Inspection Reports for
Aegis Health and Rehabilitation
1441 CHARIC DR, WILDWOOD, MO, 63021-2001
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
19.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
247% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
94% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Life Safety
Census: 41
Capacity: 66
Deficiencies: 2
Date: Apr 9, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations, specifically focusing on oxygen cylinder storage safety.
Findings
The facility failed to maintain oxygen cylinder storage according to NFPA code, with full and empty oxygen tanks improperly stored together, posing a potential risk to occupants in one of four smoke compartments.
Deficiencies (2)
K923: The facility did not maintain oxygen cylinder storage according to NFPA 99 standards. Full and empty oxygen tanks were stored together, risking occupant safety in one of four smoke compartments.
A2010: Oxygen storage did not comply with NFPA 99, 1999 edition, as safety caps and proper racks were not used to prevent damage or dislocation of oxygen cylinders.
Report Facts
Facility capacity: 66
Resident census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding oxygen closet maintenance and tank storage | |
| Administrator | Interviewed about knowledge of oxygen tank storage practices |
Inspection Report
Life Safety
Census: 51
Deficiencies: 2
Date: Dec 11, 2023
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, specifically focusing on the sprinkler system maintenance and testing, and the essential electrical system maintenance and testing.
Findings
The facility failed to maintain the sprinkler system in accordance with NFPA 25, with corroded sprinkler heads and lack of required testing. The facility also failed to maintain the emergency generator and associated systems, including fuel level maintenance and annual fuel quality testing, which could affect all residents and staff in an emergency.
Deficiencies (2)
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system per NFPA 25, with corroded sprinkler heads in multiple locations and no documentation of required dry-type sprinkler sampling within the last 10 years.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain the emergency generator after recommended repairs, did not maintain proper fuel levels, and failed to complete an annual fuel quality test as required by NFPA 110.
Report Facts
Facility census: 51
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
Plan of Correction
Census: 39
Deficiencies: 5
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding care provided to dependent residents, including activities of daily living and pain management, and to review the facility's plan of correction for cited deficiencies.
Findings
The facility failed to ensure residents unable to carry out activities of daily living received necessary services such as showers and personal care. Additionally, the facility failed to provide adequate pain management for residents requiring such services.
Deficiencies (5)
F 677 ADL Care Provided for Dependent Residents. The facility failed to ensure residents unable to carry out activities of daily living received scheduled showers and personal care as evidenced by missed showers and inadequate documentation.
F 697 Pain Management. The facility failed to ensure as-needed pain medication was available and administered properly to a resident, resulting in untreated pain and lack of documentation.
A4075 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This was not met as cited at F697.
A4076 Clean, Dry, Odor Free. Each resident shall be clean, dry, and free of offensive body and mouth odor. This was not met as cited at F677.
A4082 Skin Care-Oil, Lotion, Cream. Each resident shall have skin care including application of oil, lotion, and cream as needed to prevent dryness and scaling. This was not met as cited at F677.
Report Facts
Sample size: 13
Resident census: 39
Missed showers: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitch Bachtel | Executive Director | Signed plan of correction |
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
Plan of Correction
Census: 36
Deficiencies: 2
Date: Mar 1, 2023
Visit Reason
The inspection was conducted to evaluate compliance with discharge summary and post-discharge plan requirements for residents with anticipated discharges.
Findings
The facility failed to ensure comprehensive discharge summaries and post-discharge plans were developed for residents with anticipated discharges. Documentation was incomplete or missing for residents #10, #35, and #36, including lack of discharge summaries, post-discharge plans, and medication reconciliation.
Deficiencies (2)
F661 Discharge Summary: The facility did not ensure discharge summaries and post-discharge plans were completed for residents with anticipated discharges. Documentation was missing for residents #10, #35, and #36.
A4113 Progress Notes - transfer/discharge: The facility failed to maintain clinical records with progress notes including reasons for transfer or discharge as required.
Report Facts
Census: 36
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Interviewed regarding discharge instructions and documentation | |
| Nurse B | Interviewed regarding notification of nursing staff about planned discharges | |
| Director of Nurses | Director of Nurses | Interviewed about review of resident records and discharge documentation |
| Administrator | Administrator | Interviewed about review of resident records and discharge documentation |
| Social Services Director | Social Services Director | Interviewed about discharge arrangements and documentation |
Inspection Report
Follow-Up
Census: 39
Deficiencies: 1
Date: Jan 5, 2023
Visit Reason
This follow-up inspection was conducted to verify correction of previous deficiencies related to the facility's failure to ensure timely payments to necessary vendors providing services for residents.
Findings
The facility management company continued to fail to ensure timely payments to vendors, resulting in outstanding balances and service suspensions. The census was 39 at the time of the follow-up inspection.
