Inspection Reports for
The Gardens at Barry Road

19 CSR 30-88.010(29) Dignity/Privacy: Based on interview and record review, the facility staff failed to treat one resident (Resident #1) of three sampled residents with consideration, dignity, and respect when a Level One Medication Aide yelled at and spoke disrespectfully to the resident, returned to the room and continued to yell, and then left and slammed the door.

19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review the facility failed to implement written policies and procedures prohibiting abuse and failed to report allegations to management immediately and to protect the resident during the investigation, allowing the alleged person access and to take the resident offsite prior to conclusion of the investigation.

19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review the facility failed to develop and implement written abuse policies and failed to notify Resident #2's emergency contact when Resident #1 smacked Resident #2's arm; this deficient practice affected one of two sampled residents.

19 CSR 30-86.047(47)(A) Physicians Orders Followed: Based on observation, interview, and record review, the facility failed to follow physician orders when staff did not administer residents' insulin as ordered for three of three sampled residents, with doses administered late.

19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures: Based on interview and record review, the facility failed to ensure Individual Service Plans included signatures from the resident or the resident's legal representative for seven of 10 sampled residents (Residents #1, #2, #5, #6, #7, #8, and #9).

19 CSR 30-86.047(46) Safe & Effective Medication System: Based on observation, interview, and record review, the facility failed to implement a safe and effective medication system when a Level One Medication Aide (LIMA A) did not perform hand hygiene during the medication pass for four of ten sampled residents, affecting four of 10 sampled residents.

19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: Based on interview and record review, the facility failed to complete a monthly review of each resident's condition and needs for eight of 10 sampled residents (Residents #1, #2, #4, #6, #7, #8, #9, and #10).

19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources: Based on observation and interview, the facility failed to ensure food was in sound condition, free from spoilage or other contamination and safe for human consumption when staff did not date opened food and did not dispose of outdated food; examples included multiple sandwiches and an open package of hotdogs.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation and interview, the facility failed to ensure food was protected from contamination and maintained at appropriate temperatures when staff failed to keep prepared food covered and refrigerators storing potentially hazardous food were above required temperatures; no policy regarding food temperatures was provided.

19 CSR 30-88.010(22) Free From Abuse: Based on observation, record review, and interview, the facility failed to ensure ten residents were free from abuse when facility staff involuntarily secluded residents to their rooms due to bed bug activity, resulting in residents being quarantined or isolated with meals delivered and reporting loneliness, depression, and restricted participation in activities.

19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds Protection from Hazards.: Based on observation and interview on 12/28/23 the facility failed to ensure the smoke separation doors would properly close and latch; the smoke separation door latch was pulled off the door by Room 330 and would not remain closed, potentially affecting 27 of 27 residents.

19 CSR 30-86.022(12)(A) Emergency Lighting - locations Emergency Lighting.: Based on observations and an interview on 12/28/23 the facility failed to maintain emergency lighting in good repair; emergency lights were not working in the corridors by Rooms 305, 319, and 328, potentially affecting 27 of 27 residents.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal.: Based on observations and an interview on 12/28/23 the facility had non-approved wastebaskets in resident rooms (Room 315 and Room 322), potentially affecting 27 of 27 residents.

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 Resident #1 had low blood pressure and a change in condition and did not provide a policy regarding notifying the physician during a resident's change in condition.

19 CSR 30-86.047(46) Safe & Effective Medication System: Based on observation, interview and record review, the facility failed to ensure a safe and effective medication system when staff preset medication, left the medication cart unattended with keys on top, and failed to observe Resident #2 taking medications.

19 CSR 30-88.010(18) Emergency Discharges: Based on interview and record review, the facility staff failed to issue one resident and his/her next of kin, legally authorized representative or designee a written notice of discharge when the facility could no longer provide the resident with care to meet his/her needs; the facility census was 110.

