Grove At Kirkwood, The

During an interview on 1/29/26 at 1:43 P.M., Director of Nursing (DON) C said call lights were to be within the resident's reach at all times, no matter what the cognition status. 4.

Review of Resident #44's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Dependent on staff for showering and bathing.

Review of the resident's medical record, showed diagnoses included arthritis and spinal stenosis (narrowing of the spaces of the spin, causing pain).

Observations on 1/22/26 at 9:40 A.M., 1/23/26 at 7:36 A.M. and 12:35 P.M., and 1/26/26 at 8:45 A.M. showed a sign in the 200 hall shower room near in the shower stall that read, Please do not use shower.

During an interview on 1/22/26 at 9:30 A.M., the resident said he/she did not have a bathroom in his/her room.

The resident said he/she propelled him/herself in his/her wheelchair to the 200 hall shower room to use the bathroom. He/She could not take a shower in the 200 hall shower room because it was broken. It had been broken for over a month.

The resident had to go to another shower room located further down the hall. He/She usually could not propel him/herself to the shower room located further away and required assistance from the staff.

During an interview on 1/27/26 at 10:12 A.M., Maintenance Associate E said the shower had been broken for about a month.

When the shower was turned on, it leaked into the lobby below.

During an interview on 1/28/26 at 1:09 P.M., CNA CCC said the shower in the shower room on 200 hall should have been fixed because it was inconvenient for the residents to go further down the hall.

During an interview on 1/29/26 at approximately 12:30 P.M., the Maintenance Director said he was aware of the broken shower in the 200 hall shower room. It had been broken for about a month. He had not gotten around to fixing it.

During an interview on 1/29/26 at 1:43 P.M., Administrator B said he/she was not aware that the shower on the 200 hall was broken and it should be fixed immediately.

The residents should have a shower that is easily accessible to them. 26883552727896

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

require a deposit. If a resident had a $6,000 deposit and they were discharged from the facility, he would try and get that deposit back to them.

They could contact the previous management company. He was not aware of the resident's situation and the attempts to refund the deposit.

There was an increase of residents who were discharged , but they were admitting a lot of short-term residents.

The Regional Nurse Consultant said they are still under the previous management company until the change in ownership is completed.

They are still honoring the original contract.

They wanted to make as few changes as possible.During an interview on 1/29/26 at 1:43 P.M., Administrator B said the funds were not turned over during acquisition.

They have requested all information from the previous ownership. He/She was not aware of the deposit; however, the corporate BOM was aware.

The corporate BOM put in a request to refund the deposit.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 1/28/26 at 1:30 P.M., Housekeeper T said the shower rooms were cleaned once a day.

Staff cleaned the toilets, mopped the floors, refilled the toilet paper, and emptied the trash.

During an interview on 1/29/26 at 1:43 P.M., the Administrator B and DON C said the resident's shower room on the second floor should be clean, odor free and with adequate supplies.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 1/29/26 at approximately 1:00 P.M., the Social Worker said she was named the official Grievance Official on 1/28/26.

Administrator A and Administrator B were the previous Grievance Officials.

She expected grievances to be thoroughly investigated and to have findings of the investigation within five days.

The residents and their families should have free access to grievance forms and a secure box to place them in.

The Social Worker was not aware of Resident #44's grievance. 5.

During the interview on 1/29/26 at 1:43 P.M., Administrator B said he/she was not aware of Resident #44's grievance. He/She would expect grievances to be acted on immediately and to have a conclusion of the findings reported to the family and their representative within five days. 27164582681713

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 1/29/26 at 1:43 P.M., Administrator B said the funds were not turned over during acquisition by the new ownership.

They have requested all information from the previous ownership. He/She was not aware of the resident's deposit; however, the corporate BOM was aware.

The corporate BOM put in a request to refund the deposit. 27162942712809

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 1/28/26 at 9:29 A.M., the Director of Physical and Occupational Therapy (Director of PT/OT) said in her expertise, she was not sure how the resident could get up the steps to his/her home. In reading the evaluation for the resident's home, there are approximately 12+ stairs.

