Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schnepp Senior Care And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple chronic conditions was given Metoprolol without required blood pressure monitoring on several occasions, including one instance where the recorded blood pressure was below the physician-ordered threshold. The DON confirmed that vital signs were not consistently documented prior to medication administration, contrary to both physician orders and facility policy.
Two residents with severe dementia were found in a situation suggestive of possible sexual abuse, with one resident discovered naked and the other pulling up her pants. Although the incident was reported internally and assessed by a nurse, it was not promptly reported to the abuse coordinator or the State Agency, despite both residents being unable to consent. This failure to report the suspected abuse in a timely manner resulted in a deficiency.
A resident with multiple comorbidities was admitted with several pressure injuries, but staff failed to accurately assess, document, and initiate treatment for these wounds. The initial nursing assessment lacked details and treatment orders, and subsequent documentation was incomplete. A new wound developed and was not properly assessed or measured, and the resident reported not receiving wound care as ordered, resulting in the worsening of a pressure injury.
A resident who required substantial assistance with toileting and hygiene reported receiving rough and hurried care from staff, leading to feelings of being unimportant. Several other residents described frequent delays in call light response, with staff often turning off call lights and failing to return to complete care, resulting in extended waits for assistance with basic needs. These issues were documented over several months and affected multiple residents, despite facility policies and staff training intended to address them.
A resident with C. diff infection was not provided proper infection control as staff failed to use required PPE and did not perform hand hygiene with soap and water as per facility policy. Both a physical therapy assistant and a CNA either used hand sanitizer instead of soap and water or did not use PPE when assisting the resident, despite being aware of the correct procedures.
Two residents with dementia were involved in an incident where one resident inappropriately kissed another, and staff failed to notify the responsible parties as required by facility policy. Despite internal reporting among staff and ongoing inappropriate behaviors by the resident, there was no documentation or evidence that the responsible parties were informed of the event.
Two residents were involved in an incident where one resident with dementia and behavioral issues kissed another resident without consent in a supervised activity room. Although the event was witnessed and reported internally to nursing leadership, it was not reported to the State Agency as required by facility policy, and no formal investigation or documentation was completed.
Two residents with dementia were involved in an incident where one was observed kissing another inappropriately. Staff notified facility leadership, but no formal investigation was initiated, and the event was not reported to authorities as required by policy. The male resident had a history of similar behaviors, yet the facility did not document interviews or conduct a thorough inquiry.
A facility failed to accurately document a resident's behavioral symptoms in the MDS assessment, despite evidence of aggressive behaviors in the EMR. The resident, diagnosed with Alzheimer's and Dementia, exhibited behaviors such as yelling and spitting, which were not reflected in the MDS, potentially affecting the development of an individualized care plan.
A facility failed to perform ordered pressure ulcer interventions and adequately monitor a resident's pressure ulcer, leading to potential worsening of the condition. The resident, admitted with a foot ulcer and peripheral vascular disease, was not consistently provided with a foam boot as required. Weekly documentation and pictures of the wound were not maintained, and staff were unaware of the wound's status. The wound nurse practitioner confirmed the wound was still open, contradicting facility records.
A facility failed to ensure a physician reviewed a pharmacy recommendation for a resident on Mobic and Eliquis, highlighting potential serious side effects. The pharmacy's recommendation was not documented in the resident's EMR, and the Director of Nursing confirmed no benefit/risk analysis was conducted by the physician. This oversight could impact the resident's health, given their medical history.
A resident with multiple health conditions was prescribed Mobic and Eliquis concurrently, despite a pharmacist's recommendation for a benefit/risk analysis due to potential cardiovascular and gastrointestinal risks. The facility failed to document any analysis or physician's note addressing this recommendation, resulting in the potential for unnecessary medication use over several months.
The facility failed to maintain accurate medical records for two residents, leading to potential miscommunication. One resident's records incorrectly documented the use of a foam boot, while another resident's records lacked a required benefit/risk analysis for concurrent medication use. The Director of Nursing confirmed the absence of necessary documentation, highlighting a breach in the facility's policy and nursing documentation standards.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess Blood Pressure Parameters Before Administering Antihypertensive Medication
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, hypertension, type 2 diabetes, and chronic kidney disease was administered Metoprolol without proper assessment of physician-ordered parameters. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110 or pulse was less than 60. However, review of the electronic medication administration record (eMAR) showed that the resident received Metoprolol multiple times without blood pressure monitoring prior to administration. On one occasion, the resident's blood pressure was documented as 97/61, which was below the ordered threshold, yet the medication was still administered. The Director of Nursing confirmed that blood pressure readings were not consistently documented before medication administration, as required by both physician orders and facility policy. The facility's policy mandates that vital signs be obtained and recorded as necessary prior to medication administration, but this was not followed in the resident's case.
Failure to Timely Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving two residents, both with severe dementia and significant cognitive impairment. A certified nurse aide discovered a female resident pulling up her pants and a male resident, naked and with an erection, in the same room. The incident was reported to the floor nurse, who then contacted the Clinical Care Coordinator/Registered Nurse (CCC/RN). The CCC/RN assessed both residents and found no physical signs of sexual intercourse or injury but did not report the incident to the abuse coordinator as required. The Nursing Home Administrator/Abuse Coordinator (NHA/AC) was not informed of the incident until the following morning during a routine meeting and only became fully aware of the details after a concerned staff member called later that day. The incident was not reported to the State Agency, despite both residents being unable to consent due to cognitive impairment and the situation meeting the definition of an alleged violation. The failure to report the suspected abuse in a timely manner constituted the deficiency.
Failure to Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess, document, and initiate treatment for a resident with multiple pressure injuries upon admission. The resident, who had a history of dementia, hypertension, type 2 diabetes, and chronic kidney disease, was admitted with a stage 1 pressure injury to the coccyx, bruising to the left elbow, and pressure injuries to both feet. The nursing admission assessment did not specify the stage or measurements for the toe injuries, and there was no treatment order for the coccyx wound. Additionally, the physician's admission note did not mention any of the identified wounds, and there was no ongoing documentation or monitoring of the coccyx pressure injury in the nursing progress notes or skin/wound assessments for several days following admission. Subsequent documentation revealed that the resident developed moisture-associated skin damage (MASD) to the coccyx and buttocks, with a new wound identified later, but without detailed assessment or documentation of the wound's characteristics. During an observation, a probable stage 2 pressure injury was found near the anus, and the nurse did not measure the wound. The resident reported that wound care was not provided every shift as ordered. These failures in assessment, documentation, and timely intervention resulted in the worsening of the resident's coccyx wound.
Failure to Provide Dignified and Timely Personal Care
Penalty
Summary
The facility failed to provide personal care in a dignified manner for one resident and did not provide timely personal care and assistance for eight other residents. One resident with Parkinson's disease and heart failure, who was cognitively intact and required substantial assistance with toileting and hygiene, reported experiencing rough and hurried care from a female staff member. The resident described feeling as if he was 'thrown around in bed' during care, attributing the roughness to the staff being hurried rather than intentionally harmful. This resident reported such rough care occurred about once a week and expressed that it made him feel unimportant. The facility's Director of Nursing was still investigating the complaint at the time of the survey. Multiple residents reported issues with delayed responses to call lights and staff not returning to complete care after initially responding. Resident Council meeting minutes over several months documented ongoing complaints about long call light response times, inaccessible call lights, and staff turning off call lights without meeting residents' needs. Residents described situations where staff would turn off the call light, promise to return, but then fail to do so, resulting in extended waits for assistance with basic needs such as toileting, transfers, and obtaining water. Some residents reported having to wait up to an hour for assistance, which caused discomfort and anxiety, especially for those with a history of falls or medical conditions that made waiting particularly difficult. Interviews with residents revealed that these issues were not isolated incidents but occurred frequently and affected multiple individuals. Residents expressed frustration, anxiety, and feelings of being forgotten or unimportant due to the delays and lack of follow-through by staff. The facility's policy required call lights to remain on until the resident's needs were met, but documentation and resident reports indicated that this policy was not consistently followed. Staff training had been initiated to address the issue, but residents continued to report problems with call light response and the manner in which care was provided.
