Inspection Reports for
Aegis Health and Rehabilitation
1441 CHARIC DR, WILDWOOD, MO, 63021-2001
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
191% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
62 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Date: Sep 16, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly complete post-fall observation reports, notify physicians and emergency contacts after resident falls, and timely update care plans following falls.
Complaint Details
The complaint investigation found that the facility did not follow its policy and acceptable standards of practice related to fall incident reporting, notification, documentation, and care plan updates. The Regional Nurse Consultant and Administrator confirmed expectations for fall assessments, incident reporting, and notifications were not met.
Findings
The facility failed to accurately complete post-fall observation reports for 72 hours for three sampled residents, failed to notify the physician and emergency contact for one resident's fall, and failed to timely update care plans and document falls in nursing progress notes. Vital signs were often not current or documented for the day of or after the falls.
Deficiencies (4)
Failure to complete accurate post-fall observation reports for 72 hours including obtaining current vital signs for residents.
Failure to notify physician and emergency contact when a resident had a fall.
Failure to update residents' care plans timely after falls.
Failure to document a resident's fall in nurse progress notes.
Report Facts
Sample size: 3
Census: 62
Pain level: 7
Pain level: 8
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 1
Date: May 30, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with care standards, specifically focusing on the provision of perineal care to residents.
Findings
The facility failed to ensure appropriate perineal care for one resident (Resident #21), as observed during a care episode where proper cleansing techniques were not followed, potentially risking skin breakdown and infection.
Deficiencies (1)
Failure to provide appropriate perineal care, including cleansing all areas of the groin and buttocks with soap or cleanser as per facility policy.
Report Facts
Sample size: 14
Residents affected: 1
Census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) F | Observed providing inadequate perineal care | |
| Director of Nursing (DON) | Provided interview regarding proper perineal care procedures |
Inspection Report
Routine
Census: 60
Deficiencies: 9
Date: May 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, medication management, trauma-informed care, and vaccination policies.
Findings
The facility was found deficient in multiple areas including improper perineal care, failure to provide trauma-informed care and appropriate 1:1 activities for residents with PTSD, inadequate staff competencies related to behavioral health, medication cart cleanliness and labeling issues, improper use of insulin pens, failure to use required PPE for residents on enhanced barrier precautions, poor hand hygiene practices, and failure to offer influenza and pneumococcal vaccinations to eligible residents.
Deficiencies (9)
Failed to ensure appropriate perineal care for Resident #21, including inadequate cleansing technique and failure to use cleanser.
Failed to provide ongoing activities and 1:1 visits for residents with PTSD (Residents #4 and #25).
Failed to provide trauma-informed care for Resident #4, including failure to identify trauma triggers and incorporate interventions into care plans.
Failed to ensure staff had appropriate competencies and skills to meet behavioral health needs of residents with PTSD.
Medication carts were unclean and contained loose, unlabeled, or improperly stored medications.
Administered incorrect insulin pen to Resident #45, using Resident #13's insulin pen.
Failed to apply required PPE for residents on enhanced barrier precautions (Residents #33 and #32).
Failed to perform appropriate hand hygiene and glove changes during perineal care for Resident #21.
Failed to offer and vaccinate eligible residents with influenza and pneumococcal vaccines (Residents #40, #32, #21, and #44).
Report Facts
Sample size: 14
Facility census: 60
Residents with PTSD: 7
Units of insulin administered incorrectly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered incorrect insulin pen to Resident #45. |
| CNA F | Certified Nursing Assistant | Performed inadequate perineal care for Resident #21 without proper hand hygiene or glove changes. |
| Director of Nursing | Director of Nursing | Provided interviews regarding expectations for perineal care, PPE use, hand hygiene, trauma-informed care, and vaccination policies. |
| Social Services designee | Social Services designee | Involved in care planning and psychosocial assessments but lacked formal training on PTSD and behavioral health. |
| Activity supervisor | Activity Supervisor | Responsible for 1:1 activities but admitted department was disorganized and some residents with PTSD were not receiving 1:1 visits. |
| CNA A | Certified Nursing Assistant | Failed to wear gown when providing care to Resident #33 on enhanced barrier precautions. |
| CNA B | Certified Nursing Assistant | Failed to wear gown when providing care to Resident #33 on enhanced barrier precautions. |
| CNA C | Certified Nursing Assistant | Failed to wear PPE when providing care to Resident #32 on enhanced barrier precautions. |
| CNA D | Certified Nursing Assistant | Failed to wear PPE when providing care to Resident #32 on enhanced barrier precautions. |
Inspection Report
Census: 47
Deficiencies: 1
Date: May 21, 2024
Visit Reason
The inspection was conducted to assess medication error rates and ensure they were below 5 percent.
