Inspection Reports for
Fields of Florissant
1101 Garden Plaza Drive, Florissant, MO 63033, MO, 63033
Back to Facility Profile14 Reports
Inspection Report — Oct 20, 2025
Routine
Date: Oct 20, 2025
Visit Reason
Missouri Department of Health and Senior Services State Form inspections dated 05/29/2025 and 10/20/2025; the survey types are not stated.
Findings
Five Missouri state deficiencies were cited across the two State Forms. The findings address incomplete or inaccurate resident medical records and record retention, failure to develop individualized service plans, and failures to follow physician medication orders (one deficiency noted as uncorrected/past noncompliance).
Deficiencies (5)
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on interview and record review, the facility failed to ensure all residents had a complete and accurate medical record on the premises for two of six sampled residents (Residents #1 and #2).
19 CSR 30-86.047(60) Resident Records Retention: Based on interview and record review, the facility failed to ensure all resident medical records were retained for five years after discharge for one of six sampled residents (Resident #3).
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 which included resident needs, preferences, services to be provided by staff, and goals expected by the resident or the resident's legal representative for six of seven sampled residents.
19 CSR 30-86.047(47)(A) Physicians Orders Followed: Based on interview and record review, the facility failed to ensure physicians' orders were followed when medications were not administered according to physicians' orders for three of seven sampled residents.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on interview and record review, the facility failed to ensure all residents had a complete and accurate medical record for six of seven sampled residents (Residents #5, #6, #2, #3, #1, and #7).
Report Facts
residents affected: 2
residents sampled: 6
residents affected: 1
residents sampled: 6
residents affected: 6
residents sampled: 7
residents affected: 3
residents sampled: 7
residents affected: 6
Inspection Report — Aug 1, 2025
Complaint Investigation
Date: Aug 1, 2025
Visit Reason
Missouri state licensure survey (State Form); complaint investigation, complaint number MO00257425.
Complaint Details
Complaint MO00257425; the violation was determined to be an imminent danger (Class I) at the time of the complaint investigation.
Findings
Two state deficiencies were cited: one for failure to develop an individualized service plan for a resident's behavioral needs, and one for failure to keep a resident free from abuse (a staff member restrained and struck a resident and immediate protective actions were inadequate).
Deficiencies (2)
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: Based on interview and record review, the facility failed to develop an individualized service plan (ISP) related to Resident #1's behavioral needs and strategies for staff to use, affecting one sampled resident.
19 CSR 30-88.010(22) Free From Abuse: Based on interview and record review, the facility failed to ensure Resident #1 was free from physical abuse when a staff member restrained and struck the resident and immediate steps were not taken to protect residents, resulting in the alleged perpetrator continuing to provide direct care.
Report Facts
residents_affected: 1
Inspection Report — Jun 23, 2025
Routine
Date: Jun 23, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One state deficiency was cited regarding failure to ensure a licensed Administrator was employed at all times.
Deficiencies (1)
19 CSR 30-86.047(5) Administrator - Licensed: Based on interview and record review, the operator failed to ensure a licensed Administrator was employed at all times. The census was 60.
Inspection Report — Feb 24, 2025
Routine
Date: Feb 24, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Twelve state licensure deficiencies were cited addressing TB screening and staff/resident TB testing, individualized service plans and fall interventions, medication storage and security and medication destruction/return procedures, physician order signatures, resident admission/face sheet information and inventories of personal possessions, monthly summary documentation, staffing and CPR-trained staff availability, and facility cleanliness of floors and nonfood-contact surfaces.
Deficiencies (12)
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 (TB) test was completed prior to hire and a one step completed annually for three of five sampled staff; the facility also failed to ensure the required two step TB test was completed prior to admission for five of seven sampled residents and failed to do annual screenings for three of seven sampled residents.
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 (ISP) which included a resident's fall history and new interventions for each fall for six of seven sampled residents.
19 CSR 30-86.047(41) Medication Storage/Accessibility: Based on observation, interview and record review, the facility failed to properly store residents' medications in a secure locked location when medications were observed in an unlocked medication cart and an unlocked medication room and left unattended, with multiple blister packs open or partially full.
