Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Barnes-jewish Extended Care during CMS and state inspections, most recent first.
Visitation Access Restricted by Locked Front Entrance: The facility did not follow its visitation policy when it locked the front doors at 8:30 P.M. and did not allow visitors to freely enter or exit after that time. Residents and a visitor reported that staff announced visitors had to leave before the doors were locked, and the receptionist confirmed that visitors arriving after 8:30 P.M. were not allowed in unless staying overnight. The CDCS stated there should not be visiting hours and that visitors should have been able to enter at any time.
A resident with multiple pressure injuries and moderate risk for skin breakdown did not consistently receive ordered wound care and offloading interventions. The care plan addressed pressure ulcers and skin risk but did not include a specific intervention to keep heels floated, despite a physician order to float heels at all times for a left heel pressure ulcer. Over several days, surveyors observed the resident repeatedly lying on the back with heels resting directly on the mattress and no heel elevation or protectors, and a sacral dressing with visible drainage that had not been changed since a prior date. CNAs were unaware of special wound instructions beyond keeping the resident clean and dry, while the wound nurse, unit manager, and DON acknowledged expectations that staff follow wound care orders and ensure heel offloading, which was not consistently done.
A resident with a history of stroke, falls, weakness, gait impairment, cognitive communication deficit, paranoid schizophrenia, and anxiety had a care plan calling for the call light to remain within reach. Surveyors repeatedly found the resident in bed with the call light unplugged and placed away from the resident, including at the foot of the bed and on a dresser. Staff said the resident depended on assistance for all ADLs, knew how to use the call light, and was known to pull it off the wall or unplug it; the DON stated it was not acceptable to remove a resident's call light.
Failure to Identify and Document Admission Wounds: Staff did not identify a resident’s burn on admission, and wound treatment orders were delayed for several days. Staff also failed to document another resident’s sacral wound on admission, despite hospital records showing a pressure injury and later wound assessment confirming a stage III coccyx pressure ulcer. The DON stated floor nurses were responsible for admission skin assessments and documenting wounds in progress notes.
Incomplete post-fall neuro checks and missing BP monitoring: Staff failed to complete and document ordered neuro checks after resident falls, and one resident’s chart also lacked required hourly BP/vital sign monitoring and physician notification after an unwitnessed fall. Records for multiple residents showed missing pupil size/reactivity documentation, blank task entries, and incomplete post-fall notes despite physician orders and the facility’s fall protocol.
Failure to maintain hydration needs for a resident with paranoid schizophrenia, anxiety disorder, and BPH. The resident had a fluid restriction order that was later discontinued, but observations showed water placed out of reach while the resident remained in bed, called out for water, and stated being thirsty. Staff interviews confirmed the resident depended on staff for ADLs and often requested drinks, while the DON said staff were expected to offer fluids during care or when entering the room.
Two residents had significant medication errors when ordered meds were repeatedly not administered and the physician was not notified. One cognitively intact resident with diabetes missed multiple insulin lispro doses, including doses documented as not given because the resident was asleep, refused, or with no reason recorded, despite elevated blood sugars and the resident stating he/she had not refused insulin. Another cognitively intact resident with paranoid schizophrenia, anxiety, and BPH had repeated missed doses of clozapine, memantine, diazepam, finasteride, and hydroxyurea because meds were unavailable or not reordered, with staff unaware of the missed doses.
Surveyors found improper medication storage in the facility’s medication room and carts. A controlled substance e-kit drawer was left unlocked when its key broke, with no alternate locked storage in place, and medication room keys were later found in an unlocked drawer at the nurse’s station. Surveyors also found multiple expired OTC medications on a medication cart and in the medication room, while an LPN stated nurse management and the floor nurse were responsible for checking expiration dates.
Failure to Provide Meal Choices and Substitutions: Two residents were not given menus or meaningful meal choices, and substitutions were not consistently offered. One resident with CKD and DM said he/she was told it was too late to request substitutions and denied selecting items on the meal ticket, while another resident with CKD, HTN, and heart disease said he/she was unaware of the Always Available Menu and repeatedly requested coffee that never arrived, despite staff stating residents should be reviewed daily for next-day meal selections.
