Brooking Park: Surgical Wound Left Untreated After Admission - MO
The resident, identified in inspection records only as Resident 1, was admitted to the facility with a surgical wound to the abdomen. Inspectors found that staff failed to verify discharge orders from the hospital and failed to conduct a full skin assessment at admission. The wound orders that accompanied the resident from the hospital were not acted on.
The gap in care was not a matter of hours.
Resident 1 received no wound care to the abdominal surgical wound for the entire length of the stay at Brooking Park. The resident and family eventually requested a return to the hospital for wound evaluation and treatment. That discharge happened on October 28, 2025.
Inspectors noted what staff could have done and did not. If the admitting staff did not have the hospital's wound care orders in hand, they could have called the hospital directly to obtain them or ask for clarification. If the surgeon was unreachable, staff could have contacted the facility's own medical director for temporary orders to bridge the gap. Neither happened.
The inspection, triggered by a complaint, was conducted on November 4, 2025.
The violation was cited under F0684, which covers the standard that residents receive care in accordance with professional standards of practice. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
What that classification does not capture is what it means to have an open abdominal surgical wound and receive no treatment for it, day after day, until a family decides enough is enough and demands a hospital transfer.
Surgical wounds require monitoring. Without consistent care, they can break down, become infected, or fail to close. The inspection report does not describe the condition of Resident 1's wound at the time of discharge, or what treatment the hospital provided upon readmission. Those details were not available in the inspection record.
What the record does show is a straightforward failure at the point of admission. Someone arrived from a hospital with a wound. The facility did not verify what that wound needed. No one called to find out. No one brought in the medical director to cover the gap. The wound went untreated.
Brooking Park is a nursing and rehabilitation facility in Chesterfield, Missouri. The complaint inspection resulting in this citation covered three pages of findings. This violation appeared on the final page.
Resident 1 went back to the hospital because the family asked. The inspection report does not say what would have happened if they hadn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brooking Park from 2025-11-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
BROOKING PARK in CHESTERFIELD, MO was cited for violations during a health inspection on November 4, 2025.
The resident, identified in inspection records only as Resident 1, was admitted to the facility with a surgical wound to the abdomen.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.