Failure to Follow PPE and Hand Hygiene Protocols for C. diff Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene for a resident on Transmission Based Precautions due to Clostridium difficile (C. diff) infection. The resident was admitted with diagnoses including enterocolitis caused by C. diff and end stage renal disease, and had active physician orders for Contact Precautions. Observations revealed that a Physical Therapy Assistant exited the resident's room after removing gown and gloves but used hand sanitizer instead of washing hands with soap and water, contrary to facility policy and CDC guidelines for C. diff. The assistant acknowledged forgetting the correct procedure during an interview. Additionally, a Certified Nursing Assistant entered the same resident's room without performing hand hygiene or donning required PPE, and assisted the resident directly, resulting in contact between her clothing and the resident and his wheelchair. The CNA did not perform hand hygiene after the interaction. Both staff members reported awareness of the correct procedures for C. diff precautions, including the need for soap and water handwashing and use of gown and gloves, but failed to follow them. Facility policies reviewed confirmed these requirements for staff caring for residents on Contact Precautions for C. diff.
Failure to Notify Responsible Parties of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to notify the responsible parties of two residents after an incident involving inappropriate physical contact between residents. According to the facility's own policies, family or responsible parties must be notified of any change in mental, psychosocial, or behavioral management, as well as any alleged violations involving abuse. In this case, a male resident with a history of dementia and behavioral issues was observed grabbing the back of a female resident's head and kissing her. The female resident, who also had dementia and was not her own responsible party, was unable to recall the incident and showed no immediate signs of distress. However, there was no documentation or evidence that her responsible party was notified of the event. Staff interviews and record reviews confirmed that the incident was reported internally to the RN, DON, and NHA, but none of them instructed staff to notify the responsible parties of either resident involved. Text messages reviewed by the LPN and RN indicated that the LPN had asked about notifying the responsible party but was told not to do so. The DON and NHA also confirmed that they did not notify the responsible parties and could not find any documentation that such notification occurred. Additionally, observations revealed that the male resident continued to display inappropriate behaviors, such as making sexual comments and gestures toward other residents and staff, and attempting to grab others. Despite these ongoing behaviors and the initial incident, there was still no indication that the responsible parties for either resident were informed, as required by facility policy. The failure to notify responsible parties of events that may have mental or psychological impact constitutes the deficiency cited in this report.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents. According to the facility's abuse policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately to the Administrator or DON, and to appropriate licensing agencies within specified timeframes. On the date in question, an activity aide observed a male resident grab the back of a female resident's head and kiss her. The female resident, who had dementia and was not her own responsible party, was unable to recall the incident and showed no signs of distress. The incident was reported up the chain of command to the RN, DON, and NHA, but no one instructed that it be reported to the State Agency, and no documentation of interviews or further investigation was made. Further review revealed that the male resident involved had a history of dementia, Alzheimer's disease, and behavioral issues, including making sexual comments and gestures toward staff and other residents. Staff interviews confirmed that the incident was witnessed and reported internally, but the DON and NHA decided not to investigate or report the event to the State Agency because there was no intent, injury, or recall of the event by the resident. The only witness, the activity aide, described the incident as a romantic kiss and stated she intervened immediately. The facility did not document any interviews or conversations about the event. Observations also showed that the activity room, where the incident occurred, was at times left unsupervised, with only one staff member present for 12 residents, including the male resident known to require close supervision due to inappropriate behaviors. Despite the facility's policy and the nature of the incident, the required reporting and investigation procedures were not followed, resulting in a failure to notify the State Agency of the alleged abuse.
Failure to Investigate Alleged Abuse Between Residents
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents, both with dementia and other significant medical conditions. An incident occurred in which a male resident was observed grabbing the back of a female resident's head and kissing her. The female resident was unable to recall the incident, and no signs of distress or injury were noted at the time. The event was witnessed by an activity aide, who reported it to the nurse in charge when it was safe to do so. The nurse notified the RN, who in turn notified the DON and NHA via text message. However, no formal investigation was initiated, and no documentation of interviews or further inquiry was completed. Staff interviews revealed that the incident was not reported to the State Agency, and the facility leadership decided not to investigate further because there was no apparent intent, injury, or recall of the event by the resident involved. The only witness, the activity aide, was spoken to by phone, but no written records or detailed accounts were maintained. The staff involved did not recall being instructed to investigate or notify additional parties, and there was a lack of clarity regarding who else may have witnessed the event or was present at the time. Additionally, observations showed that the male resident involved had a history of inappropriate touching and sexual comments toward other residents and staff. Despite this behavioral history and the incident in question, the facility did not initiate a timely or thorough investigation as required by their abuse policy. The policy mandates immediate initiation of an investigation and reporting to appropriate authorities, which was not followed in this case.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to accurately document and correlate the Minimum Data Set (MDS) assessment information for a resident, identified as R61, who has a history of behaviors such as hitting himself and displaying aggression towards staff. The resident was admitted with diagnoses of Alzheimer's Disease and Dementia with agitation. The MDS assessment, which is crucial for developing an individualized care plan, did not accurately reflect the resident's behavioral symptoms during the specified observation periods. This inaccuracy could potentially impede the development of a care plan tailored to the resident's needs. During the assessment period from 1/25/24 to 1/31/24, the resident exhibited behaviors such as yelling, spitting, and refusing medications, as documented in the Electronic Medical Record (EMR) progress notes. However, the MDS assessment completed by the Social Services Designee (SSD) I inaccurately recorded that no physical or verbal behaviors were exhibited. This misrepresentation led to the skipping of crucial assessment sections that evaluate the impact of these behaviors on the resident's well-being and environment. Similarly, for the assessment period from 4/12/24 to 4/18/24, the MDS again failed to document the resident's behaviors accurately, despite evidence in the EMR indicating incidents of self-harm and yelling. The SSD I signed off on the MDS assessment without including these behaviors, which were noted in a Social Service Note just minutes before the MDS was finalized. This repeated failure to document accurately raises concerns about the facility's ability to assess residents properly and develop effective care plans.
Failure to Perform Ordered Pressure Ulcer Interventions and Monitoring
Penalty
Summary
The facility failed to perform ordered pressure ulcer interventions and adequately monitor and assess a pressure ulcer for a resident, resulting in the potential for worsening pressure ulcers. The resident, who was admitted with a foot ulcer, a pressure ulcer, and peripheral vascular disease, was cognitively intact with a BIMS score of 13. The care plan required the use of a foam boot while in bed to aid in pressure reduction, but this intervention was not consistently followed. The facility's policy required weekly documentation and pictures of pressure ulcers, but this was not done for the resident's right heel wound since December 2023. Despite physician orders to apply a foam boot while in bed, the resident reported not wearing the boot for months, and staff did not offer it. The Treatment Administration Record inaccurately documented the use of the foam boot, and staff were unable to locate it during observations. Interviews with staff revealed a lack of awareness and documentation regarding the resident's wound care. The LPN admitted to documenting the foam boot use in error, and the DON confirmed the absence of weekly wound measurements or pictures. The wound nurse practitioner confirmed the wound was still open and had never completely healed, contradicting the facility's records.
Failure to Document Physician Review of Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a physician reviewed a pharmacy recommendation for a resident, identified as R61, who was receiving both Mobic, a non-steroidal anti-inflammatory drug (NSAID), and Eliquis, an anticoagulant. The pharmacy recommendation, dated 12/7/23, highlighted the potential serious side effects of combining these medications, including increased cardiovascular and gastrointestinal risks. Despite this, there was no documentation in the resident's electronic medical record (EMR) indicating that the physician, MD G, or any physician designee, had conducted a benefit/risk analysis or was aware of the pharmacy's recommendation. The Director of Nursing (DON) confirmed during interviews that the benefit/risk analysis should have been documented in the resident's EMR but could not be found. The DON stated that the Clinical Care Coordinator (CCC) F, a registered nurse, had entered a follow-up note on 12/12/23, indicating that the current therapy's benefits outweighed the risks, but this was not supported by any documentation from MD G. The facility's policy required that if a prescriber did not respond to a pharmacy recommendation within 30 days, the DON and/or consultant pharmacist should contact the Medical Director, but there was no evidence that this had occurred. The lack of documentation and follow-up on the pharmacy recommendation resulted in the potential for the physician not being aware of the serious side effects associated with the combined use of Mobic and Eliquis. This oversight could have significant implications for the resident's health, given their medical history, which includes conditions such as chronic atrial fibrillation, hypertension, and a history of stroke. The facility's failure to ensure proper communication and documentation of the pharmacy's recommendation represents a deficiency in their medication management process.
Failure to Evaluate Medication Risks for a Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically concerning the concurrent use of Mobic and Eliquis. The resident, who was admitted with multiple diagnoses including right hip pain, chronic atrial fibrillation, hypertension, and a history of transient ischemic attack and cerebral infarction, was receiving Mobic, a non-steroidal anti-inflammatory drug, and Eliquis, an anticoagulant. A pharmacy recommendation highlighted the potential risks associated with this combination, including increased cardiovascular and gastrointestinal risks, and advised a benefit/risk analysis. However, the facility did not document any such analysis or physician's note addressing the pharmacist's recommendation. Despite the pharmacist's warning, the resident continued to receive both medications for approximately 6.5 months without documented evaluation by the medical director or any physician designee. The Director of Nursing confirmed the absence of a benefit/risk analysis or any physician's note in the resident's electronic medical record. This lack of documentation and evaluation resulted in the potential for the resident to have received unnecessary medications over an extended period, as the facility did not provide evidence of addressing the identified potential problem.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to potential miscommunication and an unclear picture of the residents' healthcare status. For Resident #33, the deficiency involved the incorrect documentation of the use of a foam protective boot. The resident was admitted with diagnoses including a foot ulcer and peripheral vascular disease, and the care plan required the use of a foam boot while in bed. However, the boot was not found in the resident's room, and an LPN admitted to documenting its use in error, as the resident had been wearing a post-op shoe instead. For Resident #61, the deficiency involved the lack of documentation regarding a benefit/risk analysis for the concurrent use of Mobic and Eliquis, as recommended by the pharmacy. The resident had multiple diagnoses, including right hip pain and chronic atrial fibrillation, and was at risk for cardiovascular and gastrointestinal events due to the medication combination. Despite the pharmacy's recommendation, there was no documentation in the electronic medical record indicating that the physician had conducted the necessary analysis or addressed the concurrent medication use. The Director of Nursing confirmed the absence of the required documentation for Resident #61, acknowledging that the benefit/risk analysis was not present in the resident's electronic medical record. This lack of documentation was contrary to the facility's policy and the American Nursing Association's principles for nursing documentation, which emphasize the importance of clear, accurate, and accessible records to ensure informed decisions and high-quality care.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near St. Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Healthcare Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Michigan Masonic Home | 3.5 mi | ★★★★★ | 17 | 0 |
| The Laurels Of Mt. Pleasant | 15.5 mi | ★★★★★ | 2 | 0 |
| Isabella County Medical Care Facility | 15.6 mi | ★★★★★ | 8 | 0 |
| Medilodge Of Mt. Pleasant | 16.3 mi | ★★★★★ | 6 | 0 |
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