When she saw the resident, he/she could only take six or seven steps.

The resident did therapy on some days while having COVID, and other days was too sick to participate in therapy. He/She missed two days of therapy.

The resident had 15 days of therapy. He/She could walk with one person and a gait belt. He/She would benefit from more therapy. He/She would be unsafe with stairs.

His/Her legs were extremely weak. He/She still required assistance with toileting and dressing.

The Director of PT/OT did not feel it was safe to discharge the resident back to his/her home.

During an interview on 1/28/26 at 1:30 P.M., the Admissions Coordinator said the resident changed his/her discharge plan and his/her new plan was unsafe.

They attempted to contact the resident's family member, who would not return phone calls. At 2:56 P.M., the Admissions Coordinator said when they realized the resident would not have 24/7 care at home, they realized it would be an unsafe discharge.

The Admissions Coordinator was told staff could not appeal discharges for residents.

Review of the resident's medical record, showed he/she was discharged from the facility on 1/28/26.

During an interview on 1/29/26 at 12:11 P.M., the SW said she had not received any education or guidance regarding her job duties at the facility.

She had experience with discharge planning from working in assisted living facilities (ALFs), but NOMNCs were new to her since they were not done in ALFs. If a resident wanted to appeal their NOMNC or discharge, to her knowledge, she was not allowed to do it for them.

She could not recall who informed her of not being able to assist with the appeal.

She had never done a home assessment for a resident who is going to be discharged . 2.

Review of Resident #11's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/24/25, showed:-admission date 11/17/25;-Cognitively intact;-Diagnoses included high blood pressure, peripheral vascular disease, diabetes, hyperlipidemia, depression, and asthma.

Review of the resident's Physician Order Sheets, dated December 2025, showed no physician order to discharge the resident from the facility.

Review of the resident's progress note, dated 12/20/25, showed resident discharged home with medications.

Nurse management aware.

Further review of the resident's medical record, showed:-discharge date [DATE];-No documentation of the resident's discharge planning, referrals and/or resources;-No documentation of a discharge summary. 3.

During an interview with Administrator B and Director of Nursing (DON) C on 1/29/26 at 1:47 P.M., DON C said he/she expected the SW to assist residents with discharge planning.

All services to be provided upon discharge should be documented in the resident's medical record. A discharge summary should be documented in the resident's medical record. 2715118

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Observation on 1/27/26 at 1:16 P.M., showed the resident in bed.

His/Her toenails on both feet measured approximately an eighth of an inch long and appeared jagged.

His/Her front teeth had a whitish-yellow substance caked on them.

Observation on 1/28/26 at 1:16 P.M., showed the resident in bed.

His/Her toenails on both feet appeared approximately an eighth of an inch long and jagged.

His/Her front teeth had a whitish yellow substance caked on them.

During an interview, the resident said he/she had asked for help trimming his/her nails and no staff would assist him/her.

His/Her children have had to come and help brush his/her teeth because the staff are too busy to assist him/her.

During an interview on 1/29/26 at 7:08 A.M., CNA I said nail care should be provided after the resident is showered.

Lack of staffing was the reason the resident was not being assisted with oral hygiene.

The resident required staff assistance with showers and personal hygiene. 5.

During an interview on 1/29/26 at 10:22 A.M., LPN H said CNAs and nurses can trim residents' toenails unless the resident is diabetic, and then only the nurse or podiatrist can trim them. He/She expected CNAs to document on the shower sheet and alert the nurse if the resident needs his/her nails trimmed. He/She expected CNAs to assist residents with oral hygiene.

During an interview on 1/29/26 at 9:49 A.M., DON C said he/she expected residents to have clean, trimmed toenails. He/She expected staff to assist residents with oral hygiene. 6.

Review of Resident #13's quarterly MDS, dated [DATE], showed:-Cognitively intact;-No rejection of care behavior exhibited;-Substantial to maximum assistance from staff required for rolling from left to right and movement from bed to chair and chair to bed;-Diagnosis included heart disease, kidney disease, and high blood pressure.

Review of the resident's medical record, showed no care plan completed.