Infection control failures were observed involving a resident with a PICC line and IV meds, a resident with an indwelling urinary catheter, and uncovered linen carts. An LPN entered the room of the resident on EBP without PPE and touched the IV site, a catheter drainage bag was left hanging on the rim of a trash can instead of being positioned per care plan, and housekeeping staff transported clean linens in uncovered carts despite the facility policy requiring carts to remain covered during transport.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, nor did it always offer appealing meal options, as observed and documented by surveyors.
The facility failed to maintain an infection prevention and control program when staff did not wear appropriate PPE during high-contact activities with residents on enhanced barrier precautions. Multiple instances were observed where staff entered resident rooms without donning gowns or gloves, despite the presence of EBP signs indicating the need for such precautions.
The facility failed to ensure that each resident's care plan accurately reflected their needs and medical conditions upon admission. This deficiency was observed in five residents, including omissions of a g-tube, CPAP device, urinary catheter, PICC line, and wound care for surgical incisions. Staff confirmed that these elements should have been included in the care plans, indicating a lapse in adherence to the facility's Care Planning policy.
The facility failed to ensure that two residents received at least two showers or bed baths weekly. One resident, with cellulitis and wounds, reported not having a shower since arrival, while another resident with a below-the-knee amputation reported only one bed bath. Staff interviews revealed lapses in documentation and adherence to ADL care policies.
The facility failed to ensure a resident received care according to professional standards. The resident had a PICC line and a buttocks wound, but there were no orders for PICC line care, and wound treatments were not completed as ordered. Observations and interviews confirmed these deficiencies.
The facility failed to ensure that a resident admitted with an indwelling urinary catheter had a physician's order for its care. The resident's medical record lacked documentation and orders specifying the catheter's details, despite observations confirming its use. Interviews with staff indicated an expectation for such orders, highlighting a deficiency in following the facility's policy.
A resident experienced significant weight loss due to the facility's failure to provide recommended nutritional interventions and preferred foods. The RD's recommendations were not consistently followed, and nursing staff did not adequately document meal intake. The resident was served inappropriate foods, and there was a lack of communication between nursing and dietary staff.
The facility failed to obtain physician orders for a CPAP machine for a resident and did not ensure proper storage of CPAP masks for two residents. Observations showed improper storage of CPAP masks, and staff interviews revealed inconsistencies in the understanding and execution of proper CPAP mask storage protocols.
A resident with a history of significant health issues expressed suicidal ideation and feelings of depression, but the facility failed to provide necessary behavioral health services and follow-up care. The resident spent most of their time in bed, lacked a wheelchair, and felt isolated and unsupported. The facility did not adequately address the resident's psychosocial needs or document appropriate interventions in the care plan.
The facility failed to store and dispose of expired medications in accordance with professional principles, with expired medications found in one medication room and two treatment carts. Staff interviews revealed inconsistencies in the auditing and removal process, despite facility policies requiring the disposal of expired medications.
Visitation Access Restricted by Locked Front Entrance
Penalty
Summary
The facility failed to follow its Resident Right to Access and Visitation policy and failed to ensure residents could receive visitors when the front entrance was locked at 8:30 P.M. The policy stated residents have the right to receive visitors of their choosing at the time of their choosing, and that the community shall provide 24-hour access to non-relative visitors who are visiting with the resident's consent. During a group interview, three of four resident council representatives said the facility did not allow visitors after 8:30 P.M. and that staff made announcements before that time telling all visitors to leave because the front doors would be locked. A visitor also reported needing to leave before 8:30 P.M. because the facility locked the door, and there were no other access doors for visitors to enter or exit. Observation and staff interviews confirmed the front doors were closed after the receptionist left, and visitors were not allowed after the set time unless they were staying overnight. The receptionist stated overhead announcements were made around 8:00 P.M. and 8:20 P.M. to tell visitors to leave, and if visitors were unable to leave on time they would be escorted out the back door, which was for employee access only. The receptionist also stated that if visitors arrived after 8:30 P.M., they could call the facility but would not be allowed to enter. The Corporate Director of Clinical Services stated there should not be visiting hours and that visitors were allowed to enter the building at any time, with the back door accessible after 8:30 P.M., which conflicted with the practice described by the receptionist.
Failure to Follow Pressure Ulcer Treatment Orders and Offloading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatments and services to promote healing and prevent further breakdown for one cognitively intact resident with multiple pressure injuries. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, and benign prostatic hyperplasia, and was readmitted with intact skin. A Braden Scale score was initially documented as 16 (mild risk) and later recalculated to 13 (moderate risk). The care plan identified the resident as having pressure ulcers and being at risk for skin impairment due to immobility and incontinence, with interventions such as frequent repositioning, keeping the resident clean and dry, use of a low air loss mattress and gel cushion, daily skin checks, and treatments as ordered. However, the care plan did not include an intervention to keep the resident’s heels floated at all times, despite the presence of a left heel pressure injury and a physician order to float the heels. Wound documentation dated 2/24/26 showed three open pressure injuries: an unstageable sacral wound measuring 11 cm by 9.5 cm, a right gluteal pressure ulcer measuring 2.5 cm by 0.8 cm, and a left heel pressure ulcer measuring 3.3 cm by 5.5 cm. Physician orders dated 2/20/26 directed wound care to the buttocks with barrier cream every shift and as needed, and for the left heel to apply skin prep daily and float the heels at all times. Facility policy required use of the wound product selection guide, a physician order for all wound treatments, interventions to reduce pressure such as offloading heels and repositioning, and that all dressings be dated and initialed by the nurse applying the dressing. Multiple observations over several days showed the resident lying on his/her back in bed with heels resting directly on the mattress and no elevation or heel protectors, despite the order to float heels at all times. On one observation, the resident’s head of bed was elevated and the resident had slid down with the head wedged between the mattress and bedrail, and heels still on the mattress. On another observation, a sacral dressing extending down both buttocks was noted with brownish discoloration at the inner edges and dated two days prior; the CNA present was unaware of the drainage and unaware of any special wound instructions beyond keeping the resident clean and dry. The DON confirmed the sacral dressing date and stated she expected staff to follow physician orders and float heels even with an air loss mattress, and the Unit Manager also stated she expected staff to ensure heels were elevated off the surface. The wound nurse reported that both she and floor nurses were responsible for wound care and that wound care tasks could be passed between shifts, indicating shared responsibility for treatments that were not consistently carried out as ordered.
Call Light Left Unplugged and Inaccessible
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident #30 by not ensuring the resident's call light was plugged in and accessible. The resident was admitted with a history of stroke, need for assistance with personal care, falls, generalized muscle weakness, unsteadiness on feet, gait and mobility abnormalities, cognitive communication deficit, paranoid schizophrenia, and anxiety disorder. The care plan identified the resident as high risk for falls and included interventions for the call light to be within reach and for staff to remind the resident to use it. Facility policy required call lights to be available at the bedside, toilet, and bathing areas and for staff to ensure the call light was within reach during interactions. During multiple observations, the resident was found in bed while the call light was unplugged and placed away from the resident, including beside the foot of the bed and later on top of the dresser. At one point the resident was positioned diagonally in bed with the head between the mattress and bedrail and said the call light had been unplugged and that repositioning would make the resident more comfortable. Staff interviews showed the resident depended on staff for all ADLs, knew how to use the call light, and was known to pull it off the wall or unplug it. A CNA and LPN stated the resident often yelled out or screamed for help and that someone may have unplugged the call light because the resident used it excessively. The DON stated staff were expected to follow policy and ensure residents had access to their call lights and that it was not acceptable to remove a resident's call light.
Failure to Identify and Document Admission Wounds
Penalty
Summary
The facility failed to ensure services met professional standards when staff did not identify a resident’s burn on admission, and treatment orders were not obtained for four days. Resident #101 was admitted alert and oriented with diagnoses including UTI, atrial fibrillation, high cholesterol, and anemia. The admission observation dated 2/19/26 did not check burn under alteration in skin. Progress notes over the next several days documented skin as warm and intact, until 2/24/26 when the resident reported a dressing on the left side was peeling off and staff found an old dressing with moderate serosanguineous drainage, mild odor, and a 2nd degree burn on the left flank that the resident said occurred three weeks earlier at home from hot grease while cooking French fries. The physician was then notified and wound care orders were obtained. The facility also failed to identify and document a resident’s wound on admission. Resident #53 was admitted alert and oriented, incontinent of bowel and bladder, with diagnoses including partial blindness, hypertension, and a stage III pressure ulcer of the sacral region. The admission observation dated 2/20/26 was blank, and the initial nursing note documented a wound on the back of the neck but did not document a sacral wound. Subsequent notes first referenced a sacrum area on 2/22/26, then described a sacrum pressure injury noted in the hospital and a wound consult on 2/23/26, with the resident refusing assessment that day. Hospital records showed a sacrum pressure injury documented on 2/17/26 as a deep tissue pressure injury, with recommendations for barrier treatment. The wound doctor’s initial assessment on 2/24/26 identified the wound as a stage III pressure injury to the coccyx, measuring 1.3 cm by 7 cm by 0.1 cm, and noted the original cause as pressure injury with a date acquired of 2/20/26. Interviews with the Wound Nurse, Unit Manager, and DON indicated the floor nurse was responsible for admission and skin assessments, and the DON stated staff should document bruises, rashes, or wounds and include wound descriptions in progress notes.