19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: Based on observation, record review, and interview, the facility failed to review the individualized service plan (ISP) with the resident or legal representative when there was a significant change in the resident's condition. This affected two of six sampled residents (Resident #1 and #5) and the facility census was 67.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to provide documentation that the electrical wiring had been inspected within the required two-year period; records showed no valid inspection copy and staff were unable to locate documentation.

19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: Based on observation and interview the facility failed to ensure a double fire-rated smoke-stop partition door at the southeast dining room exit would properly close, as the door was sticking on the floor and did not close when released from the magnetic hold.

19 CSR 30-86.022(12)(A) Emergency Lighting - locations Emergency Lighting: Based on observations and interview the facility failed to provide sufficient emergency lighting in the resident corridors and stairwells; numerous emergency lights throughout upper- and lower-level corridors, stairwells and near dining room exits were not working.

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 administered upon hire for two of seven sampled employees.

19 CSR 30-86.047(51)(B)(2) Controlled Substances-Reconcile by Personnel: Record review showed narcotic count records for the East, Down and West hall medication carts had multiple missing signatures and staff were not consistently signing the narcotic count reconciliation at shift change.

19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: Based on record review and interview, the facility failed to ensure residents or their legally authorized representatives were informed upon admission and at least annually of resident rights for seven of seven sampled residents.

19 CSR 30-86.047(35) Protective Oversight: Based on interviews and record review, the facility failed to provide protective oversight to one sampled resident (Resident #1) who lived in a secured unit and was at risk for elopement; the resident left the secured unit three times in one month and, aside from 30- and 15-minute checks, no additional interventions were implemented.

19 CSR 30-88.010(18) Emergency Discharges: Based on interviews and record review, the facility failed to provide one resident (Resident #1) an appropriate notice of discharge when the resident was emergency discharged on 8/26/20 following an incident; a written emergency discharge notice was not provided to the resident or the Durable Power of Attorney.

19 CSR 30-86.047(35) Protective Oversight: Based on record review and interviews, the facility failed to provide protective oversight when a staff member removed one of three sampled resident's (Resident #1) emergency call light pendant, leaving the resident no way to notify staff if he/she needed assistance.

19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: Based on record review and interviews, the facility failed to immediately report abuse or neglect once they had reasonable cause to believe that a resident had been abused or neglected; this affected one of three sampled residents (Resident #1).

19 CSR 30-86.022(12)(A) Emergency Lighting - locations: The facility failed to provide sufficient emergency lighting in residents' corridors, dining area and stairs. Multiple emergency lights were observed not functioning when tested.

19 CSR 30-86.047(47)(G) Medication Administration, Documented: Based on interview and record review, the facility failed to ensure staff recorded administration of medications on the Medication Administration Record (MAR) for two of 11 sampled residents, with multiple missed initials and missing documentation of administrations.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation and interview, facility staff failed to ensure food was protected from potential spoilage and contamination when numerous food packages were stored unsealed in the kitchen and walk-in freezer.

19 CSR 30-86.022(3)(A) Fire Extinguishers-Minimum per Floor: The facility failed to provide enough fire extinguishers to meet maximum travel distance requirements. Measurements showed over 200 feet between extinguishers and the deficiency affected all 79 residents.

19 CSR 30-86.022(9)(A) Fire Alarm Complete System: The facility failed to maintain a complete fire alarm system. Observations found no smoke detectors in the vaulted portion of the main dining/seating area, affecting all 79 residents.

19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to maintain required one-hour fire-rated smoke partitions. Observations noted multiple holes in separation walls and doors in separation walls that did not self-close or latch, affecting all 79 residents.

19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: The facility failed to maintain the sprinkler system. Multiple sprinkler heads were missing escutcheon rings and required adjustment or replacement, affecting all 79 residents.

19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles: Extension cords and power strips were used improperly with multiple items plugged in and a power strip plugged into an extension cord and another power strip in an apartment, creating electrical hazards and affecting all 79 residents.