Findings
The facility failed to maintain a medication error rate below 5 percent, with 7 errors out of 47 opportunities observed, resulting in a 14.89% error rate. This deficiency was uncorrected from a previous inspection.
Deficiencies (1)
Medication error rate exceeded 5 percent, with 7 errors out of 47 opportunities observed.
Report Facts
Medication error opportunities observed: 47
Medication errors observed: 7
Medication error rate: 14.89
Inspection Report
Routine
Census: 41
Deficiencies: 4
Date: Apr 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication administration, dietary services, and overall resident care standards at the facility.
Findings
The facility failed to maintain medication error rates below 5%, with a 28.94% error rate observed. Medication administration errors included incorrect insulin dosing and improper application of medication patches. Additionally, the facility failed to provide residents with adequate food variety, sufficient quantities, and access to menus prior to meal service, resulting in resident dissatisfaction and unmet dietary needs.
Deficiencies (4)
Medication error rate of 28.94% with 11 errors out of 38 opportunities observed.
Resident #27 insulin administered per resident request, not as ordered, without physician notification.
Resident #6 lidocaine patch applied longer than recommended standards of practice.
Failure to provide residents with a variety of food in appropriate quantity and access to menus prior to meal service.
Report Facts
Medication error rate: 28.94
Census: 41
Medication error opportunities observed: 38
Medication errors observed: 11
Eggs quantity: 180
Soup cans: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Documented resident refusal of insulin and administered insulin per resident request |
| Licensed Practical Nurse B | LPN | Interviewed regarding proper insulin administration procedures |
| Director of Nursing | DON | Provided interviews on medication administration policies and dietary concerns |
| CMT A | Certified Medication Technician | Observed administering medications including insulin and lidocaine patch |
| Dietary Manager | Dietary Manager | Interviewed regarding menu policies and food availability |
| Administrator | Facility Administrator | Interviewed regarding alternate meals, food ordering, and resident meal choices |
| Pharmacist U | Pharmacist | Provided information on polyethylene glycol powder preparation |
Inspection Report
Routine
Census: 41
Deficiencies: 13
Date: Apr 9, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to medication self-administration, resident assessments, care planning, medication administration, infection control, dietary services, and other aspects of resident care.
Findings
The facility had multiple deficiencies including failure to ensure proper assessment and physician orders for medication self-administration, inaccurate resident assessments, incomplete and non-person-centered care plans, medication errors including insulin administration and medication storage issues, failure to provide timely diagnostic services, inadequate dietary services and menu options, lapses in infection prevention and control practices, and lack of an antibiotic stewardship program.
Deficiencies (13)
Failed to ensure residents allowed to self-administer medications had been assessed and had physician orders.
Failed to ensure resident assessment was accurately coded for discharge status.
Failed to develop and implement comprehensive, person-centered care plans based on MDS care area assessment summaries for multiple residents.
Failed to provide appropriate treatment and care according to orders for wound care and medication administration.
Failed to provide appropriate care for incontinent resident, resulting in prolonged soiling and skin redness without proper care.
Failed to provide timely and appropriate pain management for a resident with femur fracture and spinal cord compression.
Failed to ensure each nurse aide had at least twelve hours of in-service education per year based on hire date.
Failed to ensure medication error rate was less than 5%, with 11 errors in 38 opportunities observed.
Failed to ensure medications were stored properly including refrigerator temperature out of range, unlabeled shared insulin, unlocked medication carts, and improper storage of schedule II drugs.
Failed to provide timely MRI and swallow test appointments for residents with medical needs.
Failed to provide residents with a variety of food in appropriate quantity, failed to provide alternates timely, and failed to provide menus prior to meal service.
Failed to follow infection prevention and control practices including hand hygiene, catheter care, wound care, and proper placement of urinary drainage bags.
Failed to implement an antibiotic stewardship program to monitor antibiotic use and review data.