Observation 1/22/26 at 10:00 A.M. and 1/27/26 at 8:55 A.M., showed the resident in bed on his/her back, wearing a green hospital gown.

During an interview on 1/27/26 at 8:55 A.M., the resident said he/she would like to get out of bed and wear clothing. He/She was reluctant to ask staff to place him/her in a chair because they leave him/her up in the chair for too long. He/She had a special chair but did not know where it was.

Observation on 1/28/26 at approximately 2:00 P.M., showed the resident in bed, wearing a green hospital gown.

During an interview, the resident said he/she had not gotten out of bed today and thought he/she was too much work for the staff since he/she required a Hoyer lift (full body mechanical lift).

The resident would like to see things outside of his/her four walls.

During an interview on 1/28/26 at approximately 2:30 P.M., the Director of Therapy said the resident had no restrictions and staff were to use a Hoyer lift to get the resident out of bed. A special high-back wheelchair had been ordered and was in the resident's room.

During an interview on 1/29/26 at 10:05 A.M., CNA BB said the resident was offered to get out of bed, but the resident would refuse.

The resident required a Hoyer lift to get out of bed.

During an interview on 1/29/26 at 2:14 P.M., the DON said the resident was expected to get out of bed every day and as requested. If the resident refused, then the nurse should be notified. He/She expected refusals of care to be documented in the medical record and on the resident's care plan.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 1/28/26 at 1:40 P.M. and on 1/29/26 at 11:55 A.M., LPN KK said the nurses are responsible to complete treatments and dressing changes. LPN KK said the resident should have compression stockings on if there is an active order.

During an interview on 1/29/26 at 1:41 P.M., Director of Nurses (DON) C said he/she expected the nurses to follow physician orders and complete the wound treatments as ordered. He/She expected staff to order supplies if they were not available. He/She expected staff to document accurately in the resident's medical record when the treatment was completed.

Staff should not document a treatment as completed when it was not administered. He/She expected compression stockings to be on a resident as per physician orders. 2.

Review of Resident #123's medical record, showed:-admission date 1/16/26;-Diagnoses included congestive heart failure (heart inability to pump), pneumonia (infection effecting the lungs filling with fluid or pus), glaucoma (impaired vision), and diabetes;-No baseline care plan to direct staff on the care needs of the resident.

Review of the electronic physician order sheet (ePOS) and treatment administration record (TAR) for January 2026, showed:-An order, dated 1/22/26, to cleanse skin tear to left lower leg with normal saline, apply xeroform, and dry dressing daily and as needed (PRN);-From 1/22/26 through 1/26/26, staff did not document the treatment as completed.

During an interview on 1/22/26 at 11:00 A.M., the resident said he/she had a wound on his/her left leg/ankle.

During an interview on 1/23/26 at 12:46 P.M., Certified Nurse Aide (CNA) ZZ said he/she was transferring the resident with Physical Therapist (PT) AA and during the transfer, the resident's leg got caught, causing the wound to the resident's leg/ankle.

Observation on 1/26/26 at 2:01 P.M., showed the dressing on the resident's left leg dated 1/22/26.

During an interview on 1/29/26 at 1:04 P.M., the Regional Nurse Consultant said nurses are responsible for documenting completion of wound treatments in the resident's electronic medical record.

Staff should follow physician orders for completion of wound treatments. 2681713

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Administrator B and DON C on 1/29/26 at 2:14 P.M., DON C said the bottle of Dakins solution should not have been in the resident's room. It would be removed and destroyed. 2722224

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, interview and record review, the facility failed to ensure ostomy (medical device used to collect bodily waste) care was provided by staff and physician orders were obtained for ostomy care for one resident who had an ileostomy (surgical procedure that creates an opening (stoma) in the abdominal wall, bringing the end of the small intestine to the surface to divert waste in an external pouch) (Resident #93).

The sample was 21.

The census was 91.

Review of the facility's Pouch Changes - Ileostomy policy, dated 7/1/25, showed:-Policy: It is the policy of this facility to ensure that residents who require colostomy services receive pouch changes consistent with professional standards of practice to minimize occupational exposure and the resident's skin exposure to fecal matter or urine;-Policy Explanation:-Ostomy care will be provided by licensed nurses under the orders of the attending physician.