19 CSR 30-86.047(47)(B) Physicians Orders Requirements: Based on interview and record review, the facility failed to ensure physician's orders were signed by a physician at least every three months for six of seven sampled residents.
19 CSR 30-86.047(56)(E)(1 - 2) Medications-Return to RX / Destroy, Records: Based on observation, interview and record review, the facility failed to ensure all unusable medication was destroyed by two people including a nurse or pharmacist and failed to document the reason for destroying unusable medication when a Medication Technician destroyed medications alone.
19 CSR 30-86.047(58)(A) Resident Record Admission Info: Based on interview and record review, the facility failed to maintain resident records that included contact information for the resident's preferred dentist, pharmacist and funeral director for six of seven sampled residents.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on interview and record review, the facility failed to ensure a monthly summary which included the general condition and needs of each resident was completed for six of seven sampled residents and failed to document an incident in the resident's medical record when the resident fell.
19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety: Based on interview and record review, the facility failed to ensure staff trained in cardiopulmonary resuscitation (CPR) were available on each shift to meet the needs of full code residents, with many shifts showing no CPR-trained person on duty.
19 CSR 30-87.020(12) Floor Surfaces: Based on observation and interview, the facility failed to ensure the floors throughout the facility were kept clean, with kitchen and other facility floors observed covered in a sticky substance and food debris.
19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed: Based on observation and interview, the facility failed to ensure all non-food contact surfaces of equipment were clean, with built up grease observed on the freestanding fryer and cooking range.
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 five 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 five of seven sampled residents.
Report Facts
sampled staff lacking documented two-step TB test: 3
sampled residents lacking documented two-step TB test upon admission: 5
Inspection Report — Jan 8, 2025
Routine
Date: Jan 8, 2025
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
The file contains one Missouri state licensure deficiency related to fire alarm testing and maintenance. It was cited Class II for failure to ensure the complete fire alarm system was tested/maintained, including no record of a required semi-annual inspection, potentially affecting 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 and no semi-annual fire alarm system inspection record could be found. The deficiency potentially affected all residents.
Report Facts
residents potentially affected: 78
Inspection Report — Oct 4, 2024
Routine
Date: Oct 4, 2024
Visit Reason
Missouri Department of Health and Senior Services State Form (Statement of Deficiencies and Plan of Correction); the survey type is not stated.
Findings
One Missouri state licensure deficiency regarding self-control of medication: staff failed to observe a resident's medication administration and left medication with a resident who did not have an order to self-administer, and the resident's record/ISP did not indicate authorization for self-administration.
Deficiencies (1)
19 CSR 30-86.047(40) Self-Control of Medication Requirements: Based on observation, interview and record review the facility failed to ensure staff observed a resident take medications and allowed medication to be left with a resident who did not have an order to self-administer, affecting one sampled resident; the resident's medical record and individualized service plan did not indicate the resident was able to self-administer medication.
Report Facts
residents sampled: 1
Inspection Report — Jun 5, 2024
Routine
Date: Jun 5, 2024
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
One state deficiency for dignity/privacy concerning a staff member taking a personal cell phone call in a resident's room; the deficiency is Class II*.
Deficiencies (1)
19 CSR 30-88.010(29) Dignity/Privacy: Housekeeper G was observed on a personal cell phone call while cleaning Resident #9's room and continued to talk while the resident expressed wanting to die; the facility failed to treat the resident with respect.
Report Facts
residents_affected: 1
Inspection Report — Mar 15, 2024
Complaint Investigation
Date: Mar 15, 2024
Visit Reason
Missouri state licensure survey (State Form); complaint investigation. Complaint numbers MO00232152, MO00220410, and MO00232889 are cited in the file.
Complaint Details
Complaint numbers cited: MO00232152, MO00220410, MO00232889. The file does not state whether the complaints were substantiated.
Findings
Three state licensure deficiencies were cited addressing individualized service plan development, resident condition/medication review and documentation related to falls and therapy notes, and staffing/fall assessment practices.
