Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Abbey Senior Health during CMS and state inspections, most recent first.
A CNA employed through an agency took a resident's wallet containing cash and debit cards without permission, then used the resident's debit card to make unauthorized payments to a car loan company, an internet provider, and a retail store. The theft was discovered when the resident noticed the missing wallet and unauthorized transactions, leading to a police investigation that identified the CNA as responsible.
A resident was subjected to verbal and mental abuse by a Dietary Aide who threw a ceramic plate at the wall behind the resident and called them a derogatory name. The incident occurred after a disagreement over the disposal of banana peels and salsa. The resident, who was cognitively intact and had a history of heart failure and depression, was seated in a wheelchair during the incident. Multiple staff members witnessed the aftermath, and the Dietary Aide admitted to the actions.
The facility failed to maintain proper hand hygiene and gloving practices during food service, leading to potential contamination. Dietary aides did not change gloves or wash hands between tasks, and food storage practices were inadequate, with open bags of food items not properly sealed. Ice and beverage machines were unclean, and dishwashing machines were not operated according to specifications, with inadequate water temperatures and improper monitoring of sanitizer levels.
The facility failed to ensure resident rights were posted in easily accessible areas. Seven residents were unaware of the location of their rights, and observations showed postings in low-traffic areas not easily accessible to residents in wheelchairs. Staff interviews confirmed the lack of visibility and accessibility of the postings.
The facility failed to provide accessible information about the State Long Term Care Ombudsman program and the State Survey Agency. Residents were unaware of how to contact these agencies, and the information was posted in locations not easily accessible or visible, particularly for those in wheelchairs. Staff interviews confirmed the inadequacy of the information's placement.
The facility failed to ensure safe transportation of residents in wheelchairs, as staff were observed pushing residents without footrests, despite their care plans indicating the need for assistance due to impaired mobility and balance. Interviews revealed inconsistent practices among staff regarding the use of footrests, with some acknowledging the risk of not using them.
The facility failed to conduct bed rail assessments consistent with its policy, which requires evaluating residents' risk for entrapment and conducting ongoing assessments. This deficiency was identified for eight residents, including those with histories of falls and mobility issues. The assessments did not evaluate the risk of entrapment, leading to non-compliance with the facility's policy.
The facility failed to implement proper infection control measures, including the use of Enhanced Barrier Precautions for residents with urinary catheters, proper hand hygiene during incontinence care, and appropriate storage of nebulizer and CPAP masks. Staff were observed not following facility policies, and there was a lack of awareness of current CDC guidelines.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, affecting eight residents. Despite the facility's policy requiring routine inspections to identify potential entrapment risks, there was no documentation of such inspections for residents with cognitive impairments and mobility issues. Interviews with staff revealed a lack of awareness and execution of inspection protocols, indicating a systemic failure in adhering to the facility's bed safety policy.
The facility failed to provide two residents or their responsible parties with a bed hold policy during hospital transfers. One resident was transferred due to uncontrolled back pain, and another due to extreme leg pain, which was later diagnosed as a hip fracture. In both cases, there was no documentation that the bed hold policy was provided, and interviews with staff revealed uncertainty about the timing of issuing the policy.
The facility failed to provide and review baseline care plans with two residents within 48 hours of admission, as required by policy. Both residents, admitted with various medical conditions, did not receive or have the care plans explained to them. Interviews with staff revealed confusion and inconsistency regarding the responsibility for completing and providing these care plans, contributing to the deficiency.
Misappropriation of Resident Property by Agency CNA
Penalty
Summary
A certified nurse aide (CNA) employed through an agency took a resident's wallet, which contained $94 in cash and debit cards, from the resident's room without the resident's knowledge or permission. The resident, who had been admitted for therapy following a head injury and was his/her own responsible party, discovered the theft after noticing unauthorized transactions on his/her bank account, including payments to a car loan company, an internet and cable provider, and a retail store. The CNA had been assigned to provide care to the resident during the time the theft occurred. Upon discovering the missing wallet and unauthorized charges, the resident notified facility staff, who confirmed the theft through interviews and review of bank records. The police were contacted, and an investigation revealed that the CNA used the resident's debit card to make the unauthorized purchases. The CNA was identified as the individual responsible for the misappropriation of the resident's property.
Resident Subjected to Verbal and Mental Abuse by Dietary Aide
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member, specifically a Dietary Aide. The incident occurred when the Dietary Aide became upset with the resident over the disposal of banana peels and salsa. The resident requested to keep these items for composting, but the Dietary Aide insisted on discarding them, citing facility protocol. This disagreement escalated when the Dietary Aide threw a ceramic plate at the wall behind the resident, causing it to shatter, and verbally abused the resident by calling them a derogatory name. The resident involved in the incident was cognitively intact and had a history of heart failure, arthritis, respiratory diseases, and depression. The resident was mobile with assistance and required help with activities of daily living. During the incident, the resident was seated in a wheelchair in the dining room when the Dietary Aide threw the plate over their head, which shattered upon impact with the wall. The resident did not anticipate the Dietary Aide's anger or the subsequent actions. Multiple staff members, including CNAs and an RN, witnessed the aftermath of the incident, hearing the crash and the verbal abuse. The Dietary Aide admitted to the actions and the verbal abuse in a written statement. The facility's abuse policy, which mandates immediate reporting and investigation of abuse allegations, was not effectively upheld in preventing the incident, although it was followed in the aftermath.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper hand hygiene and gloving practices during food service, leading to potential contamination. Observations revealed that dietary aides did not change gloves or wash hands between tasks, such as handling soiled dishes and serving food. Instances included touching residents and their belongings, handling food with soiled gloves, and consuming personal food items in food preparation areas. These actions were contrary to the facility's policies, which required handwashing and glove changes between tasks. Food storage practices were also inadequate, with open bags of food items not being properly sealed, leading to potential contamination. Observations in the kitchen dry storage room and walk-in freezer showed open bags of pancake mix, chicken, potatoes, and manicotti, which were not securely sealed. The Dietary Manager acknowledged the expectation for staff to properly seal, label, and date food items, and to discard expired items. The facility's ice and beverage machines were found to be unclean, with accumulations of debris and inadequate air gaps at the ice machine drains, posing a risk of backflow contamination. Additionally, the dishwashing machines were not operated according to the manufacturer's specifications, with inadequate water temperatures and lack of proper monitoring of sanitizer levels. Staff were unaware of the required operating parameters, leading to improper sanitization of dishware.
Resident Rights Not Easily Accessible
Penalty
Summary
The facility failed to ensure that residents were aware of their posted rights in an easily accessible area. During a group interview, seven residents reported that they did not know where the resident rights were posted. Observations revealed that the resident rights were posted along a wall around the corner from the nursing station, near an exit door, and in locations not frequently traveled by residents in wheelchairs. The same issue was noted on the second and third floors of the facility. Interviews with staff, including a Registered Nurse (RN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, confirmed that the resident rights were not posted in areas easily accessible or visible to residents. The RN and ADON were unable to identify the location of the posted rights without assistance, and the Administrator believed the location was in a high traffic area, despite evidence to the contrary.
Inaccessible Resident Rights Information
Penalty
Summary
The facility failed to protect resident rights by not providing accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency. The facility's policy on filing grievances or complaints, revised in April 2017, states that residents and their representatives have the right to file grievances either orally or in writing. However, during a group interview, seven residents expressed that while they were aware of the Ombudsman program, they did not know who their representative was or how to contact them. Additionally, they were unaware of how to contact the State Survey Agency if they had concerns. Observations revealed that the resident rights poster, which included the Ombudsman program number, was placed in a location that was not easily accessible or visible to residents, particularly those in wheelchairs. The poster was located around the corner from the nursing station, near an exit door, and not in a frequently traveled area. Similarly, the State Survey Agency hotline number was posted in a small picture frame above an automated defibrillator, making it difficult for residents to read. Interviews with facility staff, including a Registered Nurse, the Assistant Director of Nursing, the Director of Nursing, and the Administrator, confirmed that the information was not posted in high-traffic areas, making it challenging for residents to access the necessary contact information.
Deficiency in Safe Wheelchair Transportation
Penalty
Summary
The facility failed to ensure the safe transportation of residents in wheelchairs, as observed in multiple instances involving six residents. The deficiency was noted during observations where staff members transported residents without using footrests on their wheelchairs. This practice was observed with several residents, including those with severe cognitive impairments, impaired mobility, and a history of falls. For instance, Resident #26, who has severe cognitive impairment and a history of falls, was transported multiple times without footrests, causing their feet to drag or hover just above the floor. Similarly, Resident #27, who requires supervision or touch assistance for transfers and uses a manual wheelchair, was observed being pushed without footrests, with their toes pointed downward and close to the floor. Staff did not instruct the resident to lift their feet, which could lead to potential injury. Other residents, such as Resident #25 and Resident #4, were also transported without footrests, despite their care plans indicating the need for assistance due to impaired mobility and balance. Interviews with staff members, including CNAs and the Director of Nursing, revealed a lack of consistent practice regarding the use of footrests. Some staff members acknowledged that residents should not be pushed without footrests, while others mentioned that residents who self-propelled did not like footrests as they interfered with their ability to get close to tables. The Director of Nursing confirmed the expectation that staff should use footrests when transporting residents, highlighting a gap between policy and practice.
Inadequate Bed Rail Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that bed rail assessments were consistent with its policy, which requires evaluating residents' risk for entrapment and conducting ongoing assessments to ensure the proper use and safety of bed rails. This deficiency was identified for eight residents out of a sample of 20, in a facility with a census of 49. The facility's policy mandates that bed rails should only be used after attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. However, the assessments conducted did not evaluate the residents for risk of entrapment as per the facility's policy. For Resident #12, the bed rail evaluation did not specify the type of assessment and failed to evaluate the resident's risk of entrapment. The resident, diagnosed with multiple sclerosis and weakness, was dependent on staff for mobility and transfers, yet the evaluation indicated no risk associated with bed rail use. Similarly, Resident #102, with a history of falls and balance issues, had an assessment that did not address the risk of entrapment, despite the resident's reliance on assist rails for positioning and support. Other residents, such as Resident #24 and Resident #25, also had incomplete evaluations that did not assess the risk of entrapment. These residents had histories of falls and required assistance for mobility, yet their evaluations did not comply with the facility's policy. The facility's failure to conduct thorough assessments and ongoing evaluations as required by their policy led to the deficiency identified by the surveyors.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, affecting eight residents out of a sample of 20. Staff did not utilize Enhanced Barrier Precautions (EBP) during personal care for residents with urinary catheters, and there was a lack of signage and personal protective equipment (PPE) to indicate the need for EBP. Specifically, staff did not wear gowns while providing care to residents with catheters, and catheter tubing was observed on the floor, which is against the facility's policy. Interviews with staff revealed a lack of understanding and awareness of EBP requirements, and the facility's policy did not align with current CDC guidelines. Additionally, the facility did not ensure proper hand hygiene and glove use during incontinence care for a resident. A CNA was observed not washing hands before care, using multiple pairs of gloves without changing them appropriately, and failing to sanitize hands between tasks. This was contrary to the facility's hand hygiene policy, which requires handwashing before and after resident contact and when changing gloves. The facility also failed to properly store nebulizer and CPAP masks for residents, as these were left uncovered on bedside tables. This was not in accordance with the facility's policy, which requires such equipment to be stored in a plastic bag when not in use. Furthermore, during a medication pass, a CMT handled pills with bare hands after they fell into a medication drawer, which is against the facility's medication administration policy. The DON confirmed that medications should be discarded if they fall out of their packaging.
Failure to Inspect Bed Safety Equipment
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which are crucial for identifying potential entrapment risks. This deficiency affected eight residents out of a sample of 20, with the facility's total census being 49. The facility's policy mandates that maintenance staff routinely inspect all beds and related equipment to identify risks, including potential entrapment risks, and report the results to the administrator and the QAPI committee. However, the report indicates that there was no documentation of such inspections being conducted for the residents involved. Several residents, including those with cognitive impairments and mobility issues, were found to have bed rails in the raised position without evidence of routine inspections for entrapment risks. For instance, Resident #12, who was cognitively intact but had impairments in range of motion, had assist rails raised on both sides of the bed, yet there was no documentation of routine inspections. Similarly, Resident #102, who required assistance for bed mobility and transfers, had assist rails raised, but again, no documentation of inspections was found. Interviews with facility staff revealed a lack of awareness and execution of the required inspection protocols. The Maintenance Director admitted that no assessments, including measurements of bed frames, mattresses, or side rails, had been completed since a previous staff member left. The Director of Nursing and the Administrator also confirmed that there had been no ongoing assessments for risk of entrapment, highlighting a systemic failure in adhering to the facility's bed safety policy.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide two residents, or their responsible parties, with a bed hold policy at the time of their transfer to the hospital. For Resident #4, the transfer occurred due to uncontrolled back pain, and although the responsible party was notified of the clinical situation and transfer, there was no documentation that the bed hold policy was provided. The resident was readmitted to the facility after a week, but the lack of documentation regarding the bed hold policy remained. Similarly, Resident #26 was transferred to the hospital for extreme leg pain and later returned to the facility with a diagnosis of hip pain. However, the resident was sent back to the hospital after a misread x-ray revealed a hip fracture. Again, there was no documentation that the bed hold policy was provided during these transfers. Interviews with the Director of Nursing and the Administrator revealed uncertainty about the timing of issuing the bed hold policy, although it was acknowledged that the policy should be provided with every hospital transfer.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to review and provide a baseline care plan to two residents within 48 hours of their admission, as required by their policy. Resident #202, who was admitted with conditions such as acute and chronic respiratory failure, chronic heart failure, COPD, and obstructive sleep apnea, did not have the baseline care plan explained or provided to them. The resident and their spouse confirmed during an interview that they had not received or been explained the baseline care plan. The medical record showed a baseline care plan was started but lacked signatures from both the resident and the staff completing it, and there was no documentation of the plan being offered or refused. Similarly, Resident #207, admitted with a wedge compression fracture, unspecified dementia, and anxiety disorder, also did not receive or have the baseline care plan explained to them. The resident confirmed during an interview that they had not received a copy of the baseline care plan. The medical record indicated that a baseline care plan was started but, like Resident #202, lacked necessary signatures and documentation of the plan being offered or refused. Interviews with various staff members, including an LPN, RN, MDS Coordinator, ADON, and DON, revealed inconsistencies and confusion regarding the responsibility for initiating and completing the baseline care plans. Staff members were unclear about who should sign the care plans and when residents should receive copies. The MDS Coordinator and ADON noted challenges in completing the care plans within the required timeframe, especially during off hours or weekends, which contributed to the deficiency.
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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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near O Fallon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden View Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Delmar Gardens Of O'fallon | 3.7 mi | ★★★★★ | 1 | 0 |
| Sunterra Springs Dardenne Prairie | 4.3 mi | ★★★★★ | 11 | 0 |
| Cottages Of Lake St Louis | 4.9 mi | ★★★★★ | 1 | 0 |
| St Peters Post Acute | 4.9 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.