Incomplete Post-Fall Neuro Checks and Missing BP Monitoring
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards when staff did not complete and document required neuro-checks after resident falls for four of six sampled residents. The facility’s Fall Management/Reduction Program policy stated that post-fall evaluations and neuro checks were to be completed after resident falls, with neuro checks required at specific intervals for unwitnessed falls or witnessed falls in which the head was struck. The record also showed that nurses were expected to document in the medical record for 72 hours after a fall to describe the resident’s post-fall condition, injury, and interventions. For one resident with diagnoses including cancer, unsteadiness on feet, muscle weakness, and cognitive communication deficit, the record showed an unwitnessed fall from bed and a physician order for neuro checks at set intervals, but only one neuro check was documented and no other required neuro checks were found. The same resident also had a physician order to monitor blood pressure and vital signs hourly and notify the physician if blood pressure declined further, but the chart did not show hourly blood pressure documentation, physician notification when blood pressure changed from 97/68 to 87/62, or documentation that the hourly monitoring order was discontinued. The resident’s record also showed multiple blood pressure readings over the following days, including 98/61 and 90/61, without documentation that the physician was notified. For another resident with dementia, glaucoma, diabetes, and chronic urinary retention with an indwelling catheter, the record showed a fall in the dining room and a physician order for neuro checks initially and then every shift for 72 hours. The record did not reflect pupil size and reactivity as required. A third resident with high cholesterol, hypertension, hypothyroidism, peripheral arterial disease, and multiple fractures from a motor vehicle collision had a fall documented as unwitnessed, but the record failed to reflect pupil size and reactivity for the ordered neuro checks. A fourth resident with acute kidney failure, dementia, muscle weakness, unsteadiness on feet, and epilepsy had a fall with a physician order for neuro checks and monitoring for bruising, mental status changes, pain, or other injuries, but the record showed missing documentation for the ordered neuro checks and incomplete monitoring entries after the fall.
Failure to Maintain Hydration Needs
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for one resident who was cognitively intact and had diagnoses including paranoid schizophrenia, anxiety disorder, and benign prostatic hyperplasia. The resident's care plan identified risk for weight loss and included interventions related to meals and supplements, but did not address hydration needs. The facility's nursing policy stated that water should be within reach during AM and PM care and that fluid intake should be offered and encouraged with care. The resident had a physician-ordered 1500 cc/day fluid restriction that was initiated after staff reported excessive water intake and uncertainty about how much the resident was drinking. The order was later discontinued, and the physician noted the resident no longer needed fluid restriction. During observations, the resident was repeatedly found in bed with the call light unplugged and water placed out of reach on a bedside table or elsewhere in the room, while the resident was heard asking for water and saying he or she was thirsty. Staff interviews showed the CNA knew the resident depended on staff for all ADLs and that the resident was on fluid restriction, and an LPN stated the resident often yelled out because he or she wanted something to drink and was given sips of water throughout the day. The DON stated staff were expected to follow policy and ensure dependent residents received proper hydration by offering fluids during care or when entering the room.
Missed and Unreported Medication Doses
Penalty
Summary
The facility failed to ensure two residents were free from significant medication errors when medications were not administered as ordered and the physician was not notified when doses were missed. The report cites the facility’s medication administration policy, which required medications to be given according to physician orders, documented after administration, reordered when supply was low, and escalated to the nursing supervisor or physician if unavailable. The medication-related error policy defined medication errors as departures from accepted standards of practice and stated that when an error was discovered, the employee noting it must notify the supervisor, physician, resident, and, when applicable, the resident’s representative. One resident was cognitively intact and had diagnoses including diabetes, hypertensive heart disease, chronic kidney disease with heart failure. The resident had an order for insulin lispro three times daily with meals, with sliding-scale instructions based on blood sugar results. The MAR showed insulin was not administered on multiple occasions, including one instance because the resident was asleep, one because the resident refused, and one with no reason documented. The record also showed elevated blood sugar readings of 456, 413, and 401 on separate dates. During interview, the resident stated he/she had never refused insulin and understood how important it was. An LPN said residents should receive insulin as ordered and did not know why it was not administered, and the Unit Manager stated he/she was not aware the resident missed insulin. The second resident was cognitively intact and had diagnoses including paranoid schizophrenia, anxiety disorder, and benign prostatic hyperplasia. The resident had orders for clozapine, memantine, diazepam, finasteride, and hydroxyurea. The MAR showed repeated missed doses of clozapine, memantine, diazepam, finasteride, and hydroxyurea, with reasons such as medication unavailable, resupply, or reorder. The report also noted that the facility’s e-kit contained only five finasteride tablets and no other medications. Pharmacy records showed some medications were sent, but there were gaps, suspensions, and no documented reasons for some delays. Staff interviews indicated that unavailable medications should be checked in overflow or the e-kit, the pharmacy should be contacted, and the physician and resident representative should be notified if medications were refused or missed; however, the Unit Manager stated he/she was not aware the resident’s medications were unavailable, and the DON stated staff were expected to follow physician orders and facility policy.
Improper Storage of Controlled Substances and Expired Medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted standards of practice. Surveyors found that both medication rooms, five medication carts, and one treatment cart were checked, and issues were identified in one medication room and two medication carts. In the medication room, the controlled substance e-kit drawer was unlocked because the key had broken off the day before, and there was no alternative lock or locked container in place while waiting for a replacement key. The medication room door was locked, but the controlled substances drawer remained unlocked until the key was replaced later. During a later observation, the medication room key was found in an unlocked drawer at the nurse’s station, and the medication room and controlled substances drawer were opened using that key set. Surveyors also found expired over-the-counter medications stored on the third floor medication cart and in the third floor medication room. The cart contained multiple opened bottles of acetaminophen, vitamin B-12, sodium chloride, oyster shell calcium, aspirin extended release, Geri-Dryl, and a high potency multivitamin, each with expiration dates ranging from 7/2025 to 12/2025. The medication room contained three opened bottles of Ferric X-150 with an expiration date of 2/2026. An LPN stated that nurse management and the floor nurse were responsible for checking expiration dates on the medication carts. The DON stated she expected staff to follow facility policies and procedures on proper medication storage, including double-locking controlled substances.
Failure to Provide Meal Choices and Substitutions
Penalty
Summary
The facility failed to provide meal choices and failed to offer substitutions for two residents. The posted menu for 3/2/26 through 3/5/26 showed limited breakfast variety, with scrambled eggs listed for three of four days and oatmeal and grits alternating, and it did not include information about evening snack availability or choices. The facility's substitution/Always Available Menu listed items such as cheeseburgers, hot dogs, chicken tenders, grilled cheese, deli sandwiches, salads, fruit, and beverages, but the report states residents were not given menus or offered substitutions as expected. Resident #2 was admitted on 2/1/26 with chronic kidney disease and diabetes and had a care plan noting risk for weight loss and a goal to meet 75 to 100% of needs for the majority of admission. The resident said he/she did not receive a menu and sometimes was told it was too late to request a substitution because the kitchen was closed, so he/she saved half of the morning sandwich to eat later. Although dietary staff said they met with residents and completed meal tickets for the next day, Resident #2 denied giving input on the meal ticket and said items such as brussels sprouts and brown rice were marked even though he/she disliked them and would not eat them. Resident #128, admitted on 3/3/26 with chronic kidney disease, high blood pressure, and heart disease, said he/she had not been given a menu or informed about the Always Available Menu, wanted coffee at breakfast and in the evening, and had repeatedly asked for coffee but did not receive it. At breakfast, the resident received a tray with pancakes, scrambled eggs, oatmeal, and juice, but no coffee, and said he/she would have chosen cold cereal if given the option.
Infection Control Failures With EBP, Catheter Bag Positioning, and Linen Transport
Penalty
Summary
The facility failed to follow infection prevention and control standards by not implementing Enhanced Barrier Precautions for a resident with a PICC line and IV medications. The resident had diagnoses including infection following a procedure with surgical site and squamous cell carcinoma, and the care plan identified the resident as being on EBP isolation due to the PICC line. During observation, the resident’s IV pump was beeping, and an LPN entered the room without PPE, adjusted the IV tubing, and touched the resident’s IV site. The facility also failed to position an indwelling urinary catheter drainage bag appropriately for a resident with multiple myeloma, diabetes, and urinary retention. The care plan directed staff to position the bag below bladder level and store the collection bag inside a protective dignity pouch. During observation, the resident was sitting in a wheelchair eating lunch, and the catheter drainage bag was not inside a protective dignity pouch and was hanging on the rim of the trash can next to the resident. In addition, clean linens were transported in uncovered carts to hall linen closets. Housekeeping staff were observed pushing uncovered linen carts in the hallway and to multiple linen closets, and one cart was later pushed to the elevator while still uncovered. The facility’s linen policy required clean linen carts to be covered on the top, bottom, and all four sides during transportation, and the DON stated staff were expected to follow facility policies and procedures.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always provided with meals that met their specific dietary needs or preferences, as required.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program when staff did not wear appropriate personal protective equipment (PPE) during high-contact activities with residents on enhanced barrier precautions (EBP). Multiple instances were observed where staff entered resident rooms without donning gowns or gloves, despite the presence of EBP signs indicating the need for such precautions. This included activities such as administering IV medication, checking blood sugar, providing bed baths, and transferring residents, all of which are considered high-contact activities requiring PPE according to the facility's policy and CDC guidelines. For example, a Licensed Practical Nurse (LPN) was observed administering IV medication to a resident with a peripherally inserted central catheter (PICC) without wearing a gown or gloves. Similarly, a Registered Nurse (RN) and a Certified Nurses Assistant (CNA) were seen performing skin observations and bed baths without the required PPE. Another CNA was observed adjusting a resident's clothing and checking for wetness without gloves, and then handling soiled linens and entering another resident's room without sanitizing hands. Interviews with staff revealed a lack of consistent understanding and adherence to the EBP policy. Some staff members believed that gowns and gloves were only necessary for certain types of care, while others were unaware of the need to sanitize equipment and hands between resident interactions. The Director of Nursing (DON) confirmed that all staff had been educated on the use of gowns and gloves during high-contact activities, but observations indicated that this education was not effectively implemented. The facility's failure to enforce its EBP policy compromised the infection control program and increased the risk of transmission of multidrug-resistant organisms (MDROs).
Failure to Accurately Reflect Residents' Needs in Care Plans
Penalty
Summary
The facility failed to ensure that each resident's care plan accurately reflected their needs and medical conditions upon admission. This deficiency was observed in five out of seventeen sampled residents. Resident #199's care plan did not include the presence of a gastrostomy tube (g-tube) despite the resident receiving medications and nutrition through it. Similarly, Resident #299's care plan omitted the use of a continuous positive airway pressure (CPAP) device, which was necessary for treating sleep apnea. Resident #298's care plan failed to mention an indwelling urinary catheter, and Resident #301's care plan did not identify the use of a peripherally inserted central catheter (PICC) line. Lastly, Resident #248's care plan did not include wound care for surgical incisions on the right foot, despite the resident being admitted for rehabilitation and wound healing. Observations and interviews with staff confirmed these omissions. For instance, Resident #199 was observed with an enteral tube feeding infusing, and the resident confirmed the use of the g-tube for medications and nutrition. Staff members, including a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN), acknowledged that the g-tube should have been included in the care plan. Similarly, Resident #299's CPAP device was observed on the headboard, and staff confirmed that it should have been listed in the care plan. Resident #298 was observed with an indwelling urinary catheter, and staff confirmed that it should have been included in the care plan. Resident #301 was observed with a PICC line, and staff confirmed that it should have been included in the care plan. Resident #248's care plan did not include wound care for surgical incisions on the right foot, despite the resident being admitted for rehabilitation and wound healing. Interviews with the Director of Nursing (DON) and other staff members revealed that the responsibility for developing care plans lies with the Nurse Managers and the facility MDS Coordinator. The DON confirmed that baseline care plans should include all immediate needs, such as fall risks, skin conditions, and any medical devices or treatments required by the residents. The failure to include these critical elements in the care plans indicates a lapse in the facility's adherence to its Care Planning policy, which mandates the completion of initial care plans within 48 hours of admission.
Failure to Provide Required ADL Care
Penalty
Summary
The facility failed to ensure that two residents' Activities of Daily Living (ADL) needs were met by not providing at least two showers or bed baths weekly. Resident #248, who was cognitively intact and had diagnoses including cellulitis and wounds on the coccyx and right heel, was observed with greasy hair and reported not having had a shower or bed bath since arrival. Although an LPN claimed the resident received a bed bath, it was not documented. Resident #249, also cognitively intact and with a below-the-knee amputation, reported receiving only one bed bath since admission and expressed feeling dirty. The facility's documentation confirmed only one shower for this resident, and the DON mentioned a history of ADL care refusal, although no refusals were documented for this period. Interviews with staff, including a CNA and the DON, revealed that showers and refusals should be documented in the resident's chart. The DON expected all residents to receive at least two showers or bed baths weekly and for nursing staff to document these activities. The failure to document and provide the required ADL care led to the deficiency noted in the report.
Failure to Follow Professional Standards of Practice for Resident Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, admitted from the hospital, had an open area on the buttock and a double lumen peripherally inserted central catheter (PICC) in the right side of the neck. There was no order for the PICC line dressing change, flushing, or care. Additionally, the facility staff did not complete treatment orders and apply dressing changes as ordered to the buttocks wound. Observations showed that the dressing over the PICC line was dated 5/14/24, and the wound on the buttocks was not treated as per the physician's orders on multiple occasions. The facility's policies required licensed nurses to perform infusion therapy and wound care according to state law and facility policy, with a prescriber's order needed for accessing, flushing, or locking a catheter. However, the resident's electronic medical record showed no order for the PICC line care. Interviews with the RN and the Director of Nursing confirmed that the resident should have had orders for the PICC line, including flushing, dressing change, and monitoring, and that wound treatments should be performed per physician's orders. Despite these requirements, the facility staff failed to follow the prescribed treatments for the resident's buttocks wound and PICC line care.
Failure to Obtain Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling urinary catheter had a physician's order to provide care for the catheter. The resident's electronic medical record and information card did not indicate the presence of the catheter, nor was there an order specifying the catheter's size, diagnosis, balloon size, routine for changing, and monitoring output. The resident's diagnoses included sleeplessness, seizure, bipolar disorder, and neurogenic bladder. Despite these conditions, the necessary documentation and orders for the catheter were missing. Observations confirmed the use of the indwelling urinary catheter, which was attached to the resident's bedrail. Interviews with a Registered Nurse and the Director of Nursing revealed that both expected to see a physician's order for the catheter, including specific details about its management. The absence of such an order indicates a failure to follow the facility's policy on obtaining and processing physician orders, leading to a deficiency in the care provided to the resident.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in significant weight loss. The resident experienced a weight loss of -10.35% from July 2023 to January 2024. Despite the Registered Dietician (RD) completing two nutritional assessments and noting a decline in the resident's meal intake, no additional nutritional interventions were recommended. The resident was not served fortified cheesy eggs as recommended by the RD, and the RD's recommendation for fortified pudding was not added to the resident's meal ticket. Additionally, nursing staff failed to consistently chart the resident's meal intake, which is reviewed during the RD's nutrition assessments, and the resident was not served preferred foods at meals. The resident's medical record showed multiple diagnoses, including Multiple Sclerosis, autoimmune hepatitis, hypothyroidism, high blood pressure, GERD, and depression. The resident had physician orders for fortified foods and nutritional shakes, but these were not consistently provided. The resident's weights showed a significant decline over several months, and the resident's meal intake documentation was often missing or incomplete. Observations revealed that the resident was served inappropriate foods, such as raw baby carrots and large steamed broccoli florets, which were not suitable for the resident's mechanical soft diet. The resident's food preferences, such as bananas and frosted flake cereal, were not consistently provided. Interviews with staff indicated a lack of communication and coordination between nursing and dietary staff. The RD and dietary staff were not aware of the resident's food preferences, and the facility did not have certain preferred foods in stock. The RD noted that the facility had stopped making fortified cheesy eggs and was in the process of identifying other options. The resident's care plan did not reflect the significant weight loss, average meal intake, or the RD's recommendations for additional nutritional interventions. The facility's policies and procedures for nutritional interventions were not followed, leading to the resident's continued weight loss and inadequate nutritional intake.