The order should include the type of ostomy, frequency of pouch change, and type of equipment.

The nurse will allow the resident to perform as much care as possible in accordance with the resident's goals and preferences.

Review of Resident #93's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/25, showed:-Moderately impaired cognition;-Diagnoses included Chron's disease (inflammatory bowel disease causing chronic inflammation of the gastrointestinal tract), ileostomy status, chronic kidney disease, major depressive disorder, and anxiety;-Had ostomy appliance.

Review of the resident's physician order summary (POS), reviewed 1/26/26, showed no orders for ostomy care.

Review of the resident's medical record, showed no baseline or comprehensive care plan to direct staff on the resident's care needs.

During an interview on 1/22/26 at 8:49 A.M., the resident said he/she felt shaky and did not feel good. He/She was unable to answer specific questions regarding his/her medical needs.

During an interview on 1/22/26 at 9:43 A.M., the resident's family member, Family Member UUU, said he/she and another family member had been coming to the facility to assist the resident with ostomy care.

Staff were not assisting the resident with emptying his/her ostomy bag, resulting in the resident having to wait for his/her family member to help. He/She informed Director of Nursing (DON) D his/her concerns but had not heard back from any facility staff.

During an interview on 1/22/26 at 2:00 P.M., Licensed Practical Nurse (LPN) FFF said today the resident had an unwitnessed fall. LPN FFF was in the hallway with another staff member when they heard a bang come from the resident's room.

They went immediately to the resident's room where they found the resident on the floor.

The floor around the resident was covered in feces.

The resident was holding his/her ostomy bag up, trying to keep feces from coming out more.

The resident reported that he/she had been trying to walk to the bathroom to empty his/her ostomy bag.

The resident was sent out to the hospital due to shoulder pain after the fall and having an altered cognitive status. LPN FFF had not known the resident had an ostomy bag.

During an interview on 1/23/26 at 9:03 A.M., LPN O said he/she was unaware the resident had an ostomy bag.

The resident did not have any physician orders for ostomy care. He/She was unaware if the resident was able to care for his/her ostomy him/herself.

During an interview on 1/29/26 at 2:00 P.M., DON C said he/she expected staff to assist the resident with his/her colostomy care. He/She expected staff to be informed of the presence of the resident's colostomy. He/She expected for the resident to have a care plan indicating interventions for the resident's ostomy care level needs. He/She expected the resident to have physician orders for ostomy care. He/She expected DON D to have reached out to the resident or the resident's family upon being informed of care concerns. 2661256

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview 1/22/26 at 8:45 A.M., Certified Medication Technician (CMT) W said the facility recently changed over to a new system with ordering medications and is so messed up.

Medications were frequently not given because the medications had not been ordered properly. He/She did not get proper training on how the new medication system worked. If a medication wasn't available, the nurse could check the E-kit. 8.

During an interview on 1/29/26 at 10:25 A.M., Licensed Practical Nurse (LPN) H said medication should be administered per the physician's order. If a medication was unavailable, the nurse should document this in the resident's medical record and call the physician or pharmacy to obtain a new order. 9.

During an interview on 1/29/26 at 2:13 P.M, with Administrator B and DON C, DON C said holes and blank spots on a resident's MAR means the medication was not given. If medication was out or unavailable, the nurse should go to the Pyxis (a locked medication dispensing unit that requires a password) and the medication should be in there. If not, the nurse should call the pharmacy and ask for STAT (urgent) delivery. If the medication is on backorder, the nurse should contact the physician and get a substitute order. DON C said he/she expected medication to be reordered timely and the medication be administered accurately and timely. He/She expected staff to notify the pharmacy and physician after one dose was not given and not wait until multiple doses were missing.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Observation on [DATE] at 6:48 A.M., showed Licensed Practical Nurse (LPN) RRR entered the medication room and plugged the refrigerator back in.

The refrigerator temperature gauge showed 65 degrees F and the alarm displayed a message of high temperature alarm (HA).

