Below 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 Blue Circle Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to label insulin pens according to its own insulin labeling and storage policy, which required dating and resident identification when insulin is removed from refrigeration and a 28‑day limit after opening. During observation of a medication cart, an LPN showed surveyors a drawer containing 10 insulin pens in use, all with stickers for documenting the date opened and expiration date. Nine pens, including insulin aspart, insulin degludec, Lantus, and Humalog, lacked both the date opened and expiration date. The LPN stated that insulin pens should be labeled when removed from the refrigerator and acknowledged not knowing when the unlabeled pens had been opened or placed on the cart, while the administrator and DON reported they expected staff to follow the insulin labeling and storage policy.
Staff failed to follow a resident’s care plan and transfer requirements when a CNA and an LPN used a gait belt and underarm hold to transfer a dependent, cognitively impaired resident with hemiparesis/hemiplegia, despite documentation in the Kardex and staffing book that the resident required a Hoyer lift with assist x2 due to poor balance, unsteady gait, stroke-related deficits, dementia with impulsivity, and impaired decision making. During the observed transfer, the resident was lifted from a wheelchair, stood with bent knees and on toes, verbally expressed slipping and requested to be put down, and was then pivoted into bed with one foot twisting on the floor. The facility’s visual cue system for transfer status was incomplete, as no required color sticker indicating Hoyer transfer was present on the resident’s name plate, even though leadership confirmed that a Hoyer lift, not a gait belt, was required for this resident.
CMTs failed to administer prescribed nutritional supplements and ensure correct dietary items, such as whole milk, to several residents with significant medical needs, despite documentation indicating otherwise. Observations and staff interviews revealed that supplements were not provided as ordered, menu slips were not followed, and staff did not communicate or correct discrepancies, resulting in residents not receiving necessary nutritional support.
The facility used expired COVID-19 tests to test employees and residents, failing to ensure the quality of laboratory services. The tests, with lot number CP23B69, had an expired date, and the facility mistakenly believed a waiver extended their use. The Quality Control Lab Manager confirmed no further extension was applicable, and the tests should have been discarded. This issue was identified during observations and interviews with facility staff.
The facility failed to ensure recipes were followed during meal preparation, as observed in one meal service. Staff members prepared meals without using the prescribed recipes, resulting in incorrect ingredient proportions. Interviews revealed a lack of awareness and adherence to recipe usage, despite the administrator's expectation that recipes should be followed. This deficiency could impact the nutritional needs of residents.
The facility failed to reconcile resident trust accounts with bank statements for 12 months, only including RFMS statements without proper documentation. The BOM lacked full training due to the previous BOM's passing, and the administrator expected accurate and timely reconciliations.
The facility failed to provide a safe, clean, and homelike environment for residents, as evidenced by malodorous conditions due to unlaundered linen, drafts from poorly sealed air conditioners, and damaged furniture. Residents experienced discomfort from these conditions, and the facility did not address these issues promptly.
The facility failed to meet the ADL care needs of several residents, resulting in issues such as unclean nails, untrimmed facial hair, and inadequate repositioning and toileting. Observations revealed residents with soiled briefs, cracked lips, and strong body odors, indicating lapses in personal hygiene and care. Staff interviews highlighted inconsistencies in care documentation and adherence to care plans.
Several deficiencies in medication administration were observed, including a CMT failing to properly administer eye drops by not pulling down a resident's eyelid, a nurse not priming insulin pens for two residents, and a CMT leaving a resident unattended with medications in the therapy gym. These actions indicate lapses in following proper pharmaceutical protocols.
The facility failed to secure medications stored in the ADON's office, which was not designated as a medication storage room. The office contained multiple over-the-counter medications, including an open and unlabeled bottle of magnesium citrate, and was frequently observed with the door open and no staff present, allowing medications to be visible and accessible from the hallway. Interviews confirmed that the office should be locked if medications are stored there, but it was only locked at night.
The facility experienced a malfunction in the call light system affecting multiple residents, including two specific residents with cognitive impairments and mental health conditions. The system's failures led to delays in staff response, with issues such as 'ghost lights' and incorrect room indications on the console. Despite staff awareness, communication and resolution were inadequate, and temporary measures like bells were not effectively communicated to all staff.
A resident with cognitive impairment and dependent on staff for daily activities was not assisted out of bed as per their preference and physician's order due to the unavailability of a Hoyer lift pad. Despite the resident's care plan requiring the use of a mechanical lift, staff did not obtain another pad or notify the DON to resolve the issue, resulting in the resident remaining in bed with meals served at the bedside.
A resident with severe cognitive impairment was exposed to the hallway during care when a CNA failed to close the door and pull the privacy curtain. Despite facility protocols emphasizing privacy, the door remained open even after a Nurse Manager's visit. Interviews with staff, including an LPN and the DON, confirmed the expectation of maintaining resident privacy, highlighting a deficiency in practice.
