Grove at Kirkwood: Transfer Safety Failures Found - MO
Inspectors from the Centers for Medicare and Medicaid Services documented the transfer on the morning of January 26, 2026, at 8:26 a.m. The resident, identified in the report as Resident 11, had severe cognitive impairment, dementia, heart disease, and heart failure, and required maximum assistance from staff to move from bed to chair. The care plan called for one-person assist with transfers. It said nothing about grabbing waistbands.
LPN Y, as the nurse is identified in the report, did not use a gait belt. Did not use the Hoyer lift. Just lifted the resident under the arms, pulled by the pants, and swung them into the chair.
Two days later, CNA PP told inspectors that staff should always use a gait belt on that resident specifically because "he/she did not stand very well." The belt existed for exactly that scenario — if the resident's legs gave out, a staff member holding the belt could lower them safely to the floor or back into a chair. Without it, there was nothing to hold.
The Director of Nursing, identified as DON C, told inspectors on January 29 that pulling on a resident's pants to transfer them "is not acceptable." That same director had signed off on a gait belt policy, dated July 1, 2025, requiring the belts be used on any resident needing one-person transfer assistance.
Resident 11 was not the only person placed at risk during transfers. A separate set of observations involved a Hoyer lift, the mechanical sling device used to move residents who cannot bear weight. Inspectors found that one staff member was operating the Hoyer alone — a two-person job — and was doing so with the stabilizing legs of the device closed. The legs are designed to be spread wide during a transfer to keep the lift from tipping. This staff member kept them closed because, according to the inspection report, it felt like better balance to him or her.
LPN WW explained to inspectors what should happen: legs open for stability, two people present, one guiding the resident and one managing the chair. DON C said the same thing when interviewed alongside Administrator B on January 28. None of it matched what inspectors had observed.
The second major finding had nothing to do with transfers.
Across three separate observations spanning more than 24 hours, inspectors found an uncapped bottle of Dakin's 0.125% solution sitting on the television stand in the room of Resident 7. The bottle was there at 11:16 a.m. on January 27. Still there at 1:36 p.m. Still there at 5:12 p.m., when the resident was briefly out of the room. Still there the next morning at 8:32 a.m. on January 28, when the resident sat in bed eating breakfast, within arm's reach of it.
Dakin's solution is a topical antiseptic. The safety data sheet kept at the facility carried a specific warning: do not take internally, for external use only, and if swallowed, contact Poison Control immediately.
Resident 7 had severe cognitive impairment, dementia, anxiety disorder, and depression. There was no physician order in the resident's electronic records for Dakin's solution at all, meaning the bottle had no clinical reason to be in the room in the first place, let alone uncapped and unattended on a surface a confused resident could reach from the bed.
When inspectors raised the issue with DON C and Administrator B on January 29, the director said the bottle should not have been there and would be removed and destroyed.
It had been sitting there, open, for at least the previous day and a half that inspectors could document.
The inspection was conducted as a complaint survey, completed January 29, 2026. The report does not identify who brought the bottle into the room, how long it had been there before inspectors first saw it, or whether Resident 7 had any contact with it.
What the report does say is that a resident with dementia spent a morning eating breakfast next to an uncapped bottle of solution that poisons people who drink it, and that nobody on staff had noticed or removed it until federal inspectors asked why it was there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove At Kirkwood, The from 2026-01-29 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: August 17, 2026 · Our methodology
GROVE AT KIRKWOOD, THE in KIRKWOOD, MO was cited for violations during a health inspection on January 29, 2026.
Inspectors from the Centers for Medicare and Medicaid Services documented the transfer on the morning of January 26, 2026, at 8:26 a.m.
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.