Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
83% occupied
Based on a October 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 81
Deficiencies: 3
Date: Oct 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to fire safety, individualized service plans, and protective oversight at Brookdale West County assisted living facility.
Findings
The facility failed to post required signage for the area of refuge, did not develop individualized service plans for three of eight sampled residents, and failed to provide protective oversight by leaving an oven on and operational without staff present. These deficiencies had the potential to affect all residents.
Deficiencies (3)
19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements: The facility failed to post a sign or diagram depicting the location of the Area of Refuge at the bottom of exit stairwell #5, which could affect all residents.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: The facility failed to develop individualized service plans for three of eight sampled residents, including residents #7, #8, and #6, which included resident needs and services to be provided by staff.
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight by leaving an oven on and operational in the first-floor kitchenette without staff present, potentially affecting all residents.
Report Facts
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned in interview regarding oven being left on |
| Maintenance Director | Maintenance Director | Interviewed about signage and oven breaker |
| Administrator | Administrator | Interviewed about signage and oven breaker |
| Licensed Practical Nurse F | Licensed Practical Nurse | Noted resident fall in progress notes |
| Medication Technician G | Medication Technician | Noted resident fall in progress notes |
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 12
Date: Aug 21, 2024
Visit Reason
This inspection was a re-inspection visit conducted on 08/21/2024 to verify correction of previously cited deficiencies at Brookdale West County.
Findings
The facility was found to have multiple deficiencies including failure to post proper signage for the Area of Refuge, incomplete tuberculosis screening for residents and staff, unsecured medications, inadequate staffing for CPR trained personnel, unsafe storage of toxic materials, poor carpeting maintenance, and failure to maintain personal inventory lists. The census during the inspection was 79 residents.
Deficiencies (12)
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements. The facility failed to ensure proper signage was posted at the entrance to the Area of Refuge on the second and third floors.
19 CSR 30-86.047(19) TB Screen Residents & Staff. The facility failed to ensure required two-step tuberculosis testing was completed for sampled residents and employees.
19 CSR 30-86.047(41)(A) Resident Controlled Access to Meds. The facility failed to ensure all medications were secured behind locked doors or cabinets during observation.
19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety. The facility failed to ensure staff trained in CPR were available on each shift for 27 of 79 residents requiring full code status.
19 CSR 30-87.020(5) Toxic Material Storage. The facility failed to ensure poisonous or toxic materials were stored locked and inaccessible to residents.
19 CSR 30-87.020(13) Carpeting. The facility failed to maintain carpeting in good condition in resident apartments and common areas.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails. The facility failed to ensure all staff washed hands and wore gloves when preparing and plating food during observation.
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to follow abuse, neglect, and misappropriation policies when an allegation was not thoroughly investigated or reported.
19 CSR 30-88.010(36) Personal Clothing/Possessions. The facility failed to ensure personal inventory lists were completed and allowed residents to waive this requirement for six of eight sampled residents.
19 CSR 30-91.010(3) Form-request/consent to conduct EMD. The facility failed to include required consent forms for electronic monitoring devices for 12 residents.
19 CSR 30-91.010(8)(A) Notice-posting facility sign. The facility failed to post required notices alerting visitors of electronic monitoring devices at the entrance and resident rooms.
19 CSR 30-91.010(9)(A)-(E) Installation-placement of EMD. The facility failed to ensure electronic monitoring devices were installed in a fixed, stationary position and privacy was maintained for residents.
Report Facts
Census: 79
Residents requiring CPR trained staff: 27
Residents with electronic monitoring devices: 12
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 1
Date: Apr 26, 2024
Visit Reason
The document is a plan of correction related to a deficiency cited during an inspection on April 26, 2024, regarding electrical wiring maintenance.
Findings
The facility failed to ensure electrical wiring was inspected every two years by a qualified electrician as required. The last inspection was on April 11, 2022, and the facility census was 73 residents.
Deficiencies (1)
19 CSR 30-86.032(13) Electrical wiring was not inspected every two years by a qualified electrician as required. The last inspection was on April 11, 2022, which does not meet the biennial inspection requirement.