During an interview, Certified Medication Technician) SSS said it was a night shift chore to check the refrigerator. LPN RRR said he/she came in at 3:00 A.M.

There was no other nurse when he/she arrived and he/she did not confirm the refrigerator was checked. He/She was unfamiliar with the facility's policy.

Observation on [NAME] Wing refrigerator on [DATE] at approximately 6:45 A.M., showed:-7:06 A.M., 62 degrees F, alarm sounding HA;-7:11 A.M., 58 degrees F, no alarm sounding;-7:12 A.M., 57 degrees F, no alarm sounding;-7:14 A.M., 56 degrees F no alarm sounding;-7:15 A.M., 56 degrees F, alarm sounding HA;-7:18 A.M., 55 degrees F, alarm sounding HA.

Review of the facility's temperature log for [NAME] Wing, dated [DATE], showed no staff member check on the refrigerator's temperature from [DATE] through [DATE].

During an interview on [DATE] at 8:59 A.M., Director of Nursing (DON) C said everything needs to be pulled from the [NAME] Wing refrigerator and reordered. 2.

Observation on the [NAME] Hall nurse cart on [DATE] at 8:40 A.M., showed:-Dry erase markers in the top drawer;-Kwik Pen (insulin) without an open date, and resident name handwritten on the cap;-Solar Star Pen (insulin) without an open date;-Boudreaux's Butt Paste cream tube without an open date or resident name;-Desitin cream without a resident's name or open date.

Observation of the [NAME] Hall CMT cart on [DATE] at 8:40 A.M., showed half of a white circular pill in the pill cutter, marked PLI-4, for trazadone 50 milligrams (mg). 3.

Observation on the Med A Hall nurse cart on [DATE] at approximately 5:00 P.M., showed:-13 insulin pens with handwritten names and no patient labels;-Betamethasone valerate ointment (topical ointment used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) without an open date;-Aspercreme (topical cream used to relieve minor pain) without an open date;-A biohazard bag contained 24 urine tubes, expired dated [DATE], and urine culture tubes;-A plastic bag with a sticker labeled refrigerator contained two syringes of glatopa (used to treat multiple sclerosis (autoimmune disease) 40 mg/milliliters (mL).

Observation on the Med A Hall CMT cart on [DATE] at approximately 5:00 P.M., showed:-Loperamide (treats diarrhea) blister pack 2 mg without a patient label;-Cetirizine (treats allergies) blister pack contained four pills, without an open date or patient label;-A loose oval, white pill.

During an interview on [DATE] at 5:07 P.M., DON C said insulin should have a patient label on the pen and the resident's name should not be handwritten on the caps of the insulin pens.

When a resident is discharged , the nurse is primarily responsible for removing the medication no longer used and destroying it.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 1/28/26 at 2:22 P.M., the Director of Rehab said he/she started after Thanksgiving as director.

There were other therapy staff here at the time.

There was a full time OT, Certified Occupation Therapy Assistant (COTA) and everyone else was as needed (PRN).

There was no ST and they just hired a PRN ST.

One resident had a speech evaluation via telehealth, but most speech therapists do not feel comfortable doing it via telehealth. If the resident had orders for all three therapies, PT/OT/ST, they were only getting PT and OT.

They had a fulltime PT that recently left and it put them in a bind, but another PT will start in March.

There is a contracted Physical Therapy Assistant (PTA) that also just started.

The residents receive their PT/OT orders, it is being fulfilled.

They receive therapy three times a week.

Once they have more staff, it will be five times a week.

They do not have a restorative program.

There had been no restorative program since he/she started at the facility.

During an interview on 1/28/26 at 2:39 P.M., Licensed Practical Nurse (LPN) Z said there was no PT/OT in the beginning of the transition of the new ownership.

They did not have a restorative program at this time.

They have not had a restorative program since the change in ownership.

After the change in ownership, they wanted to change the restorative aide (RA) to Certified Nurse Aide (CNA), but he/she retired and they got rid of the other RA. 2.

