Brooking Park: Unsafe Lift Transfer Caught on Video - MO
It was caught on video.
The inspection, conducted November 14, 2025, stemmed from a complaint. Federal inspectors reviewed the footage and then spent the morning and afternoon interviewing the people responsible for making sure something like this never happened. Each one confirmed, in turn, that they already knew the rules. None of them had seen the video before inspectors showed up.
The resident at the center of the incident was total care for all activities of daily living. That means they depended entirely on staff for every movement, every transfer, every basic function. Their care plan required a mechanical lift for all transfers, and it required two people to operate it.
CNA D, interviewed at 9:00 in the morning, said staff learned what each resident needed through shift-to-shift verbal report. He or she knew the resident was total care. Lift transfers required two people. That much was clear.
RN E, interviewed at 8:30 that same morning, said the same thing. Staff knew what was required through aide-to-aide verbal handoff. If a CNA was ever uncertain, they could ask the nurse. Mechanical lifts required two staff members.
The Director of Nursing said staff received care requirements through verbal shift-to-shift report. If a CNA did not know, they should ask. Then she said something that cut to the heart of what the video showed: a bear hug is not a proper way to transfer a resident.
She and the Administrator both said they were not aware the video existed before that afternoon.
The Administrator, interviewed at 2:29 P.M., said he would expect staff to follow the facility's policies and procedures.
What the inspection record does not contain is any explanation for why the aide made the choice captured on that footage, or whether anyone at Brooking Park had reviewed care practices for this resident before a complaint prompted federal inspectors to come looking. The verbal reporting chain that the CNA, the charge nurse, and the Director of Nursing all described as the system for communicating resident needs did not prevent what happened. It may not have flagged it afterward, either.
Mechanical lifts exist because transferring a person who cannot bear their own weight is dangerous, for the resident and for the person doing the lifting. A bear hug transfer, performed alone, puts the full load of a non-weight-bearing person onto a single aide's grip and the resident's body. For a resident who is total care, the risk of being dropped, twisted, or simply held wrong is not theoretical.
The inspectors tagged the violation as F0689, the federal citation covering accident hazards and supervision, at a harm level of minimal harm or potential for actual harm, with few residents affected.
The Director of Nursing and the Administrator learned what their staff had done the same afternoon the inspectors did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brooking Park from 2025-11-14 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 1, 2026 · Our methodology
BROOKING PARK in CHESTERFIELD, MO was cited for violations during a health inspection on November 14, 2025.
The inspection, conducted November 14, 2025, stemmed from a complaint.
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.