A resident was immediately discharged after a minor altercation with another resident, despite the absence of severe behaviors or injuries. The facility cited the resident's care needs exceeding capacity, but failed to provide the required 30-day notice or adequate documentation. Staff had mixed observations about the resident's behavior, and the discharge did not align with state and federal regulations.
A facility failed to notify the Ombudsman after an immediate discharge of a resident following a resident-to-resident altercation. The resident, with a history of dementia and aggression, was discharged due to safety concerns. The facility's policy requires Ombudsman notification, but this was not done promptly.
A facility failed to complete a DA-124 Level 1 PASRR screen for a resident with multiple medical conditions, including stroke-related issues and bipolar disorder. The Business Office Manager could not locate the necessary documentation and was unable to obtain it from the Missouri Central Office Medical Review Unit. Interviews revealed that the Admission Coordinator was responsible for obtaining the PASRR pre-screening, but the required documentation was not provided by the survey's exit date.
A resident with aphasia and dementia was not provided with a communication board as required by their care plan, leading to diminished ability to communicate needs. Observations showed the absence of the board, and staff interviews revealed a lack of awareness and adherence to the care plan.
The facility failed to follow physician's orders for a resident's blood glucose checks and did not document a skin assessment for another resident's wound. The first resident's blood glucose checks were not alternated between morning and evening as ordered, and the second resident's wound on the right lower leg lacked documentation of assessment. Interviews with staff confirmed the expectation to follow orders and document assessments, but these were not met.
A resident with cognitive impairment and incontinence was found double briefed and very wet, indicating a lapse in care. The LPN discovered the issue and noted the need for two staff to assist due to the resident's size and mobility. Observations showed CNAs did not cleanse all areas potentially contaminated by urine. The DON confirmed double briefing is unacceptable and emphasized the need for regular checks and thorough cleaning.
A facility failed to follow physician orders for a resident's oxygen therapy, administering incorrect oxygen flow rates and not changing or dating the oxygen tubing as required. Despite orders for 2L/NC continuously, observations showed higher flow rates and undated tubing. Interviews with staff confirmed non-compliance with orders and facility policies.
The facility did not post the correct date for nurse staffing information on four out of five days. The staffing sheets, which detail RN and LPN hours, were outdated or missing. The DON confirmed that the information should be updated daily and accurately.
A LTC facility failed to maintain a medication error rate below 5%, with errors observed in insulin pen priming, vitamin D administration, and eye medication technique. Insulin pens were not primed before use, vitamin D capsules were improperly mixed with pudding, and eye drops were administered directly onto the eyeball without following proper procedure. Staff interviews confirmed non-compliance with facility policies.
The facility failed to follow infection control and medication administration protocols. Staff did not use enhanced barrier precautions for residents with indwelling devices, and catheter bags were improperly placed on the ground. Additionally, a CNA placed dirty linens on the floor, and a CMT held medications under their arm without proper hand hygiene. These actions were against the facility's policies, as confirmed by interviews with the DON and Administrator.
A resident in a wheelchair was intentionally burned on the forehead with a cigarette by another resident in the smoking area of an LTC facility. The incident occurred due to inadequate supervision, as the staff member present was assisting another resident and had their back turned. The aggressor, who had a history of schizophrenia, was later discharged for safety concerns.
A resident with multiple medical conditions developed a wound on the left lower leg due to a broken wheelchair, which was not documented or addressed by the facility. The facility failed to complete and document weekly skin and wound assessments, as required by their policy. Staff interviews revealed a lack of communication and documentation regarding the resident's wound and the condition of the wheelchair.
A resident with a history of aggressive behavior intentionally burned another resident on the forehead with a cigarette in the smoking area of an LTC facility. The facility's smoking policy requires supervision, but no staff were present at the time of the incident. The victim, who was cognitively intact but had functional impairments, was unable to defend themselves. Witnesses confirmed the act was intentional, and the victim sustained a blister. The facility's failure to provide adequate supervision directly contributed to the incident.
Failure to Label Insulin Pens per Facility Policy
Penalty
Summary
The facility failed to ensure insulin pens were labeled in accordance with its Insulin Labeling and Storage policy, which required all insulins removed from the refrigerator to be dated and labeled with the resident’s name and an expiration date, and specified that insulins are only good for 28 days after opening. During observation of the medication cart used for all residents receiving insulin, a nurse identified the drawer containing insulin pens in use and surveyors observed 10 insulin pens, each with a sticker intended for documenting the date opened and date expired. Of these, nine pens (including insulin aspart, insulin degludec, Lantus, and Humalog) had no date opened and no expiration date recorded. The LPN interviewed at the time stated that all insulin pens should be labeled when removed from the refrigerator and acknowledged they would not know when these unlabeled pens were opened or placed on the cart, despite the policy and the 28‑day usability limit after opening. In a subsequent interview, the administrator and DON stated they would expect staff to follow the facility’s insulin labeling and storage policy.
