Inspection Reports for
Brentmoor Retirement Community
8600 Delmar Blvd, St. Louis, MO 63124, United States, MO, 63124
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
42% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 15
Deficiencies: 7
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to identify deficiencies in regulatory compliance at Brentmoor Retirement Community and to document a plan of correction for those deficiencies.
Findings
The facility failed to provide specific staff responsibilities in individual evacuation plans, complete community based assessments within required timeframes, develop individualized service plans with necessary details, maintain complete resident records including admission info, preferred dentist/funeral home, resident rights, and advance directives. The census was consistently reported as 15 during the inspection.
Deficiencies (7)
19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements: The facility failed to provide responsibilities of specific staff members in an emergency on the Individual Evacuation Plan for one resident requiring assistance.
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day: The facility failed to complete a community based assessment for each resident within five calendar days of admission for two sampled residents.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually: The facility failed to complete semi-annual community based assessments for two sampled residents.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: The facility failed to develop individualized service plans including resident needs, services, and goals for two sampled residents.
19 CSR 30-86.047(58)(A) Resident Record Admission Info: The facility failed to maintain a record including admission information, preferred dentist, and funeral director for two sampled residents.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to review resident rights annually with two sampled residents or their representatives.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to review advance directives annually with two sampled residents or their representatives.
Report Facts
Census: 15
Deficiencies cited: 7
Inspection Report
Plan of Correction
Census: 15
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with the requirement to employ a licensed administrator at Brentmoor Retirement Community.
Findings
The facility failed to employ a licensed Administrator at all times since 7/23/24. The Executive Director and a Corporate Staff Member were acting as Administrators without current licenses.
Deficiencies (1)
19 CSR 30-86.047(5) Administrator - Licensed: The facility failed to employ a licensed Administrator at all times since 7/23/24. The Executive Director and a Corporate Staff Member are not currently licensed Administrators.
Report Facts
Census: 15
Inspection Report
Plan of Correction
Census: 15
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
The inspection was conducted due to a failure to report and investigate an allegation of abuse involving a resident at the facility.
Complaint Details
The visit was complaint-related due to an allegation of abuse involving Resident #1. The complaint was substantiated based on interviews and record review.
Findings
The facility failed to report and investigate an allegation of abuse for one resident, violating mandatory reporting requirements. The investigation revealed staff did not report suspected abuse and management did not ensure proper follow-up.
Deficiencies (1)
19 CSR 30-88.010(25) requires immediate reporting of suspected abuse or neglect. The facility failed to report and investigate an allegation of abuse involving a resident, violating this regulation.
Report Facts
Census: 15
Inspection Report
Plan of Correction
Census: 17
Deficiencies: 12
Date: Sep 25, 2023
Visit Reason
The inspection was conducted to identify deficiencies in regulatory compliance at Brentmoor Retirement Community and to document a plan of correction for those deficiencies.
Findings
The facility was found deficient in multiple areas including individual evacuation plans, area of refuge requirements, tuberculosis screening, personnel records, individual service plans, physician orders, medication reviews, backflow prevention, clean clothing and hair restraints, advance directive requirements, and personal clothing/possessions documentation. The census during the inspection was 17.
Deficiencies (12)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - In Resident ISP. The facility failed to ensure residents who required more than minimal assistance to safely evacuate had an individualized evacuation plan in their service plans.
19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements. The facility failed to provide responsibilities of specific staff members in the Individual Evacuation Plan for one sampled resident.
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements. The facility failed to ensure two-way communication devices and proper signage were installed and posted at the bottom of exit stairways for two areas of refuge.
19 CSR 30-86.047(19) TB Screen Residents & Staff. The facility failed to ensure annual tuberculosis screenings were completed and documented for two sampled residents and two sampled employees.
19 CSR 30-86.047(20)(I) Personnel Record-physician statement. The facility failed to ensure employees had a written statement by a licensed physician or designee indicating work limitations for two sampled employees.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to develop individualized service plans documenting residents' falls and interventions for two sampled residents.
19 CSR 30-86.047(47)(B) Physicians Orders Requirements. The facility failed to ensure physician orders were signed every three months for two sampled residents.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to complete required monthly medication reviews for two sampled residents.
19 CSR 30-87.020(28) Backflow Requirements. The facility failed to ensure an air gap between the drain pipe of ice machines and floor drains for two ice machines.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints. The facility failed to ensure proper use of hairnets and beard restraints for one day of observation of kitchen staff.
19 CSR 30-88.010(10) Advance Directive Requirements. The facility failed to review advanced directives annually for two sampled residents.
19 CSR 30-88.010(36) Personal Clothing/Possessions. The facility failed to maintain inventory lists of personal property for two sampled residents.
Report Facts
Census: 17
Deficiencies cited: 12
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse of a resident by a staff member at Brentmoor Retirement Community.
Complaint Details
The complaint investigation substantiated that a staff member abused a resident by hitting him/her in the mouth. The facility failed to report the abuse to the Department of Health and Senior Services as required. The staff member was suspended and later terminated.
Findings
The facility failed to report alleged abuse by a staff member to the Department of Health and Senior Services. The investigation included interviews and review of records, confirming the abuse incident and failure to report it as required.
Deficiencies (1)
19 CSR 30-88.010(25) Failure to report alleged abuse of a resident by a staff member to the Department of Health and Senior Services. The facility did not report the abuse incident as required by regulation.
Report Facts
Resident census: 13
Inspection Report
Plan of Correction
Census: 17
Deficiencies: 2
Date: Feb 11, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Brentmoor Retirement Community following a survey conducted on February 11, 2019.
Findings
The facility failed to ensure doors providing separation between floors were self-closing and failed to maintain the building in good repair and in accordance with fire safety rules. These deficiencies affected all 17 residents present during the inspection.
Deficiencies (2)
19 CSR 30-86.022(10)(G) Door Devices - Self/Auto closing: The facility failed to ensure doors providing separation between floors were self-closing. A synchronizer device was loosely attached and did not function properly, preventing doors from closing and latching in six attempts.
19 CSR 30-86.032(2) Substantially Constructed & Maintained: The facility failed to maintain the building in good repair and in accordance with construction and fire safety rules. Dryer vent pipes were open above the ceiling, allowing lint accumulation and creating a fire hazard.
Report Facts
Facility census: 17
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Magrath | Executive Director | Signed the plan of correction document |
Inspection Report
Plan of Correction
Census: 16
Deficiencies: 2
Date: Oct 22, 2018
Visit Reason
The document is a statement of deficiencies and plan of correction following a survey completed on 10/22/2018 at Brentmoor Retirement Community.
Findings
The facility failed to provide proper care per individualized service plans, specifically failing to document increased fall risk and services for a resident. The facility also failed to meet state laws related to advanced directives and emergency care policies.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to provide proper care per the resident's individualized service plan and did not document increased fall risk and services for one resident. The census was 16.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to meet state laws related to advanced directives and emergency life-sustaining care policies for residents.
Report Facts
Resident census: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Mentioned in interview regarding resident ISP and CPR certification | |
| Certified Medication Technician (CMT) B | Mentioned in interview regarding CPR certification |
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