Deficiencies (3)
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 (ISP) for one of five sampled residents (Resident #1) and the resident's medical record and therapy notes did not reflect required individualized ISP and therapy guidance.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on interview and record review, the facility failed to maintain a full and accurate medical record for two of five sampled residents when a resident had a fall and the fall and related therapy notes were not documented in the resident's chart (Residents #2 and #1).
19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety: Based on observation, interview and record review, facility care staff failed to notify a nurse for an assessment after a resident fell and transferred the resident off the floor without a qualified assessment for one of five sampled residents (Resident #5).
Report Facts
residents sampled: 5
residents affected: 2
Inspection Report — Dec 26, 2023
Routine
Date: Dec 26, 2023
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
2 Missouri state licensure deficiencies were cited regarding fire alarm testing/maintenance and electrical wiring inspection/maintenance requirements.
Deficiencies (2)
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; no semi-annual fire alarm inspection was documented.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Based on record review and interview, the facility failed to have electrical wiring inspected every two years by a qualified electrician; the last bi-annual electrical wiring certification on record was October 28, 2021.
Report Facts
residents potentially affected: 71
Inspection Report — Nov 21, 2022
Routine
Date: Nov 21, 2022
Visit Reason
Missouri Department of Health and Senior Services State Form (state licensure survey); the survey type is not stated.
Findings
Four state deficiencies were cited related to fire safety: failure to conduct required fire drills and failures in fire alarm system testing, inspections/certifications, and monthly testing. The facility census was 69 and the deficiencies potentially affect all residents.
Deficiencies (4)
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: Based on record review and interview, the facility failed to conduct the required minimum of twelve fire drills annually, with documented drills missing for July through September 2022; the census was 69 and the deficiency potentially affects 69 residents.
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, as no semi-annual inspection was documented; the deficiency potentially affects 69 residents.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: Based on record review and interview, the facility failed to have annual inspections and written certifications of the complete fire alarm system, with the last written certification shown as March 23, 2021; the deficiency potentially affects 69 residents.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test: Based on record review and interview, the facility failed to test the complete fire alarm system at least once monthly, with no monthly test records from July through September 2022; the deficiency potentially affects 69 residents.
Report Facts
residents potentially affected: 69
Inspection Report — Oct 18, 2021
Routine
Date: Oct 18, 2021
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Nine state licensure deficiencies were cited, all related to fire safety and building hazards. Topics include combustible storage under stairs and elsewhere, fire drills and drill records, employee fire training, monthly fire alarm testing, dryer ventilation and lint traps, compliant wastebaskets, and electrical wiring inspections.
Deficiencies (9)
19 CSR 30-86.022(2)(H) Combustibles Not Stored Under Stairways: Based on observation and interview the facility failed to ensure space under stairways was not used to store combustible materials; the north first floor stairway was observed storing ten wood top tables.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation: The facility failed to conduct the required minimum of twelve annual fire drills with at least one drill every three months on each shift; records showed drills in December 2020, August 2021 and September 2021 with no documentation from January through July 2021.
19 CSR 30-86.022(5)(E) Fire Drill Records: The facility failed to keep complete records of all fire drills including time, date, personnel participating, length and narrative; record review showed no fire drill documentation from January 2021 through July 2021.
19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees: The facility failed to ensure fire safety training was provided to all employees at least every six months and when training needs were identified by drill evaluations; record review showed no documentation of required fire safety training for all employees.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test: The facility failed to test the complete fire alarm system at least once monthly as required; record review showed no documentation of the required monthly tests.
19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of: The facility failed to ensure protection from hazards by prohibiting storage of unnecessary combustible materials in parts of the building; observation of the third floor north refuge area showed paper products, cardboard boxes, plastic trash containers, tables, furniture, microwave ovens and a mattress stored inside the room.
19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps: The facility failed to ensure electric or gas clothes dryers were vented to the outside and lint traps cleaned to protect against fire hazard; observations included a broken aluminum vent duct on the second floor laundry and a first floor dryer without a vent duct connected.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility failed to ensure only metal or UL/FM fire-resistant rated wastebaskets were used for trash; observations found plastic non-compliant wastebaskets being used in multiple resident rooms.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to have electrical wiring inspected every two years by a qualified electrician as required; records showed the last inspection and written certification was completed on April 03, 2019 and no biennial inspection was on file.