Report Facts
Facility census: 73
Inspection Report
Plan of Correction
Census: 68
Deficiencies: 3
Date: Jan 9, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to resident care, medication orders, and documentation at Brookdale West County.
Findings
The facility failed to provide skilled nursing care for a resident requiring it, did not follow physician medication orders correctly, and failed to maintain proper hospice documentation for a resident. Multiple incidents involving resident falls and injuries were documented.
Deficiencies (3)
19 CSR 30-86.047(29)(D) Not Admit/Care For-Skilled Nursing Needed. The facility failed to continue care for a resident requiring skilled nursing services, resulting in multiple falls and injuries.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to follow a physician's order for prednisone correctly for one resident, leading to medication administration errors.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to document hospice treatment properly for a resident placed on hospice care.
Report Facts
Resident census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication order and resident fall incident findings |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding resident care and documentation |
| Administrator | Administrator | Interviewed regarding hospice documentation and resident care |
Inspection Report
Plan of Correction
Census: 65
Deficiencies: 2
Date: Jun 28, 2023
Visit Reason
The document is a plan of correction responding to deficiencies identified during a survey completed on 06/28/2023 at Brookdale West County assisted living facility.
Findings
Deficiencies included failure to complete required pre-move-in screenings for residents and failure to ensure physician's orders were signed every three months for sampled residents. The facility submitted corrective actions to address incomplete screenings and unsigned or outdated physician orders.
Deficiencies (2)
19 CSR 30-86.047(28)(D) Complete a Premove-in Screening. The facility failed to complete a pre-move-in screening for three of six sampled residents. The census was 65.
19 CSR 30-86.047(47)(B) Physicians Orders Requirements. The facility failed to ensure physician's orders were signed by a physician every three months for five of six sampled residents.
Report Facts
Census: 65
Sampled residents: 6
Inspection Report
Follow-Up
Census: 59
Deficiencies: 7
Date: Apr 25, 2023
Visit Reason
The inspection was a follow-up visit to verify correction of previous deficiencies related to elevator certification, area of refuge communication system, sprinkler system checks, wastebasket compliance, heating equipment safety, extension cord use, and boiler inspection certification.
Findings
The facility failed to have current approved certifications for the elevator, boiler, and sprinkler system monthly checks. The communication system in the area of refuge was not functioning properly. Trash cans were not compliant with fire-resistant requirements. Heating equipment lacked adequate resident protection, and unapproved multi-plug adapters were in use.
Deficiencies (7)
19 CSR 30-86.012(25) Elevator Requirements: The facility failed to have a current approved elevator inspection certification from the state Division of Fire Safety Elevator Unit. The elevator inspection certificates expired on March 1, 2020.
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements: The facility failed to maintain the communication system in the area of refuge, which did not operate properly when the call button was pushed three times.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13: The facility failed to perform monthly checks on the complete sprinkler system as required by NFPA 13, 1999 edition.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility failed to ensure all trash cans were metal, UL or FM-fire-resistant rated, with non-compliant trash cans observed in multiple resident rooms.
19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: The facility failed to ensure adequate resident protection was used on heating equipment, with a natural gas simulated fireplace heater lacking guards to protect residents from burns.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles: The facility failed to supervise the use of unapproved multi-plug adapters, with unapproved plug adapters observed in several resident rooms.
9998-State Statute: The facility failed to have a current boiler inspection certification, with certificates expired on April 4, 2020, and no documentation of current inspection found.
Report Facts
Facility census: 59
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Hall | Maintenance Director | Named in relation to elevator certification, sprinkler system checks, intercom system repair, and plan of correction responsibilities |
| Jenny Hilliard | Executive Director | Named in relation to elevator certification, staff training, and plan of correction responsibilities |
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 2
Date: Feb 11, 2020
Visit Reason
The document is a statement of deficiencies issued following an inspection of Brookdale West County on February 11, 2020, identifying regulatory noncompliance related to fire alarm system testing and electrical wiring inspections.
Findings
The facility failed to ensure monthly testing of the complete fire alarm system and did not maintain records of such testing. Additionally, the facility failed to ensure electrical wiring was inspected every two years by a qualified electrician, with no documentation available to confirm the last inspection.