Deficiencies (1)
F835 Administration. The facility management company failed to ensure payments were issued or issued timely to necessary vendors providing services for residents. The deficiency remained uncorrected as of the follow-up inspection.
Report Facts
Outstanding balance: 6000
Invoice amount: 1500
Invoice amount: 10348.06
Invoice amount: 11916.35
Invoice amount: 6847.23
Invoice amount: 11520.39
Invoice amount: 5372.5
Invoice amount: 1903.44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vendor D | Medical Director | Named in finding for unpaid invoices and non-payment since April 2022. |
| Chief Executive Officer | CEO | Named in interview regarding awareness of vendor payment issues. |
| Regional Director of Operations | RDO | Named in interview regarding vendor payment oversight. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
The inspection was a COVID-19 focused infection control and emergency preparedness survey conducted from 12/16/2022 through 01/05/2023 as a complaint investigation.
Complaint Details
The complaint investigation found no deficiencies and confirmed compliance with COVID-19 infection control and emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Life Safety
Census: 40
Capacity: 66
Deficiencies: 6
Date: Aug 5, 2022
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code investigation at Ballwin Ridge Health & Rehabilitation.
Findings
The facility failed to develop and maintain an emergency preparedness communication plan including staff contact information. Life safety code deficiencies were found including obstructed emergency exits, delayed egress door issues, electrical wiring problems, and incomplete fire drills and generator testing.
Deficiencies (6)
E030: The facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all staff. This deficiency had the potential to affect all residents and staff.
K211: The facility failed to ensure emergency exits were maintained free of obstructions, including a fabric sign blocking a panic hardware push bar on an exit door.
K222: The facility failed to ensure the delayed-egress exit door at the front entrance opened as required, potentially affecting all occupants in one of three smoke compartments.
K511: The facility failed to maintain electrical wiring in compliance with the National Electrical Code, including damaged and painted-over receptacles and outlet covers in multiple areas.
K712: The facility failed to ensure fire drills were completed quarterly on each shift, with missing documentation for multiple months and quarters.
K918: The facility failed to maintain and test the emergency generator fuel level and related systems, including missing monthly load testing and incomplete documentation.
Report Facts
Facility capacity: 66
Resident census: 40
Fire drills required: 12
Fire drills completed: 1
Generator weekly inspections: 12
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 |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 9, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted on 05/20/2020 and 05/21/2020 to assess compliance with relevant CMS and CDC requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Mar 26, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to treat a resident with respect and dignity during a transfer out of bed when the resident did not want to get up.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews showing staff forced a resident to get out of bed despite the resident's refusal and complaints of pain. Staff failed to report or properly investigate the incident.
Findings
The facility failed to ensure a resident's rights were respected when staff transferred the resident out of bed against their wishes, causing distress and pain. Interviews and observations confirmed staff forced the resident to get up despite the resident's refusal and complaints.
Deficiencies (2)
F550 Resident Rights-Exercise of Rights: The facility failed to treat a resident with respect and dignity when staff transferred the resident out of bed against their wishes. The resident experienced pain and distress during the transfer and staff did not properly investigate or report the incident.
A8021 Exercise Rights-No Discrimination: The exercise of resident rights was not free from restraint, interference, coercion, discrimination, or reprisal. This deficiency is related to the violation cited at F550.
Report Facts
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide C | Certified Nurses Aide | Named in the finding for forcing the resident to get up against their wishes |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding the incident and reporting |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about the incident and investigation |
| Registered Nurse A | Registered Nurse | Interviewed regarding resident's refusal to get up |
| Certified Nurse Aide D | Certified Nurse Aide | Interviewed about assisting resident and incident |
| Administrator | Administrator | Interviewed about resident's transfer and staff actions |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 6
Date: Nov 1, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment, including an investigation into a bruise of unknown origin and an allegation of missing money involving two residents.
Complaint Details
The complaint involved allegations of abuse, neglect, exploitation, or mistreatment, specifically a bruise of unknown origin on Resident #50 and missing money for Resident #18. The investigation found the facility failed to follow its policies for investigation and reporting. The allegation of missing money was handled as a grievance rather than abuse/neglect, and the resident was given a lock box for safe keeping.
Findings
The facility failed to follow its policy to promptly and thoroughly investigate a bruise of unknown origin on Resident #50 and to report an allegation of misappropriation of funds of Resident #18. Additionally, deficiencies were found in comprehensive care planning, medication error rates, infection control, and dental care.
Deficiencies (6)
F610: The facility failed to complete a prompt and thorough investigation into a bruise of unknown origin on Resident #50 and failed to report an allegation of misappropriation of funds of Resident #18.
