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 Florissant Valley Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple neurological and vascular conditions did not receive a newly prescribed medication for nerve pain after returning from a neurology appointment, as staff failed to follow up on the physician's order and did not add the medication to the resident's regimen until it was brought to their attention by a family member.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with a history of anxiety was not given alprazolam (Xanax) as ordered after admission, due to delays in obtaining a signed prescription and lack of timely communication with the physician and pharmacy. The medication was not administered for several scheduled doses, and staff did not utilize the emergency kit or notify the physician about the missed doses, resulting in increased anxiety and tearfulness for the resident.
The facility failed to ensure that call lights and communication devices were within reach for several residents, leading to a deficiency. Residents with various impairments, including cognitive and physical limitations, were observed with call lights clipped to privacy curtains or placed on furniture out of reach. A nonverbal resident's communication tools were also inaccessible. Staff interviews confirmed the expectation for accessibility, but this was not consistently met.
The facility failed to properly manage the resident trust account, affecting 44 residents. The BOM admitted that there was no consistent cash amount on hand for withdrawals, and no ongoing tracking or monthly reconciliation was conducted. A discrepancy of $50.00 was found between the calculated and actual cash in the cash box. The Administrator expected routine reconciliation and proper tracking to prevent fund misplacement.
The facility failed to provide timely incontinence care, bathing, and repositioning for several residents, leading to potential risks of skin breakdown and urinary tract infections. Residents were left in saturated briefs for extended periods, and some did not receive the minimum of two showers per week. Observations confirmed unkempt hair and beards, and incomplete shower sheets. Residents requiring assistance with repositioning were not turned every two hours, compromising their dignity and health.
A facility failed to provide sufficient nursing staff, resulting in residents being left in bed, meals served cold, and inadequate personal care. Observations and interviews revealed that residents did not receive timely assistance with activities of daily living, such as getting out of bed and receiving showers. Staffing records showed insufficient numbers of CNAs and LPNs on duty, impacting care delivery. Staff confirmed the facility was short-staffed, affecting their ability to provide timely care and services.
The facility failed to deliver meals at safe and palatable temperatures, affecting several residents. Observations showed that warming carts were often left unplugged and open, leading to cold food. Residents with various medical conditions reported dissatisfaction with meal temperatures, and staff interviews confirmed the issue. The administrator acknowledged the problem and identified the need for proper use of warming carts.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices, leading to lapses in infection control. Staff did not consistently wear gowns and gloves during care, and hand hygiene practices were inadequate during perineal care. Additionally, the facility neglected TB screening for residents and employees, with missing documentation and tests not read before employment.
The facility did not designate a qualified infection preventionist (IP) with specialized training for its infection control program. The DON had not completed the IP certification, and the previous IP had left a month prior. The Administrator believed the DON had completed the certification and expected a designated person to be trained and certified. The facility's policy outlined responsibilities for infection surveillance, but the deficiency remained unaddressed.
The facility failed to maintain the dignity of three residents by leaving one exposed to the hallway and referring to two others as 'feeders' during meal assistance. A resident was left uncovered and visible from the hallway, while a CNA stood over two residents during meals, using disrespectful language. Staff interviews confirmed these actions violated dignity expectations.
The facility failed to ensure proper assessment and supervision of two residents during medication administration. One resident with severe cognitive impairment and another with moderate cognitive impairment were found with medications left at their bedside without supervision. Facility staff confirmed that residents should be observed during medication administration, but this protocol was not followed, resulting in a deficiency.
The facility failed to complete third party liability (TPL) forms within 30 days for deceased residents with remaining funds, affecting three residents. The Business Office Manager was behind on submissions due to her recent start and learning curve, while the Administrator expected timely compliance with state regulations.
The facility failed to maintain a safe and homelike environment for two residents due to water damage in their shared room. Observations showed water stains, peeling wallpaper, and flaking paint. Staff and family reported ongoing water leaks, with temporary measures like bedspreads used to catch water. Maintenance was aware but delayed repairs, citing a flat roof issue. The Administrator expected timely repairs and a homelike environment.
The facility failed to notify the State LTC Ombudsman of resident transfers and discharges, as required by policy. The SSD, responsible for these notifications, admitted to not sending any since starting in May 2024. The Ombudsman reported not receiving notifications for five to six months, and the Administrator expected monthly notifications. The facility's policies lacked guidance on this requirement.
The facility failed to provide transportation for two residents, resulting in missed medical appointments. One resident with multiple health issues missed appointments due to the need for special transportation, which was not arranged. Another resident with Parkinson's and Alzheimer's missed three neurology appointments. The transportation scheduling process was flawed, with communication and documentation issues noted by staff and residents.
