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: Based on observation and interview, the facility failed to ensure staff washed their hands and/or wore gloves when plating and serving food in the kitchen during breakfast, with multiple observed instances of improper hand hygiene and glove use.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Based on observation and interview, the facility failed to ensure the proper use of hair restraints when a server served food without a hairnet and the administrator was not aware staff were not using hair restraints.
Report Facts
areas of refuge without signage: 2
sampled residents: 4
residents missing admission contact info: 4
residents affected by medication administration error: 1
Inspection Report — Mar 21, 2024
Complaint Investigation
Date: Mar 21, 2024
Visit Reason
Missouri state licensure survey (State Form); complaint investigation noted (MO00233299, MO00233304).
Complaint Details
MO00233299, MO00233304; substantiation not stated in the document.
Findings
10 state deficiencies were cited covering individualized evacuation planning and evaluation, TB screening for staff, required physician employment statements, incomplete community-based assessments, failure to provide care per individualized service plans for a combative resident, inadequate fall assessment/response, failure to follow abuse/neglect policy, dignity/privacy concerns, and missing personal inventory lists.
Deficiencies (10)
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 an individualized evacuation plan with responsibilities of specific staff positions for three of six sampled residents.
19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate: Based on interview and record review, the facility failed to ensure individualized evacuation plans identified the resident's location within the facility and proximity to exits/areas of refuge for three of six sampled residents.
19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, the facility failed to ensure the required two-step tuberculosis screening test was completed prior to hire for three of three sampled employees.
19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ: Based on interview and record review, the facility failed to ensure employees had a written statement by a licensed physician or physician's designee indicating the person could work in a long-term care facility and any limitations for three of three sampled employees.
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 ensure all sections of the community based assessment (CBA) were completed for three of six sampled residents.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: Based on interview and record review, the facility failed to provide proper care as defined in individualized service plans for one of seven sampled residents, including failure to follow prescribed interventions for a combative resident.
19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety: Based on observation, interview and record review, the facility failed to notify a nurse for assessment after a resident fall and transferred residents off the floor without an assessment by a qualified person for two of seven sampled residents.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review, the facility failed to follow their abuse and neglect policy when staff failed to intervene after a resident slapped another person, for one of seven sampled residents.
19 CSR 30-88.010(29) Dignity/Privacy: Based on interview and record review, the facility failed to ensure staff treated residents with consideration, respect, and recognition of dignity when a staff member made unnecessary comments to a resident who fell, for one of seven sampled residents.
19 CSR 30-88.010(36) Personal Clothing/Possessions: Based on interview and record review, the facility failed to ensure personal inventory lists were completed for four of seven sampled residents.
Report Facts
sampled residents affected: 3
sampled employees affected: 3
sampled employees affected: 3
sampled residents affected: 3
sampled residents affected: 1
sampled residents affected: 2
sampled residents affected: 1
sampled residents affected: 4
Inspection Report — Jun 22, 2023
Routine
Date: Jun 22, 2023
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One Missouri state licensure deficiency was cited for failure to test and maintain the facility's complete fire alarm system; the deficiency potentially affected all residents.
Deficiencies (1)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition. Record review showed no semi-annual fire alarm system inspection had been completed as required and the most recent annual inspection was June 30, 2022.
Report Facts
residents potentially affected: 54
Inspection Report — Aug 8, 2022
Complaint Investigation
Date: Aug 8, 2022
Visit Reason
Missouri State Form (state licensure survey); complaint investigation MO00202880.
Complaint Details
MO00202880; substantiation not stated in the form.
Findings
One Missouri state licensure deficiency was cited concerning protective oversight. The deficiency involves failure to provide 24-hour protective oversight and to protect a resident from heat/sun exposure during an off-site outing, resulting in sunburn and subsequent injury.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight for a resident who attended a baseball game in high heat and did not adequately assess, apply sunscreen, or otherwise protect the resident from prolonged sun exposure, resulting in sunburn and later injury.
Report Facts
residents who attended the outing: 9
Inspection Report — Jul 14, 2022
Routine
Date: Jul 14, 2022
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
4 state licensure deficiencies were cited concerning the kitchen hood extinguishing system cleaning/certification, nonfunctioning area of refuge communication call boxes, incomplete fire alarm system testing/maintenance, and smoke doors failing to close.
Deficiencies (4)
19 CSR 30-86.022(4)(C) Range Hood Certification: Based on observation and interview the kitchen hood extinguishing system had grease buildup and the commercial hood cleaning sticker was dated May 2021, indicating it was not properly cleaned or maintained.
19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements: Based on observation and interview the two-way communication call boxes in multiple areas of refuge failed to function when activated.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Record review and interview found the facility failed to ensure required semi-annual inspections and testing of the complete fire alarm system were conducted.
19 CSR 30-86.022(10)(H) Smoke Sections Protection from Hazards: Observation and interview found multiple smoke doors failed to completely close, indicating automatic self-closing devices were not ensuring the doors closed.
Report Facts
residents potentially affected: 50
Inspection Report — Jul 10, 2019
Routine
Date: Jul 10, 2019
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One state deficiency (Class II) was cited concerning failure to perform and document required semi-annual fire alarm visual inspections and functional testing in accordance with NFPA 72, 1999 edition.
Deficiencies (1)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: Based on record review and interview on July 10, 2019, the facility failed to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition; record review showed no documentation that required semi-annual fire alarm visual inspections and functional testing (due October 2018) had been completed.
Report Facts
residents affected: 46
Inspection Report — May 3, 2019
Routine
Date: May 3, 2019
Visit Reason
Missouri Department of Health and Senior Services State Form (state licensure survey); the survey type is not stated.
Findings
Two state licensure deficiencies were cited concerning a fire hazard from resident-accessible kitchenettes with operable ovens and failures to maintain hot water temperatures and documentation. The deficiencies address unsafe accessible ovens and multiple fixtures and water heaters producing temperatures above the required 105-120°F range, with incomplete temperature logs.
Deficiencies (2)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard: Based on observation and interview, resident-accessible kitchenettes were equipped with working ovens that were not disabled and were accessible to residents; the administrator said she was not aware the ovens in the kitchenettes were on and they were supposed to be locked.
19 CSR 30-86.032(34) Hot Water 105-120 Degrees F: Based on observation, interview and record review the facility failed to maintain water temperatures in resident-accessible fixtures within 105-120°F; multiple sink and tub readings exceeded 120°F, water heaters were set near 146°F, and water temperature logs were incomplete or missing entries.
Report Facts
residents with Alzheimer’s disease or dementia: 39
Inspection Report — Jan 10, 2019
Complaint Investigation
Date: Jan 10, 2019
Visit Reason
Missouri Department of Health and Senior Services State Form (state licensure survey); complaint investigation for MO00150716 (self-report referenced).
Complaint Details
MO00150716; the complaint investigation determined a violation occurred (initially cited at Class I; the severity was documented as lowered to Class II at exit).
Findings
1 state deficiency for protective oversight related to an elopement and delayed staff response to door alarms and phone alerts; the facility implemented corrective actions and inservices during the onsite visit and the severity was noted to be lowered at exit.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight for a resident with a history of searching for deceased family members who eloped from the secured memory care unit and exited the building, and staff did not respond to a door alarm for approximately 21 minutes. Interviews and record review documented failures in monitoring, alarm/phone response procedures, and staff notification.
Report Facts
residents sampled: 1
minutes for staff to respond to door alarm: 21
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