Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cottages Of Lake St Louis during CMS and state inspections, most recent first.
A resident admitted with CHF and atrial fibrillation had multiple ordered medications, including metoprolol, aspirin, pregabalin, duloxetine, levothyroxine, midodrine, potassium chloride, pravastatin, trazodone, and acetaminophen, entered on the eMAR but not administered for evening and early-morning doses, which were marked as "9 (see progress note)" without any explanatory notes. Nursing staff acknowledged that medications ordered after the usual cutoff did not arrive, did not access the Stat-Safe, did not contact another nurse, pharmacy, the physician, the DON, or the family, and did not document reasons for the missed doses, despite facility policy requiring use of the E-Kit, pharmacy contact, provider notification, and documentation. The resident’s representative reported the resident missed medications and was unable to sleep, while leadership, the pharmacist, NP, and physician all confirmed they were not notified and that mechanisms existed to obtain or provide at least some of the missed medications, demonstrating a failure to follow physician orders and professional standards of medication management.
Infection control practices were not followed during blood glucose monitoring for multiple residents when an LPN placed a shared glucometer directly on resident surfaces without a barrier and did not disinfect it correctly between uses. Staff also left CPAP masks and oxygen tubing uncovered or improperly stored, failed to perform proper hand hygiene and linen handling during personal care, and used soiled gloves while applying barrier cream. The facility additionally did not follow its Legionella surveillance process, including cold water temperature monitoring and completion of a water flow map.
Incontinent care and infection control were not followed for a resident with recurrent UTIs, MDRO history, and EBP. During care, CNAs cleaned only part of the resident’s body, left urine-contaminated areas unwashed, and moved from dirty to clean tasks without hand hygiene or glove changes. The resident’s record showed repeated positive urine cultures and symptoms consistent with UTI, and staff interviews confirmed all urine- or feces-contaminated areas should have been cleansed and hand hygiene performed between tasks.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights was upheld.
Unsecured and unordered medications were found in two residents’ rooms. One resident with ALS and depression had multiple medication cards and other items in an unlocked cabinet, including several medications with no current orders and no self-medication order or assessment. Another resident with dementia and Parkinsonism had Salonpas, probiotic medication, and saline nasal spray at the bedside or in the bathroom without orders, and staff stated these medications should not have been kept there without a physician order.
Failure to Administer Ordered Medications and Follow Medication Access/Notification Protocols
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and physician orders for one resident, including not administering multiple ordered medications and not following facility policy when medications were unavailable. The resident was admitted with diagnoses including chronic diastolic congestive heart failure and atrial fibrillation, and had hospital discharge orders for several medications, such as metoprolol tartrate, aspirin, pregabalin, duloxetine, levothyroxine, midodrine, potassium chloride, pravastatin, trazodone, and acetaminophen. The facility’s nursing policy stated that if a medication was unavailable, staff were to check the Stat-Safe (E-Kit), contact the pharmacy for immediate delivery if not in the Stat-Safe, notify the physician when a dose was missed, escalate to the Medical Director and DON if the physician was unavailable, and document in the electronic health record. The facility did not provide additional policies for Medication Administration, Physician and Family Notification, or Following Physician Orders when requested. On the evening of admission, the resident’s medications were entered into the eMAR with start times beginning that night and the following morning. For each scheduled dose on the evening of admission and the early morning after admission, the eMAR showed a “9 (see progress note)” entry for pravastatin, trazodone, aspirin, duloxetine, metoprolol tartrate, potassium chloride, acetaminophen, midodrine, pregabalin, and levothyroxine, indicating the medications were not administered. There were no corresponding progress notes on those dates explaining why the medications were not given, despite the facility’s expectation that a “9” entry be accompanied by documentation of the reason and actions taken. The Stat-Safe list showed that at least metoprolol tartrate 25 mg and trazodone 50 mg were available in the emergency kit, but there was no documentation that these were accessed for the resident. Interviews confirmed that the medications were not administered and that required notifications and follow-up actions were not taken. The resident’s representative reported asking staff about the medications on the evening of admission and being reassured they would be given, but stated the resident missed evening/bedtime and early morning medications and was anxious and unable to sleep. LPN A, who worked the evening/night shifts, stated that orders entered after 5:00 P.M. would not be delivered in time for bedtime, that the medications did not arrive that evening, and that the nurse did not access the Stat-Safe or call another nurse to do so. LPN A acknowledged being aware of the missing doses, did not call the pharmacy or physician, was unaware of the option to request STAT medications from the pharmacy, and did not notify the DON. LPN A also noted the resident became more confused and had difficulty sleeping but attributed this to lack of sleep. RN