The facility failed to provide proper wound care and skin treatment for two residents. A resident with dementia and diabetes had an undocumented wound on the left flank with no treatment order, while another resident with dry skin and lower extremity issues received ineffective treatment. Staff interviews revealed a lack of awareness and follow-up on treatment plans.
The facility failed to follow physician orders for oxygen administration for two residents, leading to deficiencies in respiratory care. One resident received oxygen at 5L instead of the ordered 2L, without physician notification or documentation of oxygen saturation levels. Another resident received oxygen without the required humidifier, contrary to physician orders. Staff interviews confirmed the expectation to adhere to physician orders, which was not met in these cases.
The facility failed to document and monitor dialysis care for two residents receiving hemodialysis. One resident's care plan lacked documentation of monitoring the dialysis access site, while another's care plan did not reflect the physician's orders for AV fistula checks. Staff interviews indicated a lack of reassessment and documentation upon residents' return from dialysis.
The facility failed to store medications according to professional principles, with expired medications found in medication carts and rooms. Observations showed a FreeStyle Libre sensor kit expired in the South medication room, and Assure Platinum Strip containers in the North and South carts lacked opening dates. Interviews confirmed the need for proper labeling and removal of expired items, as per the facility's policy.
The facility failed to maintain complete and accurate documentation for two residents. One resident left with family and did not return, with no documentation of the discharge circumstances. Another resident's neurological assessments were inaccurately documented by an LPN not on duty. The facility lacked a policy for accurate medical record documentation.
The facility did not employ sufficient staff with the appropriate skills to manage the food and nutrition service after the Dietary Manager was terminated. This failure to designate a new Director of Food and Nutrition Services had the potential to impact all 76 residents.
The facility did not maintain kitchen cleanliness or adhere to cleaning schedules, resulting in unclean equipment and floors. Food was improperly stored, risking cross-contamination, and items were not labeled or dated. These issues potentially affected all 76 residents consuming food from the facility.
The facility was cited for failing to maintain an effective pest control program, leading to the presence of flies and gnats in the kitchen. This issue was identified through observation and interview during a survey, with a census of 76 residents at the time.
The facility failed to employ sufficient staff for food and nutrition services after the Dietary Manager's termination, leading to unsanitary kitchen conditions. Observations showed staff did not maintain cleanliness, proper food storage, or safety, and failed to document necessary logs. Interviews revealed the former DM did not perform required inspections, and the Administrator found the DM's office disorganized, with no sanitation surveys available.
The facility failed to maintain a clean and sanitary kitchen environment, with observations of unclean equipment, floors covered in debris, and improper food storage practices. The kitchen's back hall was cluttered, and the dry storage area was disorganized, making it difficult to rotate stock. Interviews revealed a lack of adherence to cleaning protocols and food safety practices, posing a risk to resident health.
The facility failed to maintain an effective pest control program, leading to the presence of flies and gnats in the kitchen. Observations revealed pests throughout food prep areas, near the walk-in cooler, and around the dishwasher and ice machine. Interviews with staff confirmed the kitchen's dirty condition attracted pests, despite expectations for a pest-free environment.
The facility did not follow its abuse and neglect policy by failing to conduct required background checks and federal indicator checks for a rehired RN. The RN, initially hired and later terminated, was allowed to work a shift without these checks being completed, as confirmed by the Area Director of Operations.
A resident at risk for pressure ulcers was not frequently repositioned or provided timely incontinence care, resulting in new pressure ulcers. The resident was found with soaked bedding and expressed discomfort. A CNA reported the issue, but the Wound Nurse and Physician were unaware until later. The facility's leadership acknowledged unmet expectations for care.
Failure to Follow Physician Orders for New Medication After Outside Appointment
Penalty
Summary
The facility failed to provide services in accordance with professional standards of quality for one resident when staff did not follow physician orders for a new medication. After returning from a neurology appointment, the resident, who had moderately impaired cognition and diagnoses including Wernicke's encephalopathy, muscle wasting, diabetes, and vascular diseases, was prescribed gabapentin 100 mg daily to treat nerve pain. The after-visit summary from the neurologist included this new medication order. However, the facility did not implement the physician's order for gabapentin for 10 days following the resident's return. The medication was not added to the resident's medication list, and staff did not follow up to obtain the necessary paperwork or clarify the order with the physician's office. The omission was only discovered when a family member inquired about the medication, prompting staff to contact the physician and obtain the order for gabapentin.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Administer Ordered Alprazolam and Notify Physician
Penalty
Summary
A deficiency occurred when a resident was not administered alprazolam (Xanax) as ordered following admission from the hospital. The resident had a history of anxiety and was discharged from the hospital with an order for Xanax 1 mg three times daily, which had been administered routinely during the hospital stay. Upon admission, the facility had an order for the same dosage and schedule, but the medication was not given as prescribed due to issues obtaining a signed prescription and pharmacy approval. Facility records show that the medication was not administered for several scheduled doses, with documentation indicating the medication was on hold or not available. There was no evidence that staff contacted the physician or pharmacy in a timely manner to resolve the issue or to access the medication from the emergency kit, which contained lower-dose alprazolam tablets. The physician was not notified that the resident had missed multiple doses, and the pharmacy did not receive any calls from the facility requesting access to the emergency supply. As a result of the missed doses, the resident experienced increased anxiety and tearfulness. The physician confirmed that she was unaware of the missed doses and expected to be notified of any medication issues. The facility's Director of Nursing acknowledged that staff should have verified the medication order and obtained the necessary prescription promptly, and that proper documentation and communication protocols were not followed.
Failure to Ensure Accessibility of Call Lights and Communication Devices
Penalty
Summary
The facility failed to provide reasonable accommodation of individual needs and preferences by not ensuring that call lights were within reach for six residents and a communication device was not accessible for one resident. This deficiency was observed during a survey where multiple residents were found unable to reach their call lights, which were often clipped to privacy curtains or placed on furniture out of reach. For instance, Resident #12, who had severe cognitive impairment and required assistance for various activities of daily living, was observed with a call light clipped to a privacy curtain, making it inaccessible when the resident attempted to get out of bed. Similarly, Resident #23, who was dependent on staff for toileting hygiene and other activities, had a call light positioned on top of a set of drawers, out of reach. Resident #174, who had difficulty swallowing and weakness, was found with a call light under their pillow and later on the floor, both times out of reach. Resident #20, who was cognitively intact but had a self-care performance deficit, expressed difficulty in communicating with staff due to the call light being out of reach. Additionally, Resident #126, who was nonverbal and required an assistive device to communicate, had their communication tools placed on a bedside table approximately four feet away, making them inaccessible. Interviews with staff, including CNAs and LPNs, confirmed that call lights and communication devices should be within reach of residents, but this was not consistently ensured. The facility's administrator also acknowledged the expectation that staff should ensure these items are accessible before leaving a resident's room.
Deficiency in Resident Trust Account Management
Penalty
Summary
The facility failed to adhere to general accounting principles in managing the resident trust account, affecting 44 residents. The Business Office Manager (BOM) revealed that the facility did not maintain a consistent amount of cash on hand for resident withdrawals, and there was no ongoing tracking or monthly reconciliation of the cash. Although a spreadsheet was used to record cash requests and withdrawals, it lacked a running total of the cash available at any given time. During an interview, the BOM calculated that $338.00 should be in the cash box, but upon counting, $388.00 was found, indicating a discrepancy of $50.00. The Administrator expected routine reconciliation and proper tracking of cash to prevent misplacement of funds.
Deficiencies in Incontinence Care, Bathing, and Repositioning
Penalty
Summary
The facility failed to provide timely incontinence care, bathing, and repositioning for several residents, leading to potential risks of skin breakdown and urinary tract infections. Residents were observed to be left in saturated briefs for extended periods, with some wearing double briefs, which is against facility policy. Staff interviews revealed that residents were not being checked for incontinence every two hours as required, and staffing shortages were cited as a reason for inadequate care. Multiple residents reported not receiving the minimum of two showers per week, as outlined in their care plans. Observations confirmed that residents had unkempt hair and beards, and some had not been bathed for weeks. Shower sheets were incomplete, and staff were unaware of residents' specific needs, such as the use of anti-dandruff shampoo. Interviews with staff indicated that showers were often missed due to prioritization issues and staffing shortages. Residents requiring assistance with repositioning were not turned every two hours, as required to prevent pressure ulcers. Observations showed residents remained in the same position for extended periods, and staff interviews confirmed that low air loss mattresses were incorrectly used as substitutes for regular repositioning. The facility's failure to adhere to its policies and care plans resulted in inadequate care for residents, compromising their dignity and health.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, leading to several deficiencies in care. Observations and interviews revealed that residents were left in bed, meals were not delivered timely and were served cold, residents were not changed in a timely manner, and showers were not provided according to residents' needs and preferences. The facility's assessment showed a lack of documentation for specific nurse staffing needs for each shift, contributing to these issues. Multiple residents reported that there was not enough staff across all shifts, resulting in delays in getting out of bed and receiving showers. One resident was observed with white matter on their mouth and oily hair, indicating inadequate personal care. Another resident's call light was out of reach, preventing them from requesting assistance to get out of bed. Staff interviews confirmed that the facility was short-staffed, affecting their ability to provide timely care and services. The facility's staffing records showed insufficient numbers of CNAs and LPNs on duty, which impacted the delivery of care. Staff members reported difficulties in completing tasks such as passing meal trays, assisting residents with transfers, and providing personal hygiene care due to the staffing shortages. The facility's staffing coordinator and administrator acknowledged the staffing issues and the challenges in maintaining adequate care levels, especially when staff called off or were unavailable.