Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
75% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 2
Date: Sep 17, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to individualized service plans and proper care in an assisted living facility following incidents involving resident falls and changes in condition.
Findings
The facility failed to develop and update individualized service plans (ISP) for residents, particularly after hospitalizations or changes in condition, and failed to provide proper care for residents at risk of falls. The facility implemented corrective actions to improve fall risk evaluations, update ISPs, and educate staff on protocols.
Deficiencies (2)
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to develop and update individualized service plans for residents, including after hospitalizations or changes in condition, and did not include fall prevention interventions for residents with a history of falls.
19 CSR 30-86.047(36) Proper Care Per Individualized Service Plan. The facility failed to provide proper care for two residents, including failure to call emergency services after a stroke and improper handling of a resident who had fallen, resulting in injury.
Report Facts
Facility census: 45
Inspection Report
Plan of Correction
Census: 17
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The inspection was conducted to investigate and document deficiencies related to protective oversight at Sugar Creek Assisted Living by Americare.
Findings
The facility failed to provide adequate protective oversight for one resident who exhibited unsafe and aggressive behaviors towards other residents and staff. The resident's behaviors included wandering into other residents' rooms, physical aggression, and sexual advances. Staff interventions and medication management were insufficient to control the behaviors, resulting in injuries and hospitalizations.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight for a resident who displayed disruptive and aggressive behaviors towards other residents and staff, resulting in physical altercations and injury.
Report Facts
Facility census: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LIMA D | Level One Medication Aide | Interviewed regarding Resident #1's aggressive behavior |
| LIMA B | Nurse Aide | Provided written statement and involved in managing resident behaviors |
| LIMA C | Nurse Aide | Provided written statement and interviewed about resident incidents |
| Director of Nursing | Director of Nursing | Called to manage resident behaviors and instructed staff during incidents |
Inspection Report
Follow-Up
Census: 41
Deficiencies: 2
Date: Jun 5, 2019
Visit Reason
Follow-up visit to verify correction of previous deficiencies related to proper care per individual service plan, specifically addressing fall prevention and pressure ulcer care.
Findings
The facility failed to ensure one resident received proper care to address multiple falls and failed to implement or modify an Individual Service Plan for fall prevention. The follow-up inspection found the deficiency uncorrected related to pressure ulcer care and Individual Service Plan updates.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to ensure one resident received proper care to address multiple falls and did not implement or modify an Individual Service Plan as necessary for fall prevention.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to ensure one resident received proper care to address a pressure ulcer and did not implement or modify the Individual Service Plan as necessary to address prevention of pressure ulcers.
Report Facts
Facility census: 41
Facility census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding resident falls and care |
| Level One Medication Assistant B | Level One Medication Assistant (LIMA) B | Interviewed regarding resident falls |
| Registered Nurse | Registered Nurse (RN) | Interviewed regarding service plan completion |
| Personal Care Assistant C | Personal Care Assistant (PCA) C | Interviewed regarding resident falls |
| Level One Medication Aide C | Level One Medication Aide (LIMA) C | Interviewed regarding resident open sore |
| Level One Medication Aide D | Level One Medication Aide (LIMA) D | Interviewed regarding resident open sore |
| Program Manager | Program Manager | Interviewed regarding Individual Service Plan updates |
Inspection Report
Plan of Correction
Census: 15
Deficiencies: 1
Date: May 20, 2019
Visit Reason
The document is a statement of deficiencies issued following an inspection on 05/20/2019 at Sugar Creek-Assisted Living by Americ, related to hazardous area requirements.
Findings
The facility failed to ensure that a hazardous area was separated from other spaces by smoke-resistant self-closing doors. Specifically, the kitchen had a pass-through window with wooden bi-fold doors that were not self-closing and did not provide smoke resistance.
Deficiencies (1)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to separate hazardous areas from other spaces by smoke-resistant self-closing doors as required. The kitchen had wooden bi-fold doors that were not self-closing and did not provide smoke resistance.
Report Facts
Facility census: 15
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Apr 8, 2019
Visit Reason
The inspection was conducted to assess compliance with fire safety regulations, including fire drill/evacuation plans, fire alarm system maintenance, sprinkler system maintenance, and electrical wiring safety.
Findings
The facility failed to request annual fire department consultation, maintain and test the fire alarm system semi-annually, maintain the sprinkler system properly, and maintain electrical wiring in good repair. Multiple Class II and Class III deficiencies were identified related to fire safety and hazardous area requirements.
Deficiencies (6)
A2214 Fire Drill/Evacuation Plan, Consultation was not met as the facility failed to request or have an annual fire department consultation. The facility census was 35 residents on 4/8/2019.
A2249 Fire Alarm System-Test/Maintain was not met as the facility failed to test and maintain the complete fire alarm system semi-annually. The last two annual inspections were on 3/16/2018 and 3/6/2019.
A2253 Fire Alarm System-Correct Faults was not met as the facility failed to correct a trouble signal on the fire alarm pull station and maintain the system properly. The facility census was 35 residents.
A2269 Sprinkler System Maintenance/Testing was not met as the facility failed to maintain the sprinkler system properly, with items stored too close to sprinkler heads and gaps around escutcheon rings. The facility census was 35 residents.
A3214 Electrical Wiring, Maintained, Inspected was not met as the facility failed to maintain electrical wiring in good repair, including use of multiple plug adapters and missing switch covers. The facility census was 35 residents.
A2256 Hazardous Area Requirements was not met as the facility failed to ensure hazardous areas were separated by smoke-resistant self-closing doors. The facility census was 15 residents in The Arbors building.
Report Facts
Facility census: 35
Facility census: 15
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Signed plan of correction documents |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Date: Jan 8, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident's elopement from the facility on 12/12/18.
Complaint Details
The investigation concluded that the resident did leave the community in a confused state, substantiating the complaint.
Findings
The facility failed to provide protective oversight for a confused resident who attempted to leave the facility multiple times without proper monitoring or interventions. The resident eloped and was found walking away from the facility in an area with businesses and traffic.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight for one of four sampled residents who was confused and had poor judgment, resulting in the resident eloping from the facility without adequate monitoring or interventions.
Report Facts
Facility census: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LIMA A | Level One Med Aide | Reported resident's behavior and was interviewed regarding the elopement |
| LIMA B | Level One Med Aide | Reported resident wandering and was interviewed regarding the elopement |
| Executive Director | Interviewed about facility policies and resident elopement | |
| Director of Nursing | DON | Involved in monitoring and evaluation of the resident after elopement |
| Lifestyle Enhancement Coordinator D | Interviewed about resident's behavior and elopement incident | |
| Lifestyle Enhancement Coordinator C | Interviewed about resident's behavior and elopement incident | |
| Landscaper | Reported seeing the resident outside the facility |
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 4
Date: May 23, 2018
Visit Reason
The document is a Plan of Correction submitted by Sugar Creek Assisted Living following a survey conducted on May 23, 2018. It addresses deficiencies related to community based assessments, individualized service plans, signatures on service plans, and physician orders.
Findings
The facility failed to update community based assessments and individualized service plans for residents with significant changes. Signatures were missing on service plans for some residents. Physician orders were not consistently followed, including medication administration and documentation.
Deficiencies (4)
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change. The facility failed to update two residents' community based assessments with significant changes. The facility census was 36.
19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements. The facility failed to update individualized service plans for two residents with significant changes. The facility census was 36.
19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures. The facility failed to obtain signatures from residents, legal representatives, or staff on individualized service plans for two residents. The facility census was 36.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to follow physician orders for three residents, including medication administration and documentation. The facility census was 36.
Report Facts
Facility census: 36
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in interviews regarding updating assessments and service plans |
| Executive Director | Executive Director | Named in interviews regarding responsibility for updating assessments and service plans |
| LIMA | Level I Medication Aide | Named in medication administration error finding |
| Physician | Physician (DR) | Named in interview regarding medication order changes |
Inspection Report
Life Safety
Census: 40
Deficiencies: 2
Date: May 1, 2018
Visit Reason
The inspection was a fire safety inspection conducted on May 1, 2018, to assess compliance with fire safety regulations including clothes dryer vents and sprinkler system maintenance.
Findings
The facility failed to properly maintain the clothes dryer vent and the sprinkler system, including a disconnected flexible vent pipe and a missing escutcheon ring in the corridor near resident room 9. Both deficiencies affected all 40 residents present during the inspection.
Deficiencies (2)
19 CSR 30-86.022(10)(C) Clothes Dryers Vented, Lint Traps: The facility failed to properly maintain the clothes dryer vent to the outside, with a disconnected flexible vent pipe observed.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: The facility failed to properly maintain the sprinkler system, with a missing escutcheon ring in the corridor near resident room 9.
Report Facts
Facility census: 40
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