F656: The facility failed to document in one resident's care plan, resident #11, regarding a chronic wound.
F658: The facility failed to ensure staff followed acceptable standards of practice for one resident requiring assistance with personal care, Resident #19.
F759: The facility failed to ensure medication error rates were not 5 percent or greater, with a 12.5% medication error rate observed.
F791: The facility failed to address dental needs for Resident #21, including timely dental appointments and follow-up.
F880: The facility failed to ensure staff followed their policy for infection control, specifically regarding proper glove use.
Report Facts
Resident census: 51
Medication error rate: 12.5
Medication errors: 4
Medication opportunities observed: 32
Sample size for care plan review: 13
Inspection Report
Life Safety
Census: 51
Capacity: 66
Deficiencies: 5
Date: Nov 1, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to conduct the required annual testing of battery-powered emergency lighting, maintain the kitchen range hood to NFPA code, maintain the sprinkler system according to NFPA 25 standards, and properly test electrical receptacles at resident bed locations. Additionally, oxygen cylinder storage did not comply with NFPA code requirements.
Deficiencies (5)
K291 Emergency Lighting: The facility failed to conduct yearly 90-minute tests of battery-powered emergency lighting as required by NFPA 101.
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood according to NFPA 96, evidenced by accumulation of grease and uncleaned filters.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of debris, corrosion, and ensure escutcheon plates fit tightly, violating NFPA 25 standards.
K914 Electrical Systems - Maintenance and Testing: The facility failed to assess electrical receptacles at resident bed locations for physical integrity and proper testing documentation.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage according to NFPA code, with combustibles stored in the oxygen storage closet.
Report Facts
Deficiencies cited: 5
Facility capacity: 66
Resident census: 51
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Aug 21, 2019
Visit Reason
The inspection was conducted following a complaint investigation related to behavioral health services and the facility's failure to provide necessary behavioral health care to prevent self-harm.
Complaint Details
The investigation was triggered by a complaint regarding behavioral health services and the facility's failure to prevent self-harm. The resident was found deceased after hanging in the shower room. The complaint was substantiated based on the findings.
Findings
The facility failed to keep one of two sampled residents free from self-harm by not providing adequate behavioral health care and individualized person-centered interventions. The resident committed suicide in the facility's shower room, and multiple deficiencies related to behavioral health services were cited.
Deficiencies (3)
F740 Behavioral Health Services: The facility failed to provide necessary behavioral health care and services to prevent self-harm and to implement individualized interventions for a resident, resulting in the resident's suicide.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency cited at F740.
A4099 Social Service Program: The facility shall designate a staff member responsible for the social services program capable of identifying social and emotional needs and providing services as needed. This regulation was not met as evidenced by the deficiency cited at F740.
Report Facts
Resident census: 51
Deficiencies cited: 3
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 12
Date: Jan 16, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for Ballwin Ridge Health & Rehabilitation.
Findings
The facility was found deficient in multiple areas including accounting and records of personal funds, transfer and discharge requirements, activities of daily living, accident hazards, medication labeling, and food and nutrition services. Deficiencies were documented with specific resident cases and regulatory citations.
Deficiencies (12)
F568 Accounting and Records of Personal Funds: The facility failed to maintain accurate accounting records for the resident trust account for nine months. Petty cash statements were not accurately reconciled daily.
F622 Transfer and Discharge Requirements: The facility failed to provide appropriate discharge notice and allow family opportunity to dispute discharge for one resident. Documentation was incomplete and discharge procedures were not followed.
F676 Activities Daily Living (ADLs)/Mntn Abilities: The facility failed to ensure one resident was evaluated for restorative services for ambulation after residing more than two months.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide protective oversight for a resident with a history of burning fingers while smoking. Problems were found with supervision and smoking safety.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure staff dated insulin vials when opened, risking medication safety.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to follow recipes for pureed meals and did not weigh portions properly, risking nutritional adequacy.
A4061 Medication Labeling: Prescription medications were not labeled with resident names as required by pharmacy standards and regulations.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave.
A4074 Nursing Care per Res Condition: Residents did not receive personal attention and nursing care consistent with their conditions and current acceptable nursing practice.
A5022 Standardized Recipes Used: The facility failed to use a file of standardized recipes as required.
A8015 30 Day Notice-Transfer/Discharge: The facility failed to provide proper 30-day written notice for transfer or discharge as required.
A9009 Resident Funds Reconciled Monthly: The facility failed to reconcile resident funds monthly and provide written statements to residents or their designees.