Report Facts
Medication error rate: 28.94
Medication room refrigerator temperature: 50
Medication room refrigerator temperature: 48
Urine volume in drainage bag: 1000
Wound measurement: 2.8
Wound measurement: 3.1
Resident census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple interviews related to medication administration, infection control, and facility policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in medication administration and narcotic count observations |
| Regional Nurse M | Regional Nurse | Named in interviews regarding care plans, antibiotic stewardship, and infection control |
| Certified Medication Technician A | Certified Medication Technician | Named in medication administration observations |
| Licensed Practical Nurse H | Licensed Practical Nurse | Named in medication administration and wound care observations |
| Certified Nursing Assistant I | Certified Nursing Assistant | Named in incontinent care observation |
| Certified Nursing Assistant W | Certified Nursing Assistant | Named in incontinent care observation |
| Dietary Manager | Dietary Manager | Named in interviews regarding food service and menu options |
| Registered Dietitian | Registered Dietitian | Named in interview regarding food temperature and dietary practices |
| Medical Records Supervisor | Medical Records Supervisor | Named in interviews regarding scheduling diagnostic tests |
| Pharmacist U | Pharmacist | Named in interview regarding medication preparation |
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in medication administration and narcotic count interviews |
| Licensed Practical Nurse K | Licensed Practical Nurse | Named in incontinent care and medication administration interviews |
| Licensed Practical Nurse O | Licensed Practical Nurse | Named in wound care observation |
Inspection Report
Immediate Jeopardy
Census: 51
Capacity: 66
Deficiencies: 13
Date: Nov 1, 2023
Visit Reason
The inspection was conducted due to multiple complaints and concerns regarding facility compliance with resident care, safety, and regulatory requirements including staffing, medication administration, infection control, and environmental conditions.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and safe environment, inadequate staffing including lack of RN coverage for many shifts, failure to administer medications timely and as ordered, failure to provide adequate wound care and pain management, failure to maintain and communicate resident code status, failure to provide adequate nutrition and snacks, failure to maintain a working call light system on the 300 hall, and failure to coordinate dialysis care and communication with dialysis centers.
Deficiencies (13)
Failure to maintain a clean and homelike environment with dirty floors, trash accumulation, and unclean resident rooms.
Failure to maintain an effective grievance process and failure to promptly resolve grievances.
Failure to provide appropriate discharge planning and readmission for a resident discharged due to behavioral issues.
Failure to provide residents with showers as scheduled or as needed, resulting in resident complaints and risk of infection.
Failure to maintain and communicate resident code status; failure to ensure CPR certified staff available for many shifts.
Failure to provide ordered medications and laboratory monitoring for a resident post kidney transplant, resulting in rehospitalization and death.
Failure to provide ordered wound care treatments and assessments for residents with pressure ulcers, resulting in worsening wounds and infection.
Failure to provide scheduled pain medications and document pain assessments and reasons for missed doses, resulting in resident suffering.
Failure to maintain physician orders and communication for dialysis care and failure to assess dialysis access sites before and after treatment.
Failure to provide sufficient nursing staff including lack of RN coverage for many shifts, and failure to provide adequate housekeeping and dietary staffing.
Failure to maintain sprinkler system with multiple corroded sprinkler heads and lack of timely repairs.
Failure to provide residents with call bells in rooms where call light system was disabled and failure to respond timely to call lights.
Failure to provide residents with adequate nutrition including lack of variety, insufficient food quantity, failure to provide seconds, and failure to follow dietician approved menus.
Report Facts
Days without RN coverage: 18
Residents full code: 38
Residents requiring two-person assistance for transfers: 15
Residents requiring total parenteral nutrition: 2
Residents requiring tube feedings: 2
Residents requiring IV antibiotics: 2
Residents census: 51
Licensed capacity: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #1 | Administrator | Named in relation to staffing issues and failure to respond to staffing crisis |
| Administrator #2 | Administrator | Named in relation to staffing and dietary issues |
| Director of Nursing | DON | Named in relation to staffing, medication administration, and call light system |
| Staffing Coordinator | Staffing Coordinator | Named in relation to staffing scheduling and lack of CPR certified staff |
| Regional Director of Operations | RDO | Named in relation to staffing oversight and call light system |
| Licensed Practical Nurse O | LPN | Named in relation to medication administration and call light system |
| Certified Nurse's Aide A | CNA | Named in relation to call light system and resident complaints |
| Certified Medication Technician E | CMT | Named in relation to medication administration and call light system |
| Dietary Manager | Dietary Manager | Named in relation to food supply and menu issues |
| Wound Nurse Practitioner | Wound NP | Named in relation to wound care deficiencies |
| Medical Director | MD | Named in relation to medication, pain management, dialysis, and nutrition |
Inspection Report
Routine
Census: 39
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards, specifically focusing on residents' activities of daily living (ADLs) assistance and pain management.
Findings
The facility failed to ensure residents unable to perform ADLs received showers and care as scheduled, with documentation gaps and insufficient staffing cited. Additionally, the facility did not provide timely administration and documentation of as-needed pain medication for one resident.
Deficiencies (2)
Failure to provide scheduled showers and care to residents unable to perform ADLs, with missed showers and inadequate documentation.
Failure to ensure as-needed pain medication was available and administered as ordered, and failure to document efforts to obtain medication.