Failure to Obtain Physician Orders and Properly Store CPAP Masks
Penalty
Summary
The facility failed to ensure physician orders were obtained for the use of a CPAP machine for one resident and to ensure CPAP masks were properly stored while not in use for two residents. Resident #299 had a diagnosis of obstructive sleep apnea and used a CPAP machine, but there was no physician's order for the CPAP on admission, and the CPAP device was not listed on the resident's baseline care plan. Observations showed the resident's CPAP tubing and mask were improperly stored, and interviews with staff indicated that the resident was responsible for the CPAP machine's care, but there was no clear protocol for mask storage when not in use. A new order for the CPAP was obtained later during the survey period. The Director of Nursing confirmed that there should have been an order for the CPAP machine upon admission. Resident #146, who had diagnoses including COPD and obstructive sleep apnea, had physician orders for CPAP use and cleaning, but observations showed the CPAP mask was consistently stored improperly, uncovered, and without a barrier, either on the nightstand or in an open drawer. The resident was unsure about the cleaning and storage protocol for the CPAP mask, and staff interviews revealed inconsistencies in the understanding and execution of proper CPAP mask storage. The Director of Nursing and Administrator stated that either the resident or nursing staff should rinse off the mask and store it in a bag, and it was expected that CPAP use be indicated on a resident's care plan. However, this was not consistently followed, leading to the deficiencies noted in the report.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to maintain the highest practicable psychosocial well-being for a resident who expressed feelings of being better off dead and thoughts of unplugging their left ventricular assist device (LVAD). The resident, who had a history of stroke, heart disease, and other significant health issues, was admitted to the facility and had been receiving antidepressant medication. Despite expressing suicidal ideation and feelings of depression during a quarterly assessment, the facility did not follow up adequately with behavioral health services or counseling. The Social Services Coordinator (SSC) reported the resident's suicidal thoughts to a nurse, who then informed the Nurse Practitioner (NP) and sent the resident to the hospital for a psychiatric evaluation. However, the resident did not receive consistent follow-up care or counseling upon returning to the facility. The resident's medical record showed no therapy assessments after a certain date, and there was no documentation of social services follow-up between the initial report of suicidal ideation and the time of the survey. Observations revealed that the resident spent most of their time in bed, lacked a wheelchair to leave their room, and felt sad and isolated. Interviews with staff indicated that the resident's requests for a wheelchair and therapy were not addressed, and the resident did not receive regular counseling or social services support. The resident expressed a desire to be more active and engaged but felt restricted by the facility's limitations and lack of support. The Director of Nurses (DON) and Administrator acknowledged that the resident's feelings of sadness and suicidal ideation should have been followed up with appropriate interventions and documented in the care plan. However, there was no evidence of a coordinated effort by the facility's department heads to address the resident's psychosocial needs. The resident's care plan did not identify their reported feelings of depression, suicidal ideation, or activities of interest, indicating a significant deficiency in the facility's provision of necessary behavioral health services.
Failure to Properly Store and Dispose of Expired Medications
Penalty
Summary
The facility failed to store medication and medical equipment in accordance with professional principles, specifically regarding the expiration dates on stock medications in the medication rooms and medication carts. Observations revealed expired medications in one of two medication rooms and in two of six treatment carts. Specific expired medications included SunMark gentle laxative, HealthStart melatonin supplement, Rugby meclizine, SunMark mucus relief guafenesin, Amneal Folic Acid, GeriCare Oyster Shell Calcium, GeriCare Ferric X-150, GeriCare Magnesium Oxide, NorthStarX Omeprazole, and GeriCare Milk of Magnesium. These medications were found to be expired by several months, indicating a lapse in the facility's adherence to its Pharmacy Services and Procedures Manual, which mandates the removal and proper disposal of expired medications. Interviews with facility staff, including an LPN, a CMT, the DON, and the Administrator, revealed inconsistencies in the auditing and removal process of expired medications. While a facility pharmacy representative was reported to check the medication rooms and carts periodically, staff were unsure of the regularity and thoroughness of these audits. The facility's policy expects nursing staff to remove and dispose of expired medications, but the presence of expired medications in multiple locations suggests that this policy was not effectively implemented or monitored. The DON and Administrator confirmed their expectation that expired medications should be discarded and not administered to residents, highlighting a gap between policy and practice.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcknight Place Extended Care | 1.8 mi | ★★★★★ | 0 | 0 |
| Monarch Springs Wellness & Rehabilitation | 2.4 mi | ★★★★★ | 3 | 0 |
| U-city Forest Manor | 2.4 mi | ★★★★★ | 5 | 0 |
| Oak Park Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Lutheran Convalescent Home | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.