Deficiencies (2)
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to activate the complete fire alarm system at least once a month and did not keep monthly records of testing. This deficiency affected all 63 residents present during the inspection.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to ensure electrical wiring was inspected every two years by a qualified electrician and had no documentation of the last inspection. This deficiency affected all 63 residents present during the inspection.
Report Facts
Facility census: 63
Inspection Report
Follow-Up
Census: 64
Deficiencies: 6
Date: Dec 23, 2019
Visit Reason
The visit was a follow-up inspection to verify correction of previously cited deficiencies related to individualized evacuation plans, staff requirements, resident evaluations, community based assessments, proper care per individualized service plans, and physician's orders.
Findings
The facility failed to ensure residents who required more than minimal assistance had individualized evacuation plans included in their individualized service plans (ISP). The facility also failed to include designated staff in evacuation plans, evaluate residents for risk and proximity to exits, update community based assessments for significant changes, provide proper care per individualized service plans, and ensure physician's orders were followed for hospice residents.
Deficiencies (6)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - The facility failed to ensure residents needing more than minimal assistance had individualized evacuation plans in their ISPs for five of six sampled residents. The census was 64.
19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements - The facility failed to include designated staff in resident individual evacuation plans for four of six sampled residents. The census was 64.
19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate - The facility failed to evaluate residents for risk of resistance, mobility, need for additional staff support, consciousness, response to alarms, and fire drills for four of six sampled residents. The census was 64.
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change - The facility failed to update community based assessments for significant changes in condition for two of six sampled residents. The census was 64.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan - The facility failed to ensure residents received proper care based on their individualized service plans for two of six sampled residents. The census was 64.
19 CSR 30-86.047(47)(A) Physicians Orders Followed - The facility failed to ensure hospice orders were transcribed and followed for one of two sampled hospice residents. The census was 64.
Report Facts
Census: 64
Sampled residents: 6
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 1
Date: Aug 9, 2019
Visit Reason
The visit was conducted to address allegations of abuse, neglect, and misappropriation of resident property and funds at Brookdale West County.
Complaint Details
The investigation was complaint-related based on allegations of abuse witnessed by a staff member involving two residents. The allegations were not substantiated due to lack of evidence and proper reporting.
Findings
The facility failed to follow its policy and conduct a thorough investigation to rule out physical abuse when a staff member allegedly witnessed another staff member pushing a resident in a wheelchair, slapping the resident, and telling another resident to 'shut up.' The facility did not ensure all allegations of abuse were reported and investigated properly.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to follow their policy and conduct a thorough investigation to rule out physical abuse when a staff member allegedly pushed a resident in a wheelchair, slapped the resident, and told another resident to 'shut up.' The facility did not ensure all allegations of abuse were reported and investigated properly.
Report Facts
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper C | Reported witnessing alleged abuse and was re-educated on abuse policies. | |
| CNA A | Certified Nurse's Assistant | Involved in alleged abuse incident and interviewed during investigation. |
| CNA B | Certified Nurse's Assistant | Interviewed regarding the incident and reporting procedures. |
| Executive Director | Interviewed and responsible for staff re-education and abuse reporting. | |
| Health and Wellness Director | Interviewed regarding the incident and staff communication. |
Inspection Report
Plan of Correction
Census: 71
Deficiencies: 6
Date: Mar 6, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Brookdale West County following a survey conducted on March 6, 2019. The visit was to assess compliance with regulatory requirements related to resident care and facility operations.
Findings
The facility was found deficient in multiple areas including care to meet resident needs, community-based assessments after significant changes, protective oversight, proper care per individualized service plans, and safe and effective medication systems. Several residents exhibited aggressive behavior, medication refusals, and incidents of wandering and falls. The facility failed to maintain proper documentation, monitoring, and interventions for these issues.
Deficiencies (6)
19 CSR 30-86.047(10) Care to Meet Resident Needs or Discharge. The facility failed to meet the needs of a resident with increased aggression and anxiety, resulting in unsafe behaviors and eventual discharge.
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change. The facility failed to update resident community based assessments after significant changes for two residents.