B, who worked the following day, stated the medications arrived that morning, was aware the resident had not received medications including a sleeping medication, and acknowledged not notifying the physician or DON and not consistently documenting reasons for missed doses. The DON, Administrator, pharmacist, nurse practitioner, and physician each described expectations and available options (use of Stat-Safe, contacting pharmacy, obtaining over-the-counter medications, and notifying providers and family) that were not followed in this case, and confirmed they were not notified of the missed medications. The facility’s DON stated that if a “9” was charted on the eMAR, she expected a progress note explaining why the medication was not administered and that, in the absence of such a note, the medication was not given. She also stated she would expect staff to notify the family and physician of missing medications and that over-the-counter medications such as acetaminophen and aspirin could be obtained easily from a nearby pharmacy. The Administrator reported that if medications were unavailable, staff should pull from the Stat-Safe, ask the family to bring medications, or use another 24-hour pharmacy if the primary pharmacy could not deliver in a timely manner. The pharmacist confirmed the orders were received after hours and that an on-call pharmacist was available for STAT needs, and the nurse practitioner and physician both stated they were not notified of missing medications and that at least aspirin should have been available. These interviews and records collectively show that the facility did not administer ordered medications, did not use available mechanisms to obtain them, and did not document or notify providers and family as required by professional standards and facility policy. The deficiency is specifically that the facility failed to follow physician orders and administer medications as ordered, failed to follow its own policy for obtaining medications when unavailable, and failed to notify the physician and family and document missed doses for one resident. This included medications for heart failure, blood pressure, pain, insomnia, and blood clot prevention. The resident experienced restlessness and inability to sleep, and staff observed changes in orientation, but no timely provider notification or documentation of missed medications occurred. The facility’s own leadership and external providers confirmed that the expected processes for medication access, notification, and documentation were not followed in this case.
Infection Control Failures During Glucose Monitoring, Respiratory Equipment Storage, Hand Hygiene, and Legionella Surveillance
Penalty
Summary
The facility failed to follow infection control standards during blood glucose monitoring for multiple residents. For Resident #84, who had type 2 diabetes and an order to monitor blood sugar before meals, an LPN took a multi-use glucometer from the treatment cart, placed it directly on the cart and then on the resident’s bed without a barrier, completed the finger-stick procedure, returned the glucometer to the cart without a barrier, and cleaned it with one disinfecting wipe for 30 seconds before placing it back in the drawer. Similar observations were made with Resident #81, who also had type 2 diabetes and an order for daily blood sugar monitoring, when the same glucometer was used on another resident, placed directly on the cart and bed without a barrier, and disinfected with one wipe for 15 seconds before being stored. The same infection control concerns were observed with Resident #76 and Resident #49. Resident #76 had type II diabetes mellitus and an order for daily Tresiba administration with a MAR area to record blood glucose results, and an LPN placed the glucometer directly on the resident’s bed without a barrier, completed the blood sugar check, returned the glucometer to the cart, and did not clean, sanitize, or disinfect it afterward. Resident #49 had diabetes mellitus and an order for daily accu-checks; the same LPN used the same glucometer after Resident #76, wiped food crumbs from the resident’s bed, placed the glucometer directly on the bed without a barrier, completed the accu-check, and again did not clean, sanitize, or disinfect the device before or after use. The LPN later stated he/she did not clean or disinfect the multi-use glucometer after using it on Resident #76 or Resident #49 and did not place a barrier between the glucometer and the surface. The facility also failed to store respiratory equipment properly for Residents #3, #31, and #84. Resident #3, who had COPD and moderate cognitive impairment, repeatedly had a CPAP mask left uncovered on the bedside table with no storage bag or container visible. Resident #31, who had chronic respiratory failure with hypoxia and CHF and used continuous oxygen, had oxygen tubing documented as changed on certain dates, but observations showed tubing rolled up in the bedside table, later on the floor, and no visible storage bag available; the tubing was also observed dated inconsistently with the TAR. Resident #84 also had oxygen tubing and CPAP-related equipment issues noted in the report. In addition, staff failed to perform proper hand hygiene and linen handling during personal care for Resident #28, who was dependent for toileting hygiene and incontinent of bowel and bladder, when a CNA placed soiled incontinence brief and sheet on the floor and then continued care without changing gloves or performing hand hygiene. For Resident #49, staff performed peri-care and then applied barrier cream with the same soiled gloves. The facility also failed to follow its Legionella control policy by not monitoring cold water temperatures and not completing a water flow map; the water management team had not met since the current maintenance director began, and state-obtained water temperatures showed several cold-water faucets in the range where Legionella generally grows well.