Improper Gait Belt Transfer Used Instead of Required Hoyer Lift
Penalty
Summary
Surveyors identified a deficiency in which staff failed to follow the resident’s care plan and transfer requirements, resulting in the use of an inappropriate transfer method. The facility’s policy for gait belt transfers required review of the Kardex for transfer assistance needs and specified proper use of the gait belt. Resident #3’s medical record showed diagnoses of hemiparesis and hemiplegia following a stroke on the right dominant side, severe cognitive impairment, and limited range of motion in one lower extremity. The resident’s care plan and staffing book indicated the resident was dependent for transfers and required a mechanical (Hoyer) lift with assistance of two staff for transfers, with interventions specifically directing use of a Hoyer lift due to fall risk, poor balance, unsteady gait, stroke with right hemiplegia, dementia with impulsivity, and impaired decision making. Despite these documented requirements, observation showed a CNA and an LPN entered the resident’s room to complete a skin assessment and transferred the resident using a gait belt instead of a Hoyer lift. The resident was assisted to stand from the wheelchair with staff on each side, each placing one arm under the resident’s armpit and one hand on the gait belt. The resident’s knees remained bent, the resident stood on toes, staff appeared to strain to hold the resident in a hunched position, and the resident yelled to be put down, stating they were slipping. Staff then repositioned the wheelchair parallel to the bed and again used the gait belt and underarm hold to stand and pivot the resident, during which one foot remained on the ground and twisted while the other foot lifted as staff swung the resident into bed. Interviews confirmed that transfer status is communicated via the Kardex, staffing book, and colored stickers on name plates, and that a pink sticker should have indicated Hoyer transfer status for this resident; however, no pink sticker was present on the name plate at the time of observation. The Administrator and DON stated that if a resident is identified as a Hoyer transfer in the care plan and staffing binder, it is not acceptable to use a gait belt.
Failure to Administer Ordered Nutritional Supplements and Dietary Items
Penalty
Summary
Certified Medication Technician (CMT) D failed to provide nutritional supplements as ordered to four residents, all of whom had physician orders and care plans specifying the need for supplements such as Ensure or Med Pass 2.0. Observations revealed that these supplements were not present on meal trays, not available on medication carts, and not administered during medication passes, despite CMT D initialing the Medication Administration Record (MAR) to indicate they had been given. Interviews with the CMT and other staff confirmed that the supplements were not administered as ordered, and the CMT admitted to documenting administration when it had not occurred, citing a lack of stock, which was contradicted by the Central Supply Clerk who confirmed adequate supply was available. Multiple residents with significant weight loss, malnutrition, and other medical conditions such as anemia, renal insufficiency, and pressure ulcers were affected by the failure to administer supplements. For example, one resident with a history of severe protein-calorie malnutrition and a stage 2 pressure ulcer did not receive Ensure as ordered, and another resident with cognitive impairment and a history of weight loss did not receive Med Pass 2.0. Observations also showed that dietary orders for whole milk were not followed, with residents being served 2% milk instead, and staff failing to verify or correct discrepancies between menu slips and what was served. Interviews with facility staff, including the Central Supply Clerk, Dietary Manager, and Administrator, confirmed that the responsibility for administering supplements and ensuring correct dietary items rested with both nursing and dietary staff. However, the process failed at multiple points, including communication, documentation, and direct care. The Medical Director stated an expectation that facility policies and physician orders be followed, but the observed and documented failures resulted in residents not receiving prescribed nutritional support.
Expired COVID-19 Tests Used in Facility
Penalty
Summary
The facility failed to ensure the quality of laboratory services by using expired COVID-19 tests to test employees and residents. The tests used were Access Bio COVID-19 Antigen tests with a lot number of CP23B69, which had an expiration date that had already passed. The facility believed they had a waiver extending the expiration date by six months, but upon review, it was found that the waiver did not apply to the lot number in question. The Quality Control Lab Manager from Access Bio confirmed that the lot number CP23B69 had no further extension beyond the 21-month period, and the tests should have been discarded. The deficiency was identified during observations and interviews with facility staff, including the Assistant Director of Nursing, Licensed Practical Nurses, and the Director of Nursing. The facility had one case of COVID-19 due to an employee testing positive, prompting testing of staff and residents. However, the expired tests were used during this process. The Director of Nursing acknowledged that the facility should have verified the expiration dates with the manufacturer before using the tests.