Review of the facility's therapy minutes, dated 9/1/25 through 1/22/26, showed no ST evaluations, ST minutes or services offered to residents.

During an interview on 1/28/26 at 12:20 P.M., the Dietary Manager said ST was supposed to be telehealth and there is a new person starting. 3.

During an interview on 1/29/26 at 1:43 P.M., Director of Nursing (DON) C said he/she was aware the resident received therapy outside of the facility.

The facility was looking to hire one therapist.

The facility ensured therapy was delivered by completing an assessment, and if they do not have appropriate staff, they contracted a staff member.

There was no restorative therapy program in place. If a resident received outside therapy services, he/she expected staff to arrange transportation to and from, and set the schedule and arrange it. He/She expected there to be communication between the facility and the outside therapy company.

There should be progress notes, proper documentation, and it should be care planned. 265250126464812724850

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Business Office Manager.

Messages were left requesting returned calls, but the calls were unreturned.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies.

The facility assessment did not include a monthly average number of residents who required assistance with activities of daily living.

The census was 91.

Review of the facility's Facility Assessment, updated 12/18/25, showed:-People involved in completing: Administrator A, Director of Nursing (DON) C, and Director of Maintenance;-Date reviewed with Quality Assurance Performance Improvement (QAPI) committee: 12/18/25;-Number of licensed beds: 117;-Average daily census: 100;-Average weekday admissions by shift: 3-4;-Average weekend admissions by shift: 0-1;-Average weekday discharges by shift: 3-4;-Average weekend discharges by shift: 0-1;-Assistance with activities of daily living monthly average:-Bed mobility sit to lying: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Mobility sit to stand: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Bathing: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Transfer: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Eating: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Toileting: --Set up: blank;--Supervision/partial/moderate assistance: blank;--Dependent/max assistance: blank;-Other care, describe: blank;-Staff assignments: Describe how you determine and review individual staff assignments for coordination and continuity of care for residents within and across these staff assignments: -The facility meets this requirement by considering census, individual and overall unit acuity, routine/consistent staffing assignments per unit for both licensed nurses and Certified Nursing Assistants (CNAs), and resident preferences for staff assignments.-Describe how you evaluate if your infection prevention and control program includes effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards: -Utilize acceptable infection control program, tracking and trending program infections by type, location, and antibiotic used. We provide transmission-based precautions.

Annual infection control and handwashing competency training and as needed.

Staff and volunteers participate in annual training.

Visitors are observed for signs and symptoms of contagious infections.

Signage is used to communicate isolation and any other necessary information to visitors and/or vendors.

During the course of the survey process, problems were identified which included:-Staffing and training, to include:--No required CNA 12-hour in competencies abuse and neglect and/or dementia care training for 10 out of 10 CNAs who were employed for more than one year;--Insufficient nursing staff available to meet the needs of residents, as evidenced by staff interviews, residents with missed treatments, and residents with missed activities of daily living (ADL) care;-No restorative program or speech therapy;-Infection control practices, to include:--Tuberculosis testing not completed for 5 out of 5 residents sampled;--Residents on enhanced barrier precautions (EBP) did not have signage or a supply of personal protective equipment (PPE);--Housekeeping staff failed to have Environmental Protection Agency (EPA)-registered hospital disinfectant solution to clean floors.

During an interview on 1/28/26 at 1:43 P.M., Administrator B said he/she expected the facility assessment to be fully completed with the total numbers of all residents who required assistance.

The Administrator is responsible for ensuring the facility assessment is completed.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 1/26/26 at 3:04 P.M., the Dietary Manager said they had a corporate person that ordered supplies for them.

During observation and interview on 1/28/26 at 2:19 P.M., Housekeeper T said he/she used the Medorra Limpreza All Purpose Cleaner Lavender scent for the floors. He/She poured enough cleaner to cover the bottom of the bucket.

They used to have a hook up that poured water and cleaner out of a hose. He/She liked that set up better.

Observation on 1/28/26 at 3:11 P.M., showed a bottle of Medorra Limpreza All Purpose Cleaner Lavender scent.

There was no EPA-registered number on the bottle.