19 CSR 30-86.047(35) Protective Oversight. The facility failed to provide 24-hour protective oversight to a confused resident who wandered into other resident rooms causing a physical altercation.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to provide proper care per individualized service plans for five residents, including addressing aggressive behavior, elopement risk, wandering, and falls.
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to maintain a safe and effective medication system, including failure to account for missing PRN medication for one day.
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to follow its abuse, neglect, and exploitation policies, including failure to conduct a thorough investigation of a physical abuse allegation.
Report Facts
Resident census: 71
Deficiency count: 6
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 4
Date: Feb 13, 2019
Visit Reason
The document is a Plan of Correction submitted by Brookdale West County following a state inspection conducted on February 13, 2019, addressing deficiencies found during the inspection.
Findings
The facility failed to comply with regulations regarding storage of combustibles under stairways, fire drill requirements including resident evacuation, fire alarm system testing and maintenance, and monthly fire alarm system testing. Deficiencies affected all 74 residents.
Deficiencies (4)
19 CSR 30-86.022(2)(H) Combustibles Not Stored Under Stairways. The facility failed to ensure no combustible materials were stored under stairways, with observed plastic containers, cardboard boxes, trash totes, and a mattress stored there.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to ensure fire drills included a resident evacuation at least once a year, with no record of a complete evacuation in the previous 12 months.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to test and maintain the complete fire alarm system semi-annually as required, with no documentation of required inspections and testing.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to test the complete fire alarm system monthly, with no record of monthly testing and failure to activate the fire alarm during drills.
Report Facts
Facility census: 74
Date survey completed: Feb 13, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding deficiencies and responsible for corrective actions |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: Jul 24, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to protective oversight and proper care per individual service plan following incidents involving resident wandering and aggressive behavior.
Complaint Details
The complaint investigation substantiated that Resident #1 wandered into Resident #2's room, resulting in a physical altercation and injury. The facility failed to prevent Resident #1 from wandering and did not implement adequate interventions to manage aggressive behaviors.
Findings
The facility failed to provide protective oversight for a cognitively impaired resident who was injured after wandering into another resident's room. The facility also failed to ensure individualized service plans contained interventions specific to residents' needs, resulting in inadequate management of aggressive behaviors and wandering.
Deficiencies (2)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight for a cognitively impaired resident who was injured after wandering into another resident's room.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to develop and implement individualized service plan interventions for residents with aggressive behavior and wandering tendencies.
Report Facts
Census: 76
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: May 29, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's care for a resident whose needs were not met, resulting in multiple falls and injury.
Complaint Details
At the time of the complaint investigation, the violation was determined to be an imminent danger, class I level. The facility had implemented corrective actions to address and lower the violation at the time of the onsite visit.
Findings
The facility failed to provide adequate interventions to prevent falls and injury for a resident with dementia and other health issues. The resident sustained a brain injury and died. The facility implemented corrective actions to address the deficiencies.
Deficiencies (1)
19 CSR 30-86.047(10) Care to Meet Resident Needs or Discharge - The facility continued to care for a resident whose needs could not be met, resulting in multiple falls and injury including a fatal brain injury.
Report Facts
Resident census: 44
Number of pages: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Heid | Administrator | Signed the plan of correction and report |
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 2
Date: Jan 29, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to proper care per individualized service plans and medication storage/accessibility at Brookdale West County.
Findings
The facility failed to provide proper care per the individualized service plan for a resident with increased falls and failed to ensure medications were stored securely with at least one lock at all times. Multiple incidents of resident falls and improper documentation were noted.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to provide proper care per the individualized service plan for a resident who had increased falls, including multiple incidents of the resident falling and inadequate supervision.
19 CSR 30-86.047(41) Medication Storage/Accessibility. The facility failed to ensure resident-held medication was stored behind at least one locked door at all times during observation.
Report Facts
Census: 67
Residents with diagnosis: 44
Residents with mental illness or developmental disability: 2
Medication quantities: 650
Medication quantities: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Lovellette | Health and Wellness Director | Named in plan of correction and medication storage oversight |
| Dana Klingelhoefer | RN-District Director of Clinical Services | Named in plan of correction for falls management policy |
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