Report Facts
Resident census: 44
Number of sampled residents: 12
Number of deficiencies cited: 11
Plan of correction completion dates: Feb 22, 2019
Inspection Report
Life Safety
Census: 43
Deficiencies: 4
Date: Jan 15, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to maintain portable fire extinguishers, smoke barrier walls, smoking areas, and prohibited portable space heaters in accordance with NFPA standards. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (4)
K355 Portable Fire Extinguishers: The facility failed to maintain portable fire extinguishers to NFPA standards; an extinguisher was mounted more than 60 inches above the floor.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier walls free from penetrations, allowing sprinkler pipes and data cables through the barrier.
K741 Smoking Regulations: The facility failed to maintain smoking areas according to NFPA regulations; singed materials and trash were observed in smoking areas.
K781 Portable Space Heaters: The facility failed to prohibit the use of portable space heaters; a space heater was observed under a desk in the business manager's office.
Report Facts
Facility census: 43
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 15
Date: Mar 2, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations at Ballwin Ridge Health & Rehabilitation.
Findings
The facility was found deficient in multiple areas including resident rights, admission policy, bed rails, nurse staffing information, food procurement and safety, and environmental conditions. Several residents were affected by these deficiencies, and the facility submitted a plan of correction.
Deficiencies (15)
F550 Resident Rights: Facility failed to ensure staff respected residents' dignity by timely answering call lights and providing incontinence care, affecting 10 residents. The census was 47.
F620 Admissions Policy: Facility failed to establish and implement an admissions policy that protects residents' rights and property, affecting 2 of 13 sampled residents. The census was 47.
F700 Bed Rails: Facility failed to ensure proper assessment, installation, and maintenance of bed rails, affecting 4 of 13 sampled residents. The census was 47.
F732 Nurse Staffing Information: Facility failed to post required nurse staffing data daily, including resident census and hours worked by licensed and unlicensed staff. The census was 47.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to ensure food safety by improper handling, unclean equipment, and poor sanitation in kitchen areas. The census was 47.
F921 Safe/Functional/Sanitary/Comfortable Environment: Facility failed to maintain walls, floors, and equipment in good repair, with peeling paint, exposed drywall, and uncovered toilet bolts, affecting all residents. The census was 47.
A3038 Furniture/Equip, Provide Comfort & Safety: Facility failed to maintain furniture and equipment in good condition, as cited at F921.
A4013 Policies/Procedures-Operational: Facility failed to develop policies and procedures to meet residents' needs, as cited at F620.
A4073 Protective Oversight, Voluntary Leave: Facility failed to have a procedure to inquire about residents' whereabouts during voluntary leave, as cited at F700.
A6012 Walls/Ceilings/Doors/Windows Clean: Facility failed to maintain walls, ceilings, and doors in good repair, as cited at F812 and F921.
A6015 Lavatory/Fixtures Clean/Good Repair: Facility failed to keep lavatories and fixtures clean and in good repair, as cited at F921.
A7002 Wash Hands/Arms & Clean Fingernails: Facility failed to ensure employees properly wash hands and keep fingernails clean, as cited at F812.
A7003 Clean Clothing, Hair Restraints: Facility failed to ensure employees wear clean clothing and effective hair restraints, as cited at F812.
A7015 Food-Protected, Temp, Need to Contact DHSS: Facility failed to protect food from contamination and maintain proper temperatures, as cited at F812.
A8030 Dignity/Privacy: Facility failed to ensure residents are treated with dignity and privacy, as cited at F550.
Report Facts
Resident census: 47
Residents affected: 10
Residents sampled: 13
Residents affected: 4
Residents affected: 2
Inspection Report
Life Safety
Census: 47
Capacity: 66
Deficiencies: 5
Date: Mar 2, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to complete an annual door inspection, maintain range hood suppression system nozzle caps, maintain fire alarm system visual signals, maintain sprinkler escutcheon plates and heads, and provide a remote manual stop station for the emergency generator. These deficiencies had the potential to affect all residents and occupants.
Deficiencies (5)
K211 Means of Egress - General: The facility failed to complete an annual door inspection as required by NFPA 101. This deficient practice had the potential to affect all residents.
K324 Cooking Facilities: The facility failed to ensure the range hood suppression system nozzle caps were in place at all times. This deficient practice had the potential to affect all occupants of the kitchen and adjoining dining room.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to maintain a fire alarm system in accordance with NFPA 72 by not ensuring visual signals illuminated with system activation. One strobe light on the 100 hall failed to illuminate.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler escutcheon plates and heads free of lint and corrosion. Several sprinkler heads had missing or loose escutcheon plates and lint buildup.
K918 Electrical Systems - Essential Electric System: The facility failed to provide a remote manual stop station for one emergency generator. This deficient practice had the potential to affect all occupants.
Report Facts
Facility capacity: 66
Resident census: 47
Viewing
Loading inspection reports...