Report Facts
Residents in sample: 13
Census: 39
Missed showers: 17
Admission date: 6
Pain level: 5
Pain level: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Provided expectations on shower documentation and pain medication follow-up |
| Administrator | Administrator | Commented on lack of shower documentation and expectations for care |
| Certified Nurse Aide A | Certified Nurse Aide (CNA) | Described shower schedule and staffing challenges |
| Certified Nurse Aide B | Certified Nurse Aide (CNA) | Described shower schedule and staffing challenges |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Discussed shower scheduling and documentation |
| Registered Nurse D | Registered Nurse (RN) | Explained medication order process and pain management expectations |
| Certified Medication Technician E | Certified Medication Technician (CMT) | Observed handling of resident's medication and timing of receipt |
Inspection Report
Routine
Census: 36
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with discharge summary and post-discharge planning requirements for residents with anticipated discharges.
Findings
The facility failed to ensure comprehensive discharge summaries and individualized post-discharge plans were developed and documented for residents discharged from the facility. Documentation was inconsistent or missing for discharge needs evaluation, post-discharge plans, and recapitulation of the resident's stay.
Deficiencies (1)
Failure to ensure comprehensive discharge summaries and post-discharge plans for residents with anticipated discharges.
Report Facts
Residents affected: 3
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding discharge planning and documentation | |
| Director of Nurses (DON) | Interviewed regarding discharge summary deficiencies | |
| Administrator | Interviewed regarding discharge summary deficiencies | |
| Nurse A | Interviewed about discharge procedures and documentation | |
| Nurse B | Interviewed about discharge procedures and documentation |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 16
Date: Aug 5, 2022
Visit Reason
The inspection was conducted based on complaints alleging multiple deficiencies including medication self-administration safety, resident rights violations, financial management, grievance handling, discharge planning, care planning, medication management, activity programming, food safety, and pest control.
Complaint Details
Complaint investigation revealed multiple deficiencies including medication safety, resident rights, financial access, grievance handling, discharge planning, care planning, medication management, activity programming, food safety, and pest control.
Findings
The facility was found deficient in multiple areas including failure to ensure safe resident self-administration of medications, failure to support resident rights such as dining choices and financial access, inadequate grievance policies and follow-up, improper discharge planning and notification, incomplete care plans, medication management issues including failure to follow pharmacy recommendations and psychotropic medication regulations, unsafe food handling and storage practices, insufficient activity programming, and ineffective pest control in the kitchen.
Deficiencies (16)
Failed to ensure residents could safely self-administer medications with proper assessments and orders.
Failed to support resident self-determination and choice, including removal of communal dining and drink cart.
Failed to provide residents timely access to personal funds held by the facility.
Failed to post all pertinent state agency and advocacy group contact information for resident complaints.
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letters at Medicare Part A benefit termination for residents.
Failed to exercise reasonable care for protection of resident property from loss or theft during discharge.
Failed to provide appropriate discharge plan and notice for resident transferred to hospital and refused readmission.
Failed to notify resident and representative in writing of bed hold policy at time of hospital transfer.
Failed to provide timely written notice of transfer or discharge including appeal rights for residents discharged or transferred.
Failed to develop comprehensive care plans addressing urinary catheter use and nutritional needs, and to update care plans after catheter removal.
Failed to follow policy for post-fall assessments and neurological checks for unwitnessed falls and failed to notify physician of high blood sugars.
Failed to ensure monthly drug regimen review recommendations were followed timely and failed to discontinue duplicate NSAIDs.
Failed to limit PRN psychotropic medication orders to 14 days and failed to document related diagnoses for psychotropic medications.
Failed to label opened medications and biologicals properly and failed to discard expired dressings.
Failed to serve food in accordance with professional standards including failure to date mark food, allow dishes to air dry, maintain kitchen cleanliness, and store food off the floor.
Failed to maintain an effective pest control program to prevent flies in the kitchen where resident food was prepared and served.
Report Facts
Residents affected: 40
Medication cart shift counts missing second nurse initials: 79
Medication cart shifts with no narcotic count: 14
Psychotropic PRN administrations: 13
Psychotropic PRN administrations: 11
Psychotropic PRN administrations: 2
Falls: 5
Days fluid restriction: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication self-administration and medication regimen review findings |
| Administrator | Administrator | Named in multiple findings including resident rights, discharge planning, and medication management |
| Licensed Practical Nurse C | Licensed Practical Nurse | Named in medication self-administration and activity program findings |
| Certified Medication Technician F | Certified Medication Technician | Named in narcotic count and medication self-administration findings |
| Dietary Manager | Dietary Manager | Named in food safety and kitchen sanitation findings |
| Social Worker | Social Worker | Named in discharge planning and grievance handling findings |
| Activity Director | Activity Director | Named in activity program findings |
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