Deficiencies (last 8 years)
Deficiencies (over 8 years)
4.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
25% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 1
Date: Oct 14, 2025
Visit Reason
The inspection was conducted to investigate and document deficiencies related to the facility's failure to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, specifically regarding notification of emergency contacts following an incident.
Findings
The facility failed to notify Resident #2's emergency contact when Resident #1 smacked Resident #2's arm, affecting one of two sampled residents. There was a breakdown in procedure regarding notification responsibilities among staff, and the facility's abuse and neglect policies were not properly implemented.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to develop and implement written abuse policies and procedures when Resident #2's emergency contact was not notified after Resident #1 smacked Resident #2's arm. This deficient practice affected one of two sampled residents.
Report Facts
Facility census: 31
Inspection Report
Plan of Correction
Census: 84
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The document is a plan of correction submitted in response to a deficiency related to failure to follow physician orders for insulin administration during an inspection conducted on 05/29/2025.
Findings
The facility failed to follow physician orders when staff did not administer insulin as ordered for three sampled residents, resulting in late insulin administration. The deficiency was classified as Class III.
Deficiencies (1)
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to follow physician orders when staff did not administer residents' insulin as ordered, resulting in late administration for three sampled residents.
Report Facts
Facility census: 84
Number of sampled residents with insulin administration issues: 3
Date of survey completion: May 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding insulin administration issues and staff certification |
Inspection Report
Plan of Correction
Census: 94
Deficiencies: 3
Date: Mar 19, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for The Gardens at Barry Road, an assisted living facility, following a regulatory inspection conducted on 03/19/2025.
Findings
The facility failed to ensure Individual Service Plans (ISPs) included signatures from residents or their legal representatives for seven of ten sampled residents. The facility also failed to implement a safe and effective medication system, including hand hygiene during medication passes, affecting four of ten sampled residents. Additionally, the facility did not complete monthly reviews of residents' conditions and needs for eight of ten sampled residents.
Deficiencies (3)
19 CSR 30-86.047(28)(I) Individual Service Plan - Signatures. The facility failed to ensure ISPs included signatures from the resident or legal representative for seven of ten sampled residents. The facility census was 94.
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to implement a safe medication system when a Level One Medication Aide did not perform hand hygiene during medication passes for four of ten sampled residents. The facility census was 94.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to complete monthly reviews of residents' conditions and needs for eight of ten sampled residents. The facility census was 94.
Report Facts
Facility census: 94
Sampled residents: 10
Residents with missing ISP signatures: 7
Residents affected by medication pass deficiency: 4
Residents missing monthly reviews: 8
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 2
Date: Mar 27, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety regulations related to food storage, labeling, temperature control, and protection from contamination at The Gardens at Barry Road.
Findings
The facility failed to ensure food was stored and prepared safely, with issues including undated and uncovered food, improper refrigerator temperatures, and lack of policies on food storage and labeling. These deficiencies had the potential to affect all residents.
Deficiencies (2)
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources. The facility failed to ensure food was in sound condition, free from spoilage, and properly labeled and dated. Food items such as sandwiches and tomato juice were undated or improperly stored, posing a risk to residents.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS. The facility failed to keep food protected from contamination and maintain proper refrigerator temperatures at or below 45 degrees Fahrenheit. Several food items were uncovered and refrigerators were above the required temperature.
Report Facts
Facility census: 31
Number of sandwiches observed: 22
Number of peanut butter and jelly sandwiches: 19
Refrigerator temperature: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Culinary Services Director | Interviewed regarding food labeling, storage, and refrigerator temperature policies | |
| Executive Director | Interviewed regarding refrigerator temperature and food safety responsibilities |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding potential abuse related to involuntary seclusion of residents due to bed bug infestations.
Complaint Details
The complaint investigation found the violation to be an imminent danger Class I level. The facility had implemented corrective actions during the onsite visit, and the imminent danger was removed at exit.
Findings
The facility failed to ensure ten residents were free from abuse when staff involuntarily secluded them to their rooms due to bed bugs found in belongings and rooms. Several residents reported feeling lonely and depressed due to the seclusion, which violated residents' rights to freedom from isolation and involuntary confinement.
Deficiencies (1)
19 CSR 30-88.010(22) Free From Abuse: The facility failed to ensure ten residents were free from abuse by involuntarily secluding them to their rooms due to bed bugs, causing negative emotional outcomes.
Report Facts
Residents involved: 10
Facility census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner A | Interviewed regarding quarantine and bed bug knowledge | |
| Regional Maintenance Director | Interviewed regarding staff following bed bug policy | |
| Executive Director | Interviewed regarding bed bug protocol and resident isolation | |
| Pest Control Professional A | Interviewed regarding bed bug treatment protocol | |
| Activity Director | Interviewed regarding resident activities during quarantine |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 3
Date: Dec 28, 2023
Visit Reason
The document is a plan of correction submitted following a state inspection survey conducted on 12/28/2023 at The Gardens at Barry Road facility.
Findings
The facility failed to ensure smoke section partitions properly closed and latched, emergency lighting was not maintained in good repair, and wastebaskets were not all approved types. These deficiencies potentially affected all 27 residents present during the inspection.
Deficiencies (3)
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to ensure the smoke stop partition doors properly closed and latched during a fire alarm.
19 CSR 30-86.022(12)(A) Emergency Lighting - locations. The facility failed to maintain all emergency lights in good repair, with several corridor lights not working.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were approved types; some rooms had non-approved wastebaskets.
Report Facts
Facility census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Maintenance Director | Interviewed regarding corrective actions for deficiencies |
Inspection Report
Plan of Correction
Census: 103
Deficiencies: 2
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding appropriate action and notification for resident condition changes and the safe and effective medication system.
Findings
The facility failed to notify the resident's physician of a significant change in condition for Resident #1 and did not ensure a safe and effective medication system, including leaving medication carts unattended with keys accessible. The facility census was 103 at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(37) Appropriate Action & Notification: The facility failed to notify the resident's physician when Resident #1 had low blood pressure and a change in condition. The facility lacked a policy for notifying physicians during resident condition changes.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure a safe medication system when staff left the medication cart unattended with keys on top and failed to observe Resident #2 during medication administration.
Report Facts
Facility census: 103
Medication refusal: 15
Inspection Report
Census: 110
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to investigate a deficiency related to emergency discharges and the facility's failure to provide timely written notice to a resident and their legally authorized representative.
Findings
The facility failed to issue one resident and their legally authorized representative a written notice of discharge when the resident was immediately discharged due to behavioral issues. The facility census was 110 at the time of the inspection.
Deficiencies (1)
19 CSR 30-88.010(18) Emergency Discharges: The facility did not provide a resident or their legally authorized representative a written notice of discharge when the resident was immediately discharged due to physical and verbal aggression and substance use on premises.
Report Facts
Facility census: 110
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 1
Date: Jan 30, 2023
Visit Reason
The inspection was conducted to review compliance with individual service plan requirements following incidents involving resident elopement and falls.
Findings
The facility failed to review and update individualized service plans (ISPs) with residents or their legal representatives after significant changes in condition, including elopement and falls. Two residents were affected by this deficiency.
Deficiencies (1)
19 CSR 30-86.047(28)(H) Individual Service Plan-Review Requirements: The facility failed to review the individualized service plan with the resident or legal representative after significant changes in condition. Two of six sampled residents were affected.
Report Facts
Facility census: 67
Sampled residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding ISP updates for residents #1 and #5 | |
| Administrator | Interviewed regarding expectations for updating residents' ISPs |
Inspection Report
Plan of Correction
Census: 30
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
The visit was conducted to assess compliance with electrical wiring maintenance regulations and to address deficiencies related to electrical inspection documentation.
Findings
The facility failed to provide documentation showing that electrical wiring had been inspected within the last two years as required. The Area Maintenance Director was unable to locate documentation from the outside contract company responsible for inspections.
Deficiencies (1)
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to show documentation that electrical wiring had been inspected within the last two years by a qualified electrician.
Report Facts
Facility census: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Area Maintenance Director | Interviewed regarding electrical inspection documentation |
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 2
Date: Dec 14, 2021
Visit Reason
The document is a plan of correction submitted in response to deficiencies identified during a state survey conducted on 12/14/2021 at The Gardens at Barry Road.
Findings
The facility failed to ensure smoke section partitions properly closed and did not provide sufficient emergency lighting in resident corridors and stairwells. Multiple emergency lights were found not working throughout the facility.
Deficiencies (2)
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds Protection from Hazards. The facility failed to ensure the smoke stop partition doors would properly close, affecting all 67 residents.
19 CSR 30-86.022(12)(A) Emergency Lighting - locations Emergency lighting of sufficient intensity was not provided for exits, stairs, resident corridors, and required attendants' station, affecting all 67 residents.
Report Facts
Facility census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding repair plans for smoke partition doors and emergency lighting |
Inspection Report
Plan of Correction
Census: 74
Deficiencies: 3
Date: Nov 9, 2021
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening, controlled substances reconciliation, and resident rights admission/annual review regulations at The Gardens at Barry Road.
Findings
The facility failed to ensure required two-step tuberculosis screening for employees, proper reconciliation and signing of controlled substances logs by staff, and annual review of resident rights with residents or their representatives.
Deficiencies (3)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure the required two-step tuberculosis screening test was administered upon hire for two of seven sampled employees.
19 CSR 30-86.047(51)(B)(2) Controlled Substances-Reconcile by Personnel: The facility failed to ensure two staff signed the eight hour verification log for controlled substances during shift change on all three medication carts.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to ensure resident or legally authorized representative were informed of rights upon admission and at least annually for seven sampled residents.
Report Facts
Facility census: 74
Number of sampled employees: 7
Number of sampled residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John H. Bryant | Executive Director | Signed plan of correction |
Inspection Report
Plan of Correction
Census: 28
Deficiencies: 2
Date: Sep 1, 2020
Visit Reason
The inspection was conducted to investigate deficiencies related to protective oversight and emergency discharges at The Gardens at Barry Road facility.
Findings
The facility failed to provide adequate protective oversight for a resident at risk of elopement and failed to provide appropriate notice of emergency discharge for a resident. The facility census was 28 at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight to one resident at risk for elopement, who left the secured facility multiple times without adequate interventions.
19 CSR 30-88.010(18) Emergency Discharges: The facility failed to provide one resident an appropriate notice of discharge when the resident was emergency discharged following an incident.
Report Facts
Facility census: 28
Inspection Report
Plan of Correction
Census: 33
Deficiencies: 2
Date: Mar 26, 2020
Visit Reason
The inspection was conducted to investigate deficiencies related to protective oversight and abuse/neglect reporting at The Gardens at Barry Road facility.
Findings
The facility failed to provide 24-hour protective oversight when a resident's emergency call pendant was removed, leaving the resident unable to call for help. The facility also failed to immediately report suspected abuse or neglect as required by regulation.
Deficiencies (2)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight when a staff member removed a resident's emergency call pendant, leaving the resident unable to notify staff if assistance was needed.
19 CSR 30-88.010(25) Report A/N to DHSS/DMH When Needed: The facility failed to immediately report abuse or neglect once they had reasonable cause to believe a resident had been abused or neglected.
Report Facts
Census: 33
Inspection Report
Life Safety
Census: 72
Deficiencies: 1
Date: Nov 5, 2019
Visit Reason
The inspection was a fire safety inspection conducted to evaluate emergency lighting in the facility.
Findings
The facility failed to provide sufficient emergency lighting in residents' corridors and stairs. Multiple emergency lights were observed not functioning during the inspection.
Deficiencies (1)
19 CSR 30-86.022(12)(A) Emergency Lighting - locations. The facility failed to provide sufficient emergency lighting in residents corridors and stairs as evidenced by multiple emergency lights not functioning when tested.
Report Facts
Facility census: 72
Inspection Report
Plan of Correction
Census: 77
Deficiencies: 2
Date: Oct 23, 2019
Visit Reason
The inspection was conducted to assess compliance with medication administration documentation and food protection regulations at the facility.
Findings
The facility failed to ensure proper documentation of medication administration for sampled residents and did not protect food from potential contamination due to improper storage practices.
Deficiencies (2)
19 CSR 30-86.047(47)(G) Medication Administration. The facility failed to ensure staff recorded administration of medications on the Medication Administration Record for two of 11 sampled residents. Initials were missing for multiple medication doses.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS. The facility failed to protect food from potential contamination by not storing foods in sealed containers, as evidenced by unsealed bags of fries, chicken tenders, tater tots, curly fries, and waffles in the kitchen freezer.
Report Facts
Facility census: 77
Sampled residents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication administration documentation | |
| Culinary Services Director | Interviewed regarding food storage and labeling practices |
Inspection Report
Plan of Correction
Census: 79
Deficiencies: 5
Date: Jul 16, 2018
Visit Reason
The inspection was a fire safety inspection conducted on July 16, 2018, to assess compliance with fire safety regulations including fire extinguishers, fire alarm systems, smoke partitions, sprinkler system maintenance, and extension cord usage.
Findings
The facility failed to meet several fire safety regulations including insufficient fire extinguishers, incomplete fire alarm system, inadequate smoke partitions, missing sprinkler system components, and improper use of extension cords. The deficiencies affected all 79 residents present during the inspection.
Deficiencies (5)
19 CSR 30-86.022(3)(A) Fire Extinguishers-Minimum per Floor. The facility failed to provide enough fire extinguishers to meet the maximum travel distance requirement, with over 200 feet between extinguishers.
19 CSR 30-86.022(9)(A) Fire Alarm Complete System. The facility failed to install a complete fire alarm system including required smoke detectors in the vaulted portion of the main dining/seating area.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to maintain one-hour fire-rated smoke partitions with multiple holes and doors that did not self-close or latch properly.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to maintain the sprinkler system with missing escutcheon rings and inadequate coverage due to recessed sprinkler heads.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles. The facility had multiple extension cords in use with more than one item plugged into them, violating electrical safety standards.
Report Facts
Facility census: 79
Deficiency affected residents: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gary Holmes | Executive Director | Named in relation to interviews and corrective actions during the inspection |
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