Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
67% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 99
Deficiencies: 2
Date: Apr 1, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication administration and physician order following a complaint or deficiency related to medication management and documentation.
Findings
The facility failed to maintain a safe and effective medication system, including failure to administer ordered medications and document physician orders and vital sign checks for one resident. The facility census was 99 at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to ensure ordered medications were available and administered as prescribed for one resident, resulting in missed doses and lack of proper medication monitoring.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to document completion of vital sign checks and physician notifications as ordered for one resident with high blood pressure.
Report Facts
Facility census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| K. Brown | Executive Director | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted due to a complaint related to a resident eloping from the facility and the facility's failure to provide protective oversight 24 hours a day.
Complaint Details
The complaint was substantiated as the resident eloped from the facility, was found injured by police, and the facility failed to provide adequate protective oversight and monitoring.
Findings
The facility failed to provide 24-hour protective oversight for residents, resulting in a resident eloping and sustaining injuries. The facility lacked policies for two-hour checks and monitoring of memory care doors, and staff failed to complete comprehensive assessments and interventions for exit-seeking behaviors.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: Facility staff failed to provide protective oversight 24 hours a day, resulting in a resident eloping and being found injured outside the facility. The facility lacked policies for two-hour checks and monitoring of memory care doors in the secured unit.
Report Facts
Facility census: 105
Completion date for plan of correction: Aug 25, 2024
Resident #1 admission date: Oct 24, 2022
Resident #1 hospital discharge date: Jul 8, 2024
Inspection Report
Plan of Correction
Census: 90
Deficiencies: 2
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to proper care per individual service plans and safe and effective medication systems at The Gardens facility.
Findings
The facility failed to ensure timely response to call lights for residents and did not have a policy regarding call light response. Additionally, the facility failed to provide a safe and effective medication administration system, resulting in multiple missed or undocumented medications for residents.
Deficiencies (2)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. Facility staff failed to ensure proper care when call lights were not answered timely for two residents. The facility lacked a policy on answering call lights.
19 CSR 30-86.047(46) Safe & Effective Medication System. Facility staff failed to provide a safe medication system when multiple medications were not given as ordered and physician notification was not documented for missed doses.
Report Facts
Facility census: 90
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 1
Date: Feb 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration errors at The Gardens facility.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews showing medication errors involving controlled substances and failure to follow medication administration protocols.
Findings
The facility failed to provide a safe and effective medication system, evidenced by staff taping a wrong pill to a medication card and potential administration of incorrect medication to a resident. Interviews and record reviews confirmed protocol breaches in controlled medication handling and documentation.
Deficiencies (1)
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure a safe medication system when staff taped a wrong pill to a medication card and could have administered incorrect medication to a resident.
Report Facts
Census: 100
Inspection Report
Plan of Correction
Census: 99
Deficiencies: 2
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to assess compliance with community-based assessment requirements and dignity/privacy regulations in an assisted living facility following observed resident behavioral issues and staff documentation concerns.
Findings
The facility failed to update one resident's community-based assessment after significant behavioral changes and did not ensure all residents were treated with dignity and respect, as evidenced by staff failing to prevent verbal threats and aggressive behaviors among residents.
Deficiencies (2)
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change. The facility failed to update one resident's community-based assessment after the resident displayed ongoing behaviors towards other residents.
19 CSR 30-88.010(29) Dignity/Privacy. Facility staff failed to ensure all residents were treated with dignity and respect when staff failed to prevent one resident from yelling, cussing, and threatening two other residents.
Report Facts
Facility census: 99
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 2
Date: Mar 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of abuse and neglect involving a resident who suffered a fall resulting in a hip fracture and brain bleed.
Complaint Details
The complaint investigation substantiated that a resident was verbally abused by a Level One Medication Aide (LIMA) A, who cursed at and forcibly removed the resident from a room, causing the resident to fall and sustain a broken hip and brain bleed. The facility census was 100 at the time of the investigation.
Findings
The facility failed to take appropriate action to treat and assess a resident after a fall, resulting in serious injury. Additionally, a staff member was found to have verbally abused a resident, and the facility failed to ensure all residents were free from abuse.
Deficiencies (2)
19 CSR 30-86.047(37) Appropriate Action & Notification: The facility failed to take timely and appropriate action to treat and assess a resident after a fall resulting in a hip fracture, brain bleed, and hospitalization.
19 CSR 30-88.010(22) Free From Abuse: The facility failed to ensure all residents were free from abuse when a staff member verbally abused a resident, cursing and forcibly removing the resident from a room, resulting in injury.
Report Facts
Facility census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Level One Medication Aide (LIMA) A | Named in abuse finding for verbally abusing and forcibly removing a resident | |
| Director of Nursing (DON) | Documented resident assessment after fall and interviewed during investigation | |
| Licensed Practical Nurse (LPN) D | Involved in resident care and interviewed during investigation | |
| Executive Director | Interviewed regarding incident and facility response |
Inspection Report
Plan of Correction
Census: 100
Deficiencies: 2
Date: Jan 27, 2023
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements and safe and effective medication system regulations in a long-term care facility.
Findings
The facility failed to ensure timely administration of the second step of the two-step tuberculosis screening test for staff and residents. Additionally, the facility did not implement a safe and effective medication control system, resulting in medication administration issues for one resident.
Deficiencies (2)
19 CSR 30-86.047(19) Tuberculosis screening was not completed timely for two of four sampled staff members. The facility census was 100.
19 CSR 30-86.047(46) The facility failed to implement a safe and effective medication system when medications were unavailable for one resident. The facility census was 100.
Report Facts
Facility census: 100
Number of sampled staff with incomplete TB screening: 2
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary A | Staff member missing timely second step TB screening | |
| Dietary B | Staff member missing timely second step TB screening | |
| Director of Nursing | Director of Nursing (DON) | Responsible for TB testing and medication system oversight |
| Level One Medication Aide (LIMA) A | Provided information about medication administration system |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Dec 8, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding protective oversight failures related to resident behaviors and safety.
Complaint Details
The complaint investigation substantiated that staff failed to provide adequate protective oversight and timely reporting of sexual behaviors by Resident #1 towards other residents, leading to safety concerns.
Findings
The facility failed to provide 24-hour protective oversight and timely reporting of sexual behaviors exhibited by Resident #1 towards other residents. Staff did not document interventions or frequent monitoring to ensure resident safety.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: Facility staff failed to provide 24-hour protective oversight and timely reporting of sexual behaviors by Resident #1 towards other residents. Staff did not document interventions or monitoring changes to protect residents.
Report Facts
Facility census: 101
Inspection Report
Plan of Correction
Census: 85
Deficiencies: 1
Date: Mar 23, 2021
Visit Reason
The inspection was conducted to assess compliance with tuberculosis (TB) screening requirements for residents and staff at the facility.
Findings
The facility failed to ensure timely administration of the required two-step TB screening test for staff members. Specifically, three of six sampled staff did not receive the TB test within the required timeframe after their hire date.
Deficiencies (1)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure the required two-step tuberculosis screening test was administered timely for three of six sampled staff members. The facility census was 85.
Report Facts
Facility census: 85
Staff sampled for TB screening: 6
Staff with untimely TB screening: 3
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Date: Oct 8, 2020
Visit Reason
The inspection was conducted in response to an allegation of abuse involving a resident at the facility.
Complaint Details
The complaint was substantiated based on video evidence, interviews, and record review showing abuse by a staff member and failure to report the incident promptly.
Findings
The facility failed to provide protective oversight to all residents when staff did not immediately report an allegation of abuse involving a resident and failed to take immediate steps to protect residents from the accused staff member. Video and interviews confirmed that a Level One Medication Aide verbally and physically abused a resident.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight twenty-four hours a day and did not immediately report an allegation of abuse involving a resident or take immediate protective steps.
Report Facts
Facility census: 99
Suspension duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Level One Medication Aide (LIMA) A | Accused staff member who verbally and physically abused a resident | |
| Level One Medication Aide (LIMA) B | Reported the resident had a bruise and assisted the resident | |
| LIMA G | Witnessed and should have reported the incident | |
| Licensed Practical Nurse (LPN) E | Interviewed regarding the resident's bruise | |
| LIMA C | Interviewed about the resident's behavior and care | |
| LIMA F | Interviewed about abuse policy and reporting | |
| Administrator | Interviewed about abuse reporting requirements |
Inspection Report
Life Safety
Census: 104
Deficiencies: 2
Date: Aug 13, 2019
Visit Reason
The inspection was a fire safety inspection conducted on August 13, 2019, to assess compliance with hazardous area and wastebasket fire safety regulations at The Gardens assisted living facility.
Findings
The facility failed to maintain self-closing devices on the laundry room door in the memory care unit and used non-fire-resistant wastebaskets in multiple resident rooms and common areas. Corrective actions were planned and implemented by the maintenance director to address these deficiencies.
Deficiencies (2)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to maintain self-closing devices on the laundry room door in the memory care unit, which did not operate or close properly.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility used non-fire-resistant wastebaskets, including wire mesh and plastic types, in resident rooms and other areas.
Report Facts
Facility census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding the laundry room door and wastebasket deficiencies and responsible for corrective actions |
Inspection Report
Life Safety
Census: 105
Deficiencies: 9
Date: Jul 9, 2018
Visit Reason
The inspection was a fire safety inspection conducted on July 9, 2018, to assess compliance with fire alarm systems, emergency lighting, hazardous area requirements, and fire resistance of materials in the facility.
Findings
The facility failed to comply with several fire safety regulations including improper placement of smoke detectors, failure to test and maintain the fire alarm system, lack of semiannual fire alarm inspections, absence of self-closing doors on hazardous areas, inadequate emergency lighting, non-fire-resistant curtains and wastebaskets, and a hole in the ceiling. Corrective actions and timelines were provided for each deficiency.
Deficiencies (9)
19 CSR 30-86.022(9)(A)(1) Smoke Detectors NFPA 13: Smoke detectors were improperly installed too close to HVAC vents in multiple areas, violating the 36-inch clearance requirement.
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)(G) Fire Alarm System-Correct Faults: The facility failed to correct a fault with the fire alarm system control panel showing trouble signals.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to install or maintain self-closing doors on hazardous areas, allowing smoke to pass through vents into memory care areas.
19 CSR 30-86.022(12)(A) Emergency Lighting - locations: Emergency lighting was not installed at all required attendant stations and failed to activate during testing in multiple locations.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs: The facility failed to maintain emergency lighting in good repair; several emergency lights failed to activate during testing.
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant: Curtains and drapes in resident rooms and common areas lacked documentation of fire resistance rating.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM - Requirements: Non-fire-resistant plastic wastebaskets were used in resident rooms and other areas instead of required metal or UL/FM fire-resistant wastebaskets.
19 CSR 30-86.032(2) Substantially Constructed & Maintained: The building was not maintained in good repair; a 3'x3' hole in the ceiling of the activity area was observed.
Report Facts
Facility census: 105
Deficiencies cited: 9
Inspection Report
Plan of Correction
Census: 105
Deficiencies: 1
Date: Mar 30, 2018
Visit Reason
The inspection was conducted to address deficiencies related to rodent control following observations of mice in resident rooms and concerns about sanitation and pest management.
Complaint Details
Complaint # MO00140102 was investigated. The higher classification was merited due to the violations' effect on the resident and the extent of the violation.
Findings
The facility failed to maintain effective measures to minimize the presence of rodents, flies, cockroaches, and other insects. Multiple observations and interviews revealed mice presence in resident rooms, clutter and hoarding behaviors contributing to the problem, and inadequate pest control policies and practices.
Deficiencies (1)
19 CSR 30-87.020(39) Inspect/Rodent Control: The facility failed to maintain effective measures to minimize rodents as evidenced by mice found in two residents' rooms and inadequate pest control policies.
Report Facts
Facility census: 105
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