Report Facts
residents potentially affected: 64
combustible items observed under stairway: 10
Inspection Report — Aug 21, 2019
Routine
Date: Aug 21, 2019
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Eight Missouri state deficiencies were cited covering individual evacuation plans, community-based assessments (semi-annual, significant change), individualized service plan care, resident admission/face sheet information, monthly summaries/medication review, resident rights admission/annual review, and advance directive requirements. The report lists 8 state deficiencies (4 Class II and 4 Class III).
Deficiencies (8)
19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate: Based on interview and record review, the facility failed to include proximity to areas of refuge or exits in resident individual evacuation plans for two of five sampled residents.
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 a community based assessment at least semiannually for three of five sampled residents.
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment - Significant Change: Based on interview and record review, the facility failed to update the community based assessment for a significant change in condition for one of five sampled residents.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: Based on interview and record review, the facility failed to ensure residents received proper care as outlined in individualized service plans for two of five sampled residents.
19 CSR 30-86.047(58)(A) Resident Record Admission Info: Based on interview and record review, the facility failed to ensure resident admission records included a preferred dentist for two of five sampled residents.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on interview and record review, the facility failed to complete monthly summaries and reviews of resident condition and needs for five of five sampled residents.
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 representatives upon admission and annually for four of five sampled residents.
19 CSR 30-88.010(10) Advance Directive Requirements: Based on interview and record review, the facility failed to conduct annual reviews of advance directives and related facility policies for three of five sampled residents.
Report Facts
sampled residents: 5
residents affected (A4508): 2
residents affected (A4750): 3
Inspection Report — Dec 14, 2018
Complaint Investigation
Date: Dec 14, 2018
Visit Reason
Missouri Department of Health and Senior Services State Forms (state licensure surveys); complaint investigation. Complaint numbers MO00149684 and MO00149687 are cited in the file.
Complaint Details
Complaint numbers MO00149684 and MO00149687; the complaint investigation indicated the violation was determined to be at an imminent danger (Class I) at the time of investigation and the severity was later lowered to Class II at exit.
Findings
Three state deficiencies were cited covering protective oversight and an elopement incident, missing individualized evacuation plans (IEPs) in residents' ISPs, and failure to provide proper care per individualized service plans (failure to identify elopement risk and implement interventions).
Deficiencies (3)
19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview and record review, the facility failed to provide protective oversight for a resident with dementia who exited the building unattended on 11/17/18 and was later found with hypothermia; staff and security did not adequately monitor door alarms and elopement risk.
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - In Resident ISP: Based on observation, interview and record review, the facility failed to ensure residents who required more than minimal assistance to evacuate had individualized evacuation plans (IEPs) in their individualized service plans (ISPs) for two of two sampled residents.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: Based on observation, interview and record review, the facility failed to provide protective oversight and implement interventions for residents with dementia at risk for elopement for two of two sampled residents.
Report Facts
residents sampled: 2
residents sampled: 2
Inspection Report — Sep 25, 2018
Routine
Date: Sep 25, 2018
Visit Reason
Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three state deficiencies were cited concerning TB screening for residents and staff, cleanliness/repair of walls and ceilings, and cleaning of nonfood-contact surfaces in the kitchen; two state items were Class III.
Deficiencies (3)
19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, the facility failed to ensure a newly admitted resident received a two-step tuberculosis (TB) test and failed to ensure employees received the first step of a two-step TB test prior to employment, affecting two of five sampled employees and one of six sampled residents.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: Based on observation and interview, the facility failed to ensure walls, ceilings, doors and windows were kept clean and in good repair for one day of observation; observations in the kitchen included water beads on a light cover, a puddle from a ceiling leak, stained and sagging ceiling tiles and brown streaks and spots.
19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed: Based on observation and interview, the facility failed to keep non-food-contact surfaces clean and free of debris on the food warmer, fryer, shelf under the stove knobs, wall behind the steam table, water filter box on the floor, and front door of the oven, with dried food residue and grease observed.
Report Facts
employees affected: 2
employees sampled: 5
residents affected: 1
residents sampled: 6
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