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that meals delivered to residents were at a safe and palatable temperature, affecting six residents. Observations and interviews revealed that residents consistently received cold food, with some meals being described as soggy or lacking taste. The facility's food safety and handling policy, which aligns with FDA guidelines, was not adhered to, as evidenced by the cold temperatures of food items such as sausage, waffles, and oatmeal. Multiple residents, including those with conditions such as heart disease, diabetes, kidney failure, and anemia, reported dissatisfaction with the temperature and quality of their meals. Observations showed that warming carts used to transport meals were often left unplugged and with doors open, leading to significant drops in food temperature. For instance, test trays showed sausage at 87.7 degrees Fahrenheit and waffles at 93.2 degrees Fahrenheit, well below the required minimum internal temperature for safe consumption. Interviews with staff, including CNAs, dietary aides, and the dietary manager, confirmed that the warming carts were not consistently plugged in or kept closed, contributing to the issue of cold food. The administrator acknowledged the expectation for food to be delivered at appropriate temperatures and identified the need for warming carts to remain plugged in and closed to maintain food warmth. Staffing issues were also cited as a reason for delayed meal delivery, further exacerbating the problem of cold food.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) as recommended by the CDC and required by CMS. This deficiency was observed in several residents with medical devices such as gastrostomy tubes, wounds requiring treatment, and peripherally inserted central catheters. Staff members were observed not wearing gowns while providing care to residents with these conditions, despite the presence of EBP signage and the availability of personal protective equipment. Interviews with staff, including LPNs and the Assistant Director of Nurses, confirmed that there was an expectation for staff to wear gowns and gloves during such care, but this was not consistently followed. Additionally, the facility failed to ensure proper infection control practices during perineal care for two residents. Observations revealed that staff did not perform hand hygiene after removing soiled gloves and before applying new ones, and they touched clean surfaces and clothing with contaminated gloves. Interviews with staff members indicated an awareness of the correct procedures, but these were not consistently practiced, leading to lapses in infection control. The facility also neglected to provide tuberculosis (TB) screening tests for several residents and employees. Records showed missing documentation of TB tests or results, and some employees began working before their TB test results were read. Interviews with the Assistant Director of Nurses and the Administrator highlighted a lack of adherence to state guidelines for TB testing, with responsibilities for tracking and administering tests not being effectively managed. This oversight in TB screening further contributed to the facility's failure to meet infection control standards.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) with specialized training in infection prevention and control for its infection control program. The facility's policy on Surveillance of Healthcare Associated Infections, reviewed on October 7, 2021, outlined responsibilities for the Director of Nursing (DON), infection control designee, and licensed nurses to conduct surveillance for healthcare-associated infections. However, during an interview on November 20, 2024, the DON admitted she had not completed the IP certification, despite working on it overnight. The previous IP had left the facility about a month prior. In a subsequent interview on November 22, 2024, the Administrator expressed her belief that the DON had completed the IP certification and expected the facility to have a designated person to complete the training and receive certification. The facility census was 83 at the time of the survey.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity of three residents by exposing them to undignified situations. One resident was left exposed to the hallway, lying in bed with no covers and an exposed brief, while staff members walked past without providing privacy. This situation persisted until a Licensed Practical Nurse eventually covered the resident with a sheet and blanket. The resident's baseline care plan did not address their activity of daily living needs, which contributed to the oversight. Additionally, two other residents were subjected to unprofessional behavior by staff during meal assistance. A Certified Nursing Assistant (CNA) stood over these residents while feeding them and referred to them as 'feeders' in the presence of other residents. This behavior was noted as disrespectful and a violation of the residents' dignity. Interviews with staff confirmed that such actions were against the facility's expectations for maintaining resident dignity.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to self-administer medications and that staff adequately supervised residents during medication administration. Specifically, two residents, one with severe cognitive impairment and another with moderate cognitive impairment, were involved in incidents where medications were left at their bedside without proper supervision. The facility's policy requires that residents be observed after medication administration to ensure the dose is ingested, but this was not adhered to in these cases. Resident #26, who has severe cognitive impairment due to conditions such as stroke, Alzheimer's disease, and dementia, was found with a cup containing five medications on their bedside table. