Deficiencies (last 5 years)
Deficiencies (over 5 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
59% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 1
Date: Dec 17, 2024
Visit Reason
The document is a Plan of Correction following a deficiency related to physician orders and proper care for residents, specifically regarding the management of Coumadin medication and related lab monitoring.
Findings
The facility failed to provide proper care by not transcribing orders for Coumadin lab monitoring, failing to follow up with the physician/clinic after lab results, and lacking a policy for anticoagulant care. Resident #1's records showed inadequate monitoring of PT/INR labs and follow-up, resulting in bruising and potential safety risks.
Deficiencies (1)
19 CSR 30-86.042(40) Physicians Orders & Proper Care: Facility staff failed to transcribe orders for Coumadin lab monitoring, did not follow up with the physician after lab results, and lacked a policy for anticoagulant care. Resident #1 had incomplete PT/INR monitoring and follow-up, leading to bruising and safety concerns.
Report Facts
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Entered late progress notes related to resident medication incident |
| Executive Director | Executive Director | Provided interview statements regarding facility protocols and monitoring |
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 10
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to regulatory compliance at Bungalows at Chesterfield Village, including employee background checks, tuberculosis screening, medication self-control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to complete employee disqualification inquiries, incomplete tuberculosis screening for residents and staff, inadequate self-control medication orders and storage, and poor maintenance of air ducts, floors, walls, and food safety practices.
Deficiencies (10)
19 CSR 30-86.042(11)(B) EDL inquiry: The facility failed to ensure newly hired employees were checked against the employee disqualification list prior to contact with residents.
19 CSR 30-86.042(18) TB Screen Resident/Staff: The facility failed to complete required two-step tuberculosis tests and annual evaluations for several residents.
19 CSR 30-86.042(45) Self-Control of Medication: The facility failed to ensure a resident had a physician order for self-administration of medication and allowed unsecured medications in the resident's room.
19 CSR 30-86.042(46)(A) Resident Controlled Access to Meds: Staff failed to ensure medications were kept secured in locked containers for residents self-administering medications.
19 CSR 30-87.020(9) Air Ducts-Maintain: The facility failed to maintain cleanliness of air ducts, which were covered with black grime and dust.
19 CSR 30-87.020(12) Floor Surfaces: The facility failed to maintain clean and good repair floors in the kitchen and dining areas, with visible dirt, grime, and blackened grout.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: The facility failed to ensure all walls were kept clean and maintained in good repair.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: The facility failed to ensure all food was properly labeled, dated, and protected from contamination.
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: The facility failed to keep cooking equipment clean and free of grease and debris.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: The facility failed to clean nonfood contact surfaces adequately, including kitchen surfaces and equipment.
Report Facts
Facility census: 67
Inspection Report
Census: 60
Deficiencies: 4
Date: Dec 4, 2023
Visit Reason
The inspection was conducted to assess compliance with fire drills, fire alarm system testing, sprinkler system inspections, and electrical wiring maintenance regulations.
Findings
The facility failed to keep records of all fire drills, failed to test the complete fire alarm system monthly, failed to maintain a complete sprinkler system with proper inspections, and failed to have electrical wiring inspected every two years. These deficiencies affected all 60 residents present during the inspection.
Deficiencies (4)
19 CSR 30-86.022(5)(E) Fire Drill Records. The facility failed to keep a record of all fire drills including time, date, personnel, and special problems. This deficiency affects all 60 residents.
19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test. The facility failed to test the complete fire alarm system at least once a month. This deficiency affects all 60 residents.
19 CSR 30-86.022(11)(F) Sprinkler Systems-Inspections, Cert. The facility failed to maintain a complete sprinkler system with annual inspections and certifications as required. This deficiency affects all 60 residents.
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. This deficiency affects all 60 residents.
Report Facts
Facility census: 60
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 1
Date: Nov 21, 2023
Visit Reason
The inspection was conducted to investigate compliance with employee disqualification list (EDL) requirements prior to allowing newly hired employees to have contact with residents.
Findings
The facility failed to ensure that newly hired employees were checked against the employee disqualification list (EDL) prior to allowing them to work with residents. Documentation of EDL checks was missing for four of five sampled staff members.
Deficiencies (1)
19 CSR 30-86.042(11)(B) EDL Inquiry: The facility did not complete required EDL checks for newly hired employees before allowing them to have contact with residents.
Report Facts
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed on 11/21/23 regarding EDL documentation |
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 2
Date: Aug 11, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to resident restraint use and operator/administrator responsibilities, including access to residents' electronic medical records.
Findings
The facility failed to protect residents' rights to be free from unauthorized physical restraints and did not provide policy regarding surveyor access to medical records. The facility census was 63 for the restraint deficiency and 52 for the operator responsibility deficiency.
Deficiencies (2)
19 CSR 30-88.010(26)(A) Restraints-Medical Symptom Must Be Authorized. The facility failed to protect residents' rights to be free from physical restraints unless authorized by a physician. Staff placed furniture in front of a resident's door to prevent wandering without a physician's order.
19 CSR 30-86.042(4) Operator/Administrator Responsibilities. The facility operator failed to ensure compliance with laws by not providing surveyors access to residents' electronic medical records as required by law.
Report Facts
Facility census: 63
Facility census: 52
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 2
Date: Jun 9, 2023
Visit Reason
The inspection was conducted to assess compliance with tuberculosis (TB) screening requirements and protective oversight regulations at Bungalows at Chesterfield Village.
Findings
The facility failed to ensure required two-step TB screening for staff and residents, including missing documentation of TB tests and annual screenings. Additionally, the facility failed to provide 24-hour protective oversight for a resident with short-term memory loss, resulting in the resident leaving the facility unsupervised.
Deficiencies (2)
19 CSR 30-86.042(18) TB Screen Resident/Staff: The facility did not complete required two-step TB screening for staff and residents and failed to document annual TB screenings for some residents.
19 CSR 30-86.042(39) Protective Oversight: The facility failed to provide 24-hour protective oversight for a resident with short-term memory loss, resulting in the resident leaving the facility unsupervised.
Report Facts
Facility census: 66
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA B | Certified Medication Aide | Named in TB screening deficiency for missing TB test documentation |
| CMA C | Certified Medication Aide | Named in TB screening deficiency for missing TB test documentation |
| Director of Wellness | Responsible for ensuring staff and residents have TB testing and protective oversight | |
| Level One Medication Aide (LIMA) F | Reported resident found after elopement | |
| Community Engagement Director (CED) H | Involved in resident elopement incident and follow-up | |
| Business Office Manager (BOM) A | Interviewed regarding resident behavior and elopement | |
| Director of Wellness (DOW) | Interviewed about resident behavior and elopement |
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 1
Date: Jan 6, 2023
Visit Reason
The inspection was conducted to evaluate the facility's medication administration system and ensure compliance with safe and effective medication control and use.
Findings
The facility failed to ensure a safe and effective medication administration system for one resident when staff did not ensure the electronic medication administration record (eMAR) directions matched the medication label. The resident was given an incorrect dose of warfarin due to failure to update the eMAR after a physician's order change.
Deficiencies (1)
19 CSR 30-86.042(51) Safe/Effective Medication System. The facility failed to ensure a safe and effective medication administration system was in place for one resident when staff failed to ensure the electronic medication administration record directions and medication label matched.
Report Facts
Facility census: 66
Medication doses incorrectly administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Level One Medication Aide (LIMA) | Administered incorrect warfarin doses to Resident #1 | |
| Director of Wellness (DOW) | Interviewed regarding medication order communication |
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 2
Date: Apr 5, 2022
Visit Reason
The inspection was conducted to assess compliance with state regulations regarding employee disqualification list (EDL) inquiries and tuberculosis (TB) screening for residents and staff at The Bungalows at Chesterfield Village.
Findings
The facility failed to ensure newly hired employees were checked against the employee disqualification list prior to contact with residents. Additionally, the facility did not ensure required two-step tuberculosis screening tests were administered to residents upon admission as required by regulations.
Deficiencies (2)
19 CSR 30-86.042(11)(B) EDL Inquiry: The facility failed to check that newly hired employees were not listed on the employee disqualification list prior to allowing contact with residents. The facility census was 64.
19 CSR 30-86.042(18) TB Screen Resident/Staff: The facility failed to ensure the required two-step tuberculosis screening test was administered upon admission for two sampled residents. The facility census was 64.
Report Facts
Facility census: 64
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 1
Date: Feb 18, 2021
Visit Reason
The inspection was conducted to evaluate compliance with medication administration standards following a complaint or identified deficiency related to medication management for a resident who had a dental procedure.
Findings
The facility failed to follow acceptable medication administration standards, resulting in a delay in obtaining appropriate pain medication for one resident allergic to hydrocodone. Staff did not consistently ensure timely delivery of prescribed medications and failed to promptly communicate with the pharmacy and physician regarding the resident's allergy and medication needs.
Deficiencies (1)
19 CSR 30-86.042(51) Safe/Effective Medication System: The facility failed to obtain medication in a timely manner for a resident allergic to hydrocodone, causing a delay in pain management after a dental procedure.
Report Facts
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Signed the report and plan of correction | |
| Level 1 Medication Aide (L1MA) | Interviewed regarding medication delivery and communication | |
| Director of Resident Care (DRC) | Interviewed and involved in medication ordering and follow-up | |
| Assistant Director of Resident Care (ADRC) | Interviewed regarding medication allergy checks and pharmacy communication | |
| Administrator | Interviewed regarding medication delivery procedures |
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 1
Date: Jan 22, 2021
Visit Reason
The inspection was conducted following a fire incident in the facility's laundry room to assess compliance with fire safety monitoring requirements.
Findings
The facility failed to complete documented hourly visual checks for 24 hours after the fire incident as required. The fire watch procedures did not include monitoring the area of the fire for 24 hours, and the heat sensor damaged in the fire was not replaced promptly.
Deficiencies (1)
19 CSR 30-86.022(2)(E) Fire-24hr Monitor, Hourly Checks. The facility failed to complete documented hourly visual checks for 24 hours after a fire occurred in the laundry room. The fire watch procedures did not include monitoring the area of the fire for 24 hours.
Report Facts
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding fire alarm and fire watch procedures and observations | |
| Administrator | Interviewed regarding fire alarm event and fire watch procedures | |
| Executive Director | Named in plan of correction to provide inservicing on fire safety policy updates |
Inspection Report
Life Safety
Census: 76
Deficiencies: 9
Date: Sep 4, 2018
Visit Reason
The inspection was a fire safety inspection conducted on September 4, 2018, to assess compliance with fire drills, fire safety training, fire alarm systems, hazardous area requirements, sprinkler system maintenance, and electrical wiring regulations.
Findings
The facility failed to meet several fire safety regulations including lack of consultation with the local fire department, inadequate fire safety training for employees, incomplete fire alarm system installation and maintenance, absence of a written fire watch program, missing self-closing devices on hazardous area doors, failure to maintain sprinkler system checks, and improper electrical wiring maintenance.
Deficiencies (9)
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation. The facility failed to request or have a consultation from the local fire department or notify the State Fire Marshal in writing and request assistance.
19 CSR 30-86.022(6)(A)(1-3) Fire Safety Training Requirements-employees. The facility failed to ensure fire safety training was provided to all employees at least every six months.
19 CSR 30-86.022(9)(A) Fire Alarm Complete System. The facility failed to properly install a complete fire alarm system in accordance with NFPA 72, 1999 edition.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition.
19 CSR 30-86.022(9)(H) Fire Alarm System Out of Service > than 4hrs. The facility failed to have a written fire watch program in place when the fire alarm system was out of service for more than four hours.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to install or maintain smoke resistant self-closing doors on hazardous areas.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to inspect and maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998 edition.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to use only metal, UL or FM fire-resistant rated wastebaskets for trash.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to maintain electrical wiring in accordance with NEC requirements and failed to have protective covers on junction boxes.
Report Facts
Facility census: 76
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding fire safety training, fire alarm system issues, and compliance with fire safety regulations | |
| Maintenance Director | Responsible for fire safety consultation scheduling, fire training, fire alarm system maintenance, and electrical wiring corrections | |
| Maintenance Supervisor | Monitors installation and replacement of fire safety equipment such as wastebaskets |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Jun 22, 2018
Visit Reason
The inspection was conducted due to a complaint alleging physical abuse of a resident by facility staff.
Complaint Details
The complaint investigation substantiated that staff failed to report an allegation of physical abuse of Resident #1 in a timely manner and did not suspend the alleged abuser pending investigation.
Findings
The facility failed to immediately report an allegation of physical abuse of a resident to the Department of Health & Senior Services. Staff did not follow facility policy regarding timely reporting and suspension of the alleged abuser pending investigation.
Deficiencies (1)
19 CSR 30-88.010(25) requires immediate reporting of suspected abuse or neglect. Facility staff failed to notify the Department of Health & Senior Services of a physical abuse allegation for one resident and did not immediately notify the facility administrator. The facility census was 80.
Report Facts
Facility census: 80
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