Incontinent Care and Infection Control Not Followed During Resident Care
Penalty
Summary
The facility failed to provide incontinent care consistent with acceptable standards of practice and failed to follow proper infection control procedures for one resident with a history of UTIs and MDROs who was on Enhanced Barrier Precautions. The resident was dependent on staff for ADLs, incontinent of bowel and bladder, and had diagnoses including renal insufficiency and obstructive uropathy. The resident’s record also showed a history of VRE, recurrent positive urine cultures, and multiple episodes of suspected or confirmed UTI with symptoms including confusion, shortness of breath, shaking, feeling warm, nausea, blood in the urine, and burning with urination. During observation of incontinent care, two CNAs donned gowns and gloves because the resident was on EBP. One CNA cleaned the resident’s front perineal folds, then rolled the resident and unfastened a urine-saturated brief, pad, and sheet. The CNA wiped between the buttocks and removed fecal matter, but did not wash the resident’s buttocks, thighs, or lower back that were in contact with urine. Without changing gloves or performing hand hygiene, the CNA rolled the resident to the other side. The other CNA then pulled the urine-soaked brief, pad, and sheet out from under the resident and rolled the resident back without cleaning urine from the resident’s buttocks. The observation also showed bright red blood on the soiled sheet, and the CNAs adjusted the resident, touched items on the overbed table, and put away wipes while still wearing soiled gloves. Interviews confirmed the care was not performed as expected. One CNA stated all areas of the body that come into contact with urine or feces should be cleaned and that hand hygiene should be performed between glove changes and after touching dirty items. The other CNA stated every part of the body that had come into contact with urine or feces should have been cleaned and gloves should have been changed before touching clean items or the resident. An LPN, the Infection Preventionist, and the DON each stated staff should perform hand hygiene before applying gloves and after incontinent care, and that all areas of the body in contact with urine or feces should be cleansed.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Unsecured and Unordered Medications Found in Resident Rooms
Penalty
Summary
The facility failed to follow acceptable standards of practice for two residents when current ordered medications were not the only medications available and medications were not kept secured in the residents’ individual medication storage cabinets. Resident #10 had diagnoses of ALS and major depressive disorder, was dependent on staff for activities of daily living, and had a BIMS score of 14. Observation of the resident’s room showed a locked medication cabinet and, in a separate unlocked cabinet, multiple medication cards and items including baclofen, meclizine, omeprazole, fluticasone, albuterol inhaler, potassium chloride, riluzole, vitamins, and fleets enemas. Several of the medication cards were dated March 2025 and the box of individual pill pouches was dated 2024. Review of July 2025 physician orders showed orders for some medications but no orders for others found in the cabinet, and there was no assessment or order for self-medication. Resident #72 had diagnoses including dementia, anxiety, Parkinsonism, and vertebral fractures, and had a BIMS score of 11. Review of the resident’s record showed no self-medication assessment or order to self-medicate. Observation showed a bottle of Salonpas on the over-bed table without a pharmacy label, an open bottle of probiotic medication, and saline nasal spray on the bathroom sink. Review of July 2025 physician orders showed no order for the Salonpas, probiotic, or nasal spray. An LPN stated the resident should not have medication at the bedside without a physician order, and the DON stated medications should be in locked medication cabinets in each resident’s room unless there was a physician order to keep them at bedside.
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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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Nursing homes near Lake Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunterra Springs Dardenne Prairie | 1.4 mi | ★★★★★ | 11 | 0 |
| Delmar Gardens Of O'fallon | 3.4 mi | ★★★★★ | 1 | 0 |
| Abbey Senior Health | 4.9 mi | ★★★★★ | 1 | 0 |
| Garden View Care Center | 5 mi | ★★★★★ | 2 | 0 |
| Lutheran Senior Services At Breeze Park | 7.5 mi | ★★★★★ | 0 | 0 |
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