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F0584
E

Failure to Maintain Safe, Clean, and Homelike Environment

Saint Louis, Missouri Survey Completed on 12-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Excessive noise levels were noted, including loud overhead announcements that interrupted resident conversations and a smoke room door that repeatedly slammed shut, disturbing residents in the vicinity. Despite previous attempts to fix the door, the issue persisted, and the noise was audible even in the administrator's office. No complaints were reported regarding the overhead speakers, but residents expressed discomfort with the noise disruptions. Sanitation and cleanliness issues were observed throughout the facility. In one instance, a resident's bathroom contained soiled briefs on the floor over multiple days, with staff indicating that residents were expected to request trash bags for disposal, and that housekeeping would not remove soiled briefs from bathrooms. Another resident's toilet was clogged and dirty with feces and toilet paper for at least two days, resulting in a strong odor permeating the room. The resident, who had diagnoses including major depressive disorder, schizoaffective disorder, and epilepsy, and was moderately cognitively impaired, reported being unable to use the toilet during this time. Widespread maintenance and cleanliness deficiencies were documented in various facility areas, including hallways, dining rooms, bathrooms, and common spaces. Observations included dirt buildup on floors and cove bases, chipped and missing paint, broken fixtures, exposed wiring, cracked tiles, and dirty or damaged windows. Staff interviews revealed that short staffing, particularly in housekeeping and floor technician roles, contributed to lapses in deep cleaning and maintenance. Housekeeping and laundry staff were often required to cover for each other, and there was no set schedule for deep cleaning. Staff acknowledged that the environment was not being maintained to expected standards, with visible dirt, dust, and damage throughout the facility.

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