Failure to Follow Recipes During Meal Preparation
Penalty
Summary
The facility failed to ensure that recipes were followed during meal preparation, as observed during one of two meal services. During the lunch meal service preparation, a staff member, [NAME] H, was seen removing steak patties from a box and placing them directly on the skillet without following the Swiss steak recipe, which required seasoning and additional preparation steps. Furthermore, [NAME] H prepared pureed stewed tomatoes and pureed Swiss steak without using the prescribed recipes, resulting in incorrect ingredient proportions. The absence of recipes in the food preparation area was noted, and [NAME] H admitted to not following any recipes, instead relying on personal judgment and package directions. Interviews with staff revealed a lack of awareness and adherence to recipe usage. [NAME] I, another staff member, acknowledged not knowing where to find recipes and often relied on package directions. Despite the expectation from the facility's administrator that cooks should use and know where to find recipes, the staff demonstrated a lack of compliance with this requirement. This deficiency in following recipes could potentially impact the nutritional needs and dietary requirements of the residents, although the report does not specify any direct consequences or risks to the residents.
Failure to Reconcile Resident Trust Accounts
Penalty
Summary
The facility failed to complete and maintain monthly account reconciliations of the facility's bank statements for all 12 months of the year. Additionally, the facility did not reconcile the resident trust at the end of the month for two specific months. The facility's undated resident rights policy outlines the right of residents to manage their financial affairs, receive information about available services and charges, and have personal funds over certain amounts deposited in a separate interest-bearing account with financial statements provided quarterly or upon request. However, the review of the facility's resident trust showed that for each month from January to November 2024, the reconciliations only included the Resident Fund Management Service (RFMS) statement without documentation of the bank statement or end-of-month reconciliation. Interviews conducted during the investigation revealed that the Business Office Manager (BOM) had some training but was not fully informed about the reconciliation process due to the previous BOM's passing. The BOM stated that she was instructed only to print the RFMS and reconciliation and did not receive the bank statements, which might be held by corporate. The facility administrator expressed an expectation for the resident trust to be reconciled accurately and timely with the bank statements, indicating a gap between the expected and actual practices in managing residents' personal funds.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. Residents were found to be living in rooms with malodorous conditions due to the facility's failure to launder dirty linen promptly. For instance, Resident #38 was observed with stained and odorous bedding, and the dirty linen was left in the room for an extended period, causing a strong feces odor. Similarly, Resident #24 complained about the infrequent changing of bedding and the persistent smell in the room due to the roommate's incontinence. Additionally, the facility did not maintain the physical environment adequately, leading to discomfort for the residents. Residents #23 and #37 experienced drafts of cold air due to gaps around their air conditioner units, which were not properly sealed. Resident #21 had broken tiles in the room, and Resident #13 had damaged baseboards and window blinds. These issues were not addressed in a timely manner, contributing to an environment that was not homelike or comfortable. The facility also failed to ensure that resident furniture was in good repair. Resident #1 reported broken bathroom drawers, which were observed to be in disrepair during multiple visits. Furthermore, Resident #65 had an active leak under the air conditioner unit, with a towel placed to absorb the water, and a ripped mattress cover. Despite these observations, there was a lack of prompt action to rectify these issues, indicating a failure in maintaining a safe and comfortable living environment for the residents.
Deficiencies in Resident ADL Care
Penalty
Summary
The facility failed to meet the Activities of Daily Living (ADL) care needs of several residents, as observed during a survey. Resident #4 was not repositioned or toileted in a timely manner, resulting in reddened areas in the genital region and heavily soiled briefs with a strong odor of urine. Additionally, the resident's nails were observed to be dirty and untrimmed, despite the care plan indicating the need for regular hygiene and nail care. Staff interviews revealed inconsistencies in the understanding of the resident's transfer needs and the documentation of care provided. Resident #65 was found to have dry, cracked lips, indicating a lack of proper oral hygiene and grooming, despite being dependent on staff for personal care. The Director of Nursing (DON) was unaware of the issue, highlighting a gap in communication and oversight. Similarly, Resident #3 exhibited a strong body odor and untrimmed facial hair, with bloody discharge observed at the catheter site, suggesting inadequate personal hygiene and catheter care. Staff interviews confirmed expectations for cleanliness and grooming, which were not met in this case. Resident #1 reported that staff did not consistently assist with washing their face, as evidenced by the presence of white matter around the mouth and eye. Resident #24 was observed with dark matter under their nails, which were not cleaned despite the resident eating with their hands. Staff interviews indicated that refusals of care should be documented and revisited, but this was not consistently practiced. Overall, the facility's failure to adhere to care plans and policies resulted in unmet personal care needs for multiple residents.
Medication Administration Deficiencies
Penalty
Summary
The report identifies several deficiencies in the administration of pharmaceutical services to residents. A CMT was observed placing a box of eye drops under her arm and failing to pull down the left eyelid of a resident while administering eye drops. Additionally, a nurse did not prime the insulin pen for two residents, which is a necessary step to ensure accurate dosing. Another incident involved a CMT leaving a resident with medications unattended in the therapy gym while she went to retrieve a water bottle for the resident. These actions and inactions demonstrate a lack of adherence to proper medication administration protocols, potentially compromising resident care.
Unsecured Medication Storage in ADON's Office
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. Specifically, medications were found unsecured in the Assistant Director of Nursing's (ADON) office, which was not designated as a medication storage room. The ADON's office contained multiple bottles of over-the-counter medications and vitamins, including an open and unlabeled bottle of magnesium citrate. The office was frequently observed with the door open and no staff present, allowing medications to be visible and accessible from the hallway. Interviews with the Director of Nursing (DON) and the ADON confirmed that the facility had only two designated medication rooms, both located near the nurse's station. The DON acknowledged that the ADON's office should be considered a medication room if medications are stored there and should be kept locked. Despite this, the ADON admitted to locking the office only at night, leaving it unsecured during the day. Observations over several days consistently showed the office door open and medications visible, indicating a failure to adhere to the facility's Medication Administration Policy.
Call Light System Malfunction in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light system was in working order for multiple residents, including two specific residents, Resident #24 and Resident #29. The call light system was found to be malfunctioning in 24 additional resident rooms, potentially affecting all residents in those rooms. The facility's call light policy outlines the importance of responding to residents' requests promptly, but the system's failures hindered this process. The nurse call system report indicated numerous issues, such as call lights not annunciating on the correct consoles or not lighting up corridor lights, which were not addressed in a timely manner. Resident #24, who was cognitively intact and diagnosed with dementia, anxiety, and major depressive disorder, experienced delays in staff response due to a malfunctioning call light. Observations showed that the call light panel at the nurse's station indicated activation, but the light above the resident's door was off. Staff referred to this as a 'ghost light,' and despite being aware of the issue, the problem persisted without immediate resolution. Similarly, Resident #29, who was also cognitively intact and diagnosed with high blood pressure and schizophrenia, faced issues with the call light system. The call light for this resident activated incorrectly, showing up as a different room on the console, and the resident was unaware of the ongoing issues. Interviews with staff, including CNAs, LPNs, and the Maintenance Director, revealed awareness of the call light issues but a lack of effective communication and resolution. The Maintenance Director acknowledged the need for repairs and mentioned that residents were given bells as a temporary measure. However, agency staff were not adequately informed about the malfunctioning call lights or the interim solutions, leading to further confusion and potential delays in resident care. The Administrator expected the call lights to be in working order and staff to be informed about the current system status, but the issues remained unresolved at the time of the report.
Failure to Facilitate Resident Choice Due to Equipment Unavailability
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for a resident who had an order to be up in a wheelchair before lunch. The resident, who was cognitively impaired and dependent on staff for activities of daily living, was observed lying in bed throughout the morning and early afternoon on two consecutive days. Despite having an order to be up before lunch, the staff did not offer to assist the resident out of bed, and the resident remained in bed with meals served at the bedside. The deficiency occurred because the staff could not find a Hoyer lift pad, which was necessary for transferring the resident from bed to wheelchair. Although the resident's care plan indicated the use of a mechanical lift with the assistance of two staff members, the staff did not obtain another Hoyer pad or notify the Director of Nursing to find a solution. The resident's preference to be up during the day was not honored, and the staff failed to facilitate the resident's choice due to the unavailability of the necessary equipment.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure privacy during care for a resident, identified as Resident #3, who had diagnoses including aphasia, dementia, and major depressive disorder, and was noted to have severe cognitive impairment. During an observation, a Certified Nursing Assistant (CNA) was seen providing care to the resident with the door wide open and the privacy curtain not pulled, exposing the resident's stomach and brief to the hallway. This lack of privacy was further compounded when a Nurse Manager entered the room, asked if assistance was needed, and left the door open upon exiting. Interviews with staff members, including a CNA, an LPN, and the Director of Nursing (DON), revealed that the facility's protocol was to close the resident's door and pull the privacy curtain when providing care to ensure the resident's dignity and privacy. The DON confirmed the expectation that staff should provide privacy to residents during care. However, the observed actions of the staff did not align with these expectations, leading to a deficiency in maintaining the resident's privacy.
Inappropriate Immediate Discharge Following Resident Altercation
Penalty
Summary
The facility failed to provide an appropriate discharge for a resident following a resident-to-resident altercation. The resident, who was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of 15, was involved in an altercation that was de-escalated by staff without incident or reported injuries. Despite the absence of severe behaviors, the facility issued an immediate discharge, citing that the resident's care and protective oversight exceeded the facility's current capacity. The facility's policy requires that discharges be conducted according to state and federal regulations, with adequate preparation and documentation. However, the immediate discharge of the resident did not align with these requirements. The resident's care plan indicated potential for physical and verbal aggression, but there was no documentation of aggressive behaviors towards other residents in the progress notes. The facility's investigation into the altercation showed that both residents involved were swinging at each other, but no physical injuries were reported. Interviews with staff revealed mixed observations about the resident's behavior, with some staff noting aggressive behaviors and others not witnessing any. The facility's decision for an immediate discharge was based on the resident's dementia progression and exit-seeking behaviors, as well as concerns for the safety of other residents. However, the facility did not provide the required 30-day written notice of discharge, nor did it adequately document the necessity of the discharge in the resident's clinical record.
Failure to Notify Ombudsman After Immediate Discharge
Penalty
Summary
The facility failed to notify the Ombudsman in a timely manner following the immediate discharge of a resident after a resident-to-resident altercation. The discharge was issued because the resident's care and protective oversight needs exceeded the facility's current capacity. The facility's policy requires notification of the Ombudsman, but this was not done promptly. The resident involved in the incident was cognitively intact but had diagnoses including dementia, depression, manic depression, and PTSD. The resident had a history of attempting to leave the facility unsupervised and exhibited physical aggression. The altercation occurred when the resident picked up another resident's Bingo card, leading to a physical confrontation. The facility's investigation confirmed that both residents struck each other, but no physical injuries were reported. The facility's policy mandates a 30-day written notice for discharges, except in emergencies. In this case, an immediate discharge was issued due to safety concerns, as the resident had been involved in two altercations. The Administrator acknowledged the failure to notify the Ombudsman, attributing the responsibility to the Social Worker. The decision for immediate discharge was made to ensure the safety of other residents, given the resident's progressing dementia and aggressive behavior.
Failure to Complete PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that a DA-124 Level 1 screen was completed for a resident being admitted to a Medicaid-certified facility, as required by PASRR regulations. The resident in question had a medical history that included right-sided weakness due to a stroke, diabetes, depression, aphasia, high blood pressure, epilepsy, and bipolar disorder. Despite these conditions, there was no record of a Level 1 or Level 2 PASRR screen being completed for the resident. The Business Office Manager (BOM) was unable to locate the necessary documentation and was unsuccessful in obtaining a copy from the Missouri Central Office Medical Review Unit (COMRU). Interviews conducted during the survey revealed that the BOM acknowledged that PASRR screens should be completed upon admission. The Administrator expected staff to adhere to the facility's policy for obtaining PASRR pre-screening. However, the BOM indicated that the Admission Coordinator was responsible for obtaining the PASRR pre-screening, while she was responsible for ensuring its completion. Despite these roles, the facility failed to provide the required documentation by the exit date of the survey.
Failure to Provide Communication Board for Resident with Aphasia
Penalty
Summary
The facility failed to provide necessary services to ensure that a resident's abilities in activities of daily living do not diminish due to a lack of accommodation for the resident's communication needs. The resident, who has diagnoses including aphasia, dementia, and major depressive disorder, was observed multiple times without a communication board, which is essential for their ability to communicate effectively. The resident's care plan specifically included interventions such as the use of a communication board, yet observations on several occasions showed the absence of this tool in the resident's room or within their reach. Interviews with staff, including a social worker, CNA, LPN, and the DON, revealed a lack of awareness and adherence to the resident's care plan regarding the communication board. The social worker indicated that staff should provide a communication board if it is not present, while the CNA and LPN acknowledged the importance of communication for residents but were unaware of the specific requirement for this resident. The DON confirmed that the communication board should be available and accessible to the resident as per the care plan and facility policy.
Failure to Follow Physician's Orders and Document Skin Assessments
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards, as evidenced by two specific incidents. In the first case, a resident with multiple diagnoses, including diabetes, had a physician's order to check blood glucose levels daily, alternating between morning and evening on specific days. However, the Medication Administration Record (MAR) showed that blood glucose checks were only scheduled for the morning, contrary to the physician's order. Interviews with the LPN and the Director of Nursing (DON) confirmed that the expectation was for staff to follow physician's orders as written. In the second incident, a resident with a wound on the right lower leg did not have a documented assessment of the wound. The facility's Skin Program policy requires that all residents be observed and evaluated for skin problems, and any skin issues should be documented and addressed in a care plan. Despite this, there was no documentation of how the skin tear occurred, its location, or a description in the resident's nurse's notes. The Wound Nurse and LPN confirmed that there should have been documentation and assessment of the skin tear, and the DON stated that the expectation was for nurses to investigate, assess, and document skin issues. These deficiencies highlight a failure to adhere to the facility's policies and procedures regarding physician's orders and skin assessments. The lack of proper documentation and adherence to orders could potentially impact the quality of care provided to residents, as evidenced by the incidents involving the two residents.
Inadequate Incontinence Care and Double Briefing
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bowel and bladder. The deficiency was identified when staff placed two briefs on the resident, which became saturated with urine, causing discomfort. The facility's policy requires incontinence care every two hours, but the resident was found to be very wet and moist, indicating a lapse in care. The resident, who has cognitive impairment and is dependent on staff for personal care, was unable to communicate effectively about their needs. During an observation, a Licensed Practical Nurse (LPN) discovered the resident was double briefed and very wet. The LPN noted that the resident's condition required two staff members to assist due to the resident's mobility and size. The LPN was unsure when the Certified Nursing Assistant (CNA) last provided care, and the resident could not confirm if care was given that morning. The LPN expressed concern about skin issues resulting from being left wet and instructed the CNAs to provide care and reassess the resident. Further observations revealed that the CNAs did not cleanse all areas potentially contaminated by urine, as one side of the resident's buttock area was not wiped. The Director of Nursing (DON) confirmed that double briefing is not acceptable due to potential skin issues and emphasized the importance of checking residents at least every two hours. The DON also stated that both sides of the resident's buttock area should be cleaned during incontinence care.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that respiratory services provided to a resident were consistent with professional standards of practice. Specifically, the staff did not adhere to the physician's orders regarding the rate of oxygen administration and the regular changing and dating of oxygen tubing. The resident, who was cognitively intact and required oxygen therapy, had a history of pneumonia, respiratory failure, and other significant health conditions. Despite the physician's orders for oxygen to be administered at 2 liters per nasal cannula continuously and for the oxygen tubing to be changed weekly, observations revealed discrepancies in the oxygen flow rate and the dating of the tubing. On multiple occasions, the resident was observed receiving oxygen at rates higher than prescribed, with the tubing not being changed or dated as required. For instance, the resident was seen with oxygen at 3 liters and 5 liters per nasal cannula on different days, contrary to the prescribed 2 liters. Additionally, the oxygen tubing was not dated correctly, and there was no record of the tubing being changed as scheduled. Interviews with the LPN and the DON confirmed that the nursing staff did not follow the physician's orders for oxygen therapy and tubing changes, which was against the facility's policies and expectations.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the correct date for staffing information on a daily basis for four out of five days, as required. The daily staffing sheet, which includes the total number of hours worked by categories of licensed staff such as Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), was found to be outdated or missing on several occasions. Specifically, on December 5th and 6th, the staffing sheet was dated November 27th. On December 9th and 10th, the sheet was dated December 6th, with a correction made later on December 10th. On December 11th, there was initially no staffing sheet posted, but it was later updated to reflect the correct date. The Director of Nursing acknowledged during an interview that the nurse staffing information should be updated daily and accurately.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 14.28% error rate during the survey. This was due to several observed medication administration errors involving insulin pens, vitamin D tablets, and eye medication. Specifically, insulin pens were not primed before administration, which is a necessary step to ensure the correct dosage is delivered. This error was observed in two residents with diabetes, where the Licensed Practical Nurse (LPN) did not prime the insulin pens before administering the insulin, despite the facility's policy and manufacturer instructions requiring this step. Another error involved the administration of a vitamin D tablet to a resident with a diagnosis of vitamin D deficiency. The Certified Medication Technician (CMT) opened a vitamin D capsule and mixed it with pudding, instead of administering it in the form ordered by the physician. This substitution was made without a physician's order, contrary to the facility's medication administration policy, which requires medications to be given in the form as ordered by the physician. Additionally, an error was observed in the administration of eye medication to a resident with multiple diagnoses, including encephalopathy and stroke. The CMT administered the eye drops directly onto the resident's eyeball without pulling down the lower eyelid, which is against the facility's procedure for administering ophthalmic solutions. This procedure is intended to ensure safe and effective administration of eye medication. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that the facility's policies were not followed in these instances.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, as evidenced by multiple observations of staff not using enhanced barrier precautions (EBP) when providing care to residents with indwelling medical devices. For instance, a resident with severe cognitive impairment, a gastric tube, and a urinary catheter was observed being cared for by staff who did not wear gowns, despite the facility's policy requiring such precautions. Additionally, the resident's catheter bag was found lying on the ground, contrary to expectations that it should be hung to prevent contamination. Another incident involved a resident with cognitive impairment and multiple dependencies for daily activities. During care, a CNA was observed placing dirty linens on the floor and using a washcloth directly from the sink, which is against the facility's infection control policy. The Director of Nursing confirmed that linens should not be placed on the floor and that a basin should be used for washcloths. Further deficiencies were noted in medication administration practices. A CMT was observed placing medication under their arm while administering eye drops to two residents, without performing hand hygiene afterward. This practice was acknowledged by staff as inappropriate, as medications should not be held under the arm, and hand hygiene should be maintained during administration. Interviews with staff, including the DON and Administrator, confirmed that these actions were against the facility's policies on medication administration and infection control.
Resident Burned by Another Resident Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when one resident intentionally burned another resident with a cigarette. The incident occurred in the designated smoking area where a resident, who was cognitively intact and had no prior behaviors, was sitting in a wheelchair. Another resident, also cognitively intact but with a history of schizophrenia and anxiety disorder, approached and demanded the resident in the wheelchair to move. When the resident did not comply, the aggressor used a lit cigarette to burn the resident's forehead, causing a blister. The facility's policy required residents involved in altercations to be separated until an investigation was completed. However, at the time of the incident, there was no staff member directly supervising the smoking area. A dietary aide was present but was assisting another resident and had their back turned to the incident. This lack of supervision allowed the altercation to occur without immediate intervention, leading to the resident sustaining a burn injury. Interviews with other residents who witnessed the incident confirmed that the aggressor intentionally burned the resident with the cigarette. Despite the facility's policy and the presence of a staff member, the incident was not prevented, indicating a failure in monitoring and supervision in the smoking area. The aggressor was later discharged from the facility due to safety concerns for other residents.
Failure to Document and Address Resident's Wound and Equipment Issues
Penalty
Summary
The facility failed to ensure that nurses completed and documented weekly risk skin assessments and wound assessments for residents, particularly for a resident with multiple medical conditions including heart failure, end-stage kidney disease, and diabetes mellitus. The resident, who was cognitively intact and dependent on staff for various activities, was found to have a wound on the left lower leg that was not documented in the electronic medical record (EMR) in a timely manner. The facility's skin program policy required weekly assessments and documentation, but these were not consistently performed or recorded. The resident's wound was reportedly caused by a broken wheelchair, which had a missing left leg pad, exposing metal and screws that likely caused the trauma. Despite the resident's report of the wheelchair causing the wound, there was no documentation of the incident or investigation into the cause of the wound. The Wound Nurse and other staff failed to document the discovery of the wound, the condition of the wheelchair, or any measures taken to address the issue. The facility's policy required nurses to notify the primary care physician and responsible party, initiate new treatment, and document the wound in progress notes, but these actions were not completed. Interviews with staff revealed a lack of communication and documentation regarding the resident's wound and the condition of the wheelchair. The Wound Nurse was aware of the wound but did not document it in the progress notes, expecting others to do so. The Administrator expected staff to follow facility policies, complete assessments, and document findings, but these expectations were not met. The facility also failed to upload wound management team reports into the resident's EMR, further contributing to the lack of documentation and oversight.
Lack of Supervision Leads to Resident Harm in Smoking Area
Penalty
Summary
The facility failed to provide adequate supervision in the smoking area, leading to an incident where one resident intentionally burned another resident on the forehead with a cigarette. The facility's smoking policy mandates that all residents be supervised while smoking, and staff are responsible for lighting smoking products and providing necessary assistance. However, during the incident, there was no staff member present in the smoking area to monitor the residents, which allowed the altercation to occur. The resident who committed the act had a history of behavioral issues, including verbal aggression and difficulty adjusting to living in the facility. Despite being cognitively intact, the resident had diagnoses of schizophrenia and anxiety disorder, which contributed to their challenging behavior. Prior to the incident, the resident had been involved in verbal altercations and had exhibited aggressive behavior towards staff and other residents. The care plan for this resident included monitoring for safety during smoking and reporting any concerns, but these measures were not effectively implemented at the time of the incident. The victim of the incident was a resident with functional impairments due to a stroke, requiring a wheelchair for mobility. This resident was also cognitively intact and had no history of behaviors. The lack of supervision in the smoking area allowed the aggressive resident to approach and harm the victim without intervention. Witnesses confirmed that the act was intentional, and the victim sustained a blister on the forehead as a result. The facility's failure to ensure staff presence and oversight in the smoking area directly contributed to the occurrence of this incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,008 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Grand Manor Health Care Center | 0.7 mi | ★★★★★ | 7 | 1 |
| Life Care Center Of St Louis | 1.8 mi | ★★★★★ | 14 | 0 |
| Bernard Care Center | 1.9 mi | ★★★★★ | 31 | 0 |
| Beauvais Rehab And Healthcare Center | 3.1 mi | ★★★★★ | 1 | 0 |
| Delhaven Manor | 3.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Blue Circle Rehab And Nursing.
100% money-back within 48 hours.
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.