There was no documentation of EPA approved or hospital grade disinfectant.

Review of EPA-approved, certified products on EPA.gov, reviewed 2/6/25, showed no result for Medorra Limpreza All Purpose Cleaner Lavender scent.

Review of the Medorra Limpreza official website, reviewed1/28/26, 1/29/26, 2/5/26, and 2/6/26, showed the website had a critical error.

The product or EPA registration could not be verified on the website.

During an interview on 1/29/26 at 10:00 A.M., Central Supply PPP said he/she worked in the building for several years. On 9/1/25, when the new management took over, he/she was given duties of medical records and accounts payable in October 2025. He/She tried to do everything, but it is a lot.

They never had issues with the supplies, but it changed drastically.

Before the management change, there was never a problem with supplies.

When they took over, there was a budget issue, and the facility went from having supplies to limited supplies.

During an interview on 1/29/26 at 1:09 P.M., the Regional Nurse Consultant said housekeeping did their own ordering.

They did not have a Housekeeping Director.

There was no training for staff on how much floor chemicals to use.

During an interview on 1/29/26 at 1:43 P.M., Administrator B said there were extra supplies in the basement, so he/she told staff to educate someone on where to find it. He/She expected housekeeping to use appropriate supplies to clean all areas of the facility. He/She expected housekeeping staff to know how much chemicals to use. 27209122703232271295626798782724850

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use.

The census was 91.

Review of the facility's Antibiotic Stewardship policy, dated, 7/1/25, showed:-Intention: It is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program.

The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use;-Policy: The Medical Director, Director of Nursing (DON), Infection Prevention Control (IPC) Nurse, and Consultant Pharmacist serve as leaders of antibiotic stewardship program and receive support from the Administrator and governing officials at the facility.

During an interview on 1/23/26 at 2:19 P.M., Administrator A said the antibiotic stewardship program had not been updated since March 2025.

The IPC Nurse recently quit, and the facility just started the program back up on 1/22/26.

Administrator A said he/she expected the antibiotic stewardship program to be in place.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Grove at Kirkwood, The

711 South Kirkwood Road Kirkwood, MO 63122

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to offer the COVID-19 vaccine for five out of five residents reviewed (Resident # 12, #13, #8, #9, and #6).

The census was 91.

Review of the facility's COVID Vaccine policy, dated, 7/1/25, showed:-Policy: The facility will offer the COVID vaccine to assist in mitigating the spreads of COVID-19;-Procedure: COVID-19 vaccinations shall be offered to all residents unless such immunization is medically contraindicated; Residents shall be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including the information of the benefits and risks with the Centers for Disease Control and Prevention (CDC) or Food and Drug administration (FDA); Residents shall be offered the opportunity to ask questions about the risk and benefits of the vaccination; The facility shall maintain documentation of COVID-19 vaccine for all residents in the medical record. 1.Review of Resident #12's medical record showed:-Diagnoses that included heart failure and kidney disease;-No documentation that the resident was offered or received the COVID-19 vaccine. 2.Review of Resident #13's medical record showed:-Diagnoses that included asthma and kidney disease;-No documentation that the resident was offered or received the COVID-19 vaccine. 3.Review of Resident #8's medical record showed:-Diagnoses that included diabetes and osteomyelitis (bone infection) of the foot;-No documentation that the resident was offered or received the COVID-19 vaccine. 4.Review of Resident #9's medical record showed:-Diagnoses that included heart failure and stroke;-No documentation that the resident was offered or received the COVID-19 vaccine. 5.Review of Resident #6's medical record showed:-Diagnoses that included stroke, dysphagia (difficulty swallowing) and kidney disease;-No documentation that the resident was offered or received the COVID-19 vaccine. 6.

During an interview on 1/29/26 at 12:57 P.M., the Regional Nurse Consultant said he is also the facility's Infection Preventionist (IP). He would expect the COVID-19 vaccinations be offered to the residents on admission or when the resident requests one.

Refusals of the vaccines and any education provided is expected to be documented in the resident's medical record.

All vaccines administered to the resident are expected to be documented in the resident's medical record.

Facility ID: