Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
56% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 2
Date: Oct 22, 2025
Visit Reason
The inspection was conducted to assess compliance with applicable laws and regulations, focusing on operator/administrator responsibilities and food protection standards. The report includes a plan of correction addressing identified deficiencies.
Findings
The facility failed to maintain an active exception approval for kitchen pass-thru window safety features and failed to protect food from contamination by not discarding expired and undated food items. Observations and interviews confirmed these deficiencies.
Deficiencies (2)
19 CSR 30-86.047(6) Operator/Administrator Responsibilities. The facility failed to maintain active exception approval for kitchen pass-thru window safety features, including self-closing doors and smoke partitions. The exception certificate was not posted and had expired.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS. Facility staff failed to protect food from contamination by not discarding expired and undated food items in storage areas. Observations showed multiple expired and undated food packages.
Report Facts
Facility census: 27
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 3
Date: Oct 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including Employee Disqualification List (EDL) checks, tuberculosis (TB) screening, and physician order requirements at Bluff Creek Terrace-Assisted Living B.
Findings
The facility failed to document EDL reviews for several employees, did not ensure required two-step TB testing for residents and staff, and failed to maintain signed physician order sheets for multiple residents. The census was reported as 29 during the inspection.
Deficiencies (3)
19 CSR 30-86.047(12) EDL Requirements: Facility staff failed to document Employee Disqualification List reviews for four sampled employees prior to contact with residents.
19 CSR 30-86.047(19) TB Screen Residents & Staff: Facility staff failed to ensure required two-step tuberculosis testing for three residents and one employee, and did not provide a resident TB testing policy.
19 CSR 30-86.047(47)(B) Physicians Orders Requirements: Facility staff failed to ensure physician order sheets were signed every three months for five of six sampled residents and did not provide a policy for POS reviews.
Report Facts
Census: 29
Census: 23
Number of sampled employees: 4
Number of sampled residents: 6
Number of residents with unsigned physician orders: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Bankhead | Licensed Nursing Home Administrator (LNHA) | Signed the inspection report and plan of correction |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 1
Date: Jan 29, 2024
Visit Reason
The inspection was a fire safety inspection conducted on January 29, 2024, to assess electrical wiring maintenance and safety compliance.
Findings
The facility failed to properly maintain electrical wiring to prevent safety or fire hazards. The last electrical inspection was done on November 30, 2021, and the facility did not have the required biennial electrical inspection.
Deficiencies (1)
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to have electrical wiring inspected every two years by a qualified electrician, creating a safety and fire hazard. The deficiency affected all 24 residents.
Report Facts
Facility census: 27
Deficiency affected residents: 24
Inspection Report
Life Safety
Census: 23
Deficiencies: 9
Date: Jan 3, 2023
Visit Reason
The inspection was a fire safety inspection conducted on January 3, 2023, to evaluate compliance with fire safety regulations and codes at Bluff Creek Terrace-Assisted Living B.
Findings
The facility failed to meet multiple fire safety regulations including fire hazard prevention, maintenance of fire extinguishers, certification of range hood extinguishing systems, fire drill requirements, fire alarm system inspections, emergency lighting, flame resistant curtains/drapes, and building maintenance. Several deficiencies affected all or most of the residents.
Deficiencies (9)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard. The facility had a smashed/kinked dryer vent hose and non-operational fire door magnets, creating a fire hazard affecting thirteen residents.
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to ensure all portable fire extinguishers were installed and maintained per NFPA 10, affecting ten residents.
19 CSR 30-86.022(4)(C) Range Hood Certification. The range hood extinguishing system was not certified at least twice annually as required, affecting twenty-three residents.
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation. The facility failed to provide documentation of annual consultation from the local fire department, affecting twenty-three residents.
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. The facility failed to conduct twelve fire drills annually with required frequency and documentation, affecting twenty-three residents.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications. The facility failed to ensure annual fire alarm system inspections were performed, affecting twenty-three residents.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The facility failed to provide battery-powered emergency lighting capable of operating at least one and one-half hours, affecting twenty-three residents.
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant. The facility failed to ensure all curtains and drapes were certified or treated to be flame-resistant, affecting twenty-three residents.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to maintain building 3104 in good repair, with gaps around sprinkler heads and holes in the attic access panel, affecting thirteen residents.
Report Facts
Facility census: 23
Facility census: 13
Facility census: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Becker | Administrator | Interviewed regarding maintenance and fire safety issues |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: Jul 6, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide 24-hour protective oversight for a resident who was found injured and unattended overnight.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate protective oversight and proper care per the resident's service plan. The violation was initially classified as imminent danger Class I but was lowered to Class II at exit after corrective actions were implemented.
Findings
The facility failed to provide 24-hour protective oversight for one resident, resulting in the resident being found with blood and feces on the walls, carpet, bedding, and bathroom. Additionally, the facility failed to document and follow up on the resident's accurate code status, leading to inappropriate medical interventions.
Deficiencies (2)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight for one resident, who was found injured and unattended overnight. Staff did not conduct required visual checks every two hours as expected.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to document and follow up on an accurate Do Not Resuscitate (DNR) code status for one resident, resulting in inappropriate intubation and blood product administration against the resident's wishes.
Report Facts
Facility census: 28
Estimated blood loss: 1000
Inspection Report
Plan of Correction
Census: 22
Deficiencies: 3
Date: Nov 15, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Bluff Creek Terrace-Assisted Living B, documenting deficiencies found during a survey conducted on November 15, 2021.
Findings
The facility failed to perform the required twelve fire drills annually with at least one every three months on each shift, failed to provide documentation of semi-annual fire alarm system inspections, and failed to have electrical wiring inspected every two years as required.
Deficiencies (3)
A2217 Fire Drill Requirements, Evacuation. The facility failed to perform one fire drill on each shift every three months and failed to perform twelve fire drills annually as required.
A2249 Fire Alarm System-Test/Maintain. The facility failed to provide documentation showing the fire alarm system in the Arbors was inspected semi-annually as required by NFPA 72, 1999 edition.
A3214 Electrical Wiring, Maintained, Inspected. The facility failed to have electrical wiring inspected every two years as required, with the most recent inspection dated December 27, 2018.
Report Facts
Facility census: 22
Fire drills required: 12
Fire drills performed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding fire drills and fire alarm system inspections |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 1
Date: Dec 3, 2019
Visit Reason
The inspection was conducted as part of a licensure inspection including a fire safety portion on December 3, 2019.
Findings
The facility failed to ensure the kitchen was separated from the remainder of the facility by a minimum of smoke stop partitions in the Arbors. A pass-through window between the kitchen and dining room could allow smoke and toxic gases to pass in the event of a fire.
Deficiencies (1)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility did not ensure the kitchen was separated from other areas by smoke stop partitions. A pass-through window with manual bi-fold doors allowed potential smoke and toxic gas passage during a fire.
Report Facts
Facility census: 37
Deficiency count: 1
Inspection Report
Routine
Census: 35
Capacity: 48
Deficiencies: 2
Date: Oct 2, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with fire drill requirements and food protection standards at Bluff Creek Terrace Assisted Living.
Findings
The facility failed to conduct the required fire drills quarterly on each shift and did not properly document fire drills for multiple quarters. Additionally, staff failed to properly date and label opened and prepackaged food, leading to potential contamination risks.
Deficiencies (2)
19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation. Facility staff failed to conduct fire drills quarterly on each shift from October 2018 to September 2019, risking delayed response in a fire emergency. The census was 35 with a capacity of 48.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS. Facility staff failed to date and label opened and prepackaged food properly, risking potential contamination. Observations showed multiple unlabeled and undated food items in kitchen and storage areas.
Report Facts
Census: 35
Total Capacity: 48
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 3
Date: Dec 4, 2018
Visit Reason
The inspection was a licensure inspection including a fire safety portion conducted on 12/4/2018 at Bluff Creek Terrace-Assisted Living B.
Findings
The facility failed to ensure monthly checks of fire extinguishers, maintain self-closing doors on the laundry room, and ensure emergency lighting operated for the required duration. These deficiencies affected all 38 residents present during the inspection.
Deficiencies (3)
19 CSR 30-86.022(3)(D) Fire Extinguishers UL/FM, Maintain/Check. The facility failed to ensure fire extinguishers were checked monthly as required; tags were not dated and no documentation was available.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to maintain self-closing devices on the laundry room door, which were broken and would not close, allowing smoke and poisonous gases to enter the hallway in a fire.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs. The facility failed to ensure emergency lights operated on battery power for at least one and one-half hours; a light in the west hall did not illuminate during testing.
Report Facts
Facility census: 38
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 4
Date: Sep 19, 2018
Visit Reason
The document is a Plan of Correction submitted by Bluff Creek Terrace following a regulatory inspection on 09/19/2018. It addresses deficiencies cited related to tuberculosis screening, medication administration, and food service.
Findings
The inspection found deficiencies including failure to document tuberculosis screening for employees, unsafe medication administration practices, and improper food service utensil storage. The facility census was 42 residents at the time of inspection.
Deficiencies (4)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to document tuberculosis screening for employees CMA E and Cook J since their hire dates.
19 CSR 30-86.047(45) Safe & Effective Medication System: Facility staff failed to ensure a safe medication system, including proper hand washing and utensil storage during medication administration for five residents.
19 CSR 30-86.047(47)(G) Medication Administration, Documented: Facility staff failed to record administration of medications on the Medication Administration Record for multiple residents.
19 CSR 30-87.030(41) Food Service-Dispensing Utensils Use/Storage: Facility staff failed to prevent contamination by improperly storing utensils with food debris in food storage bins.
Report Facts
Facility census: 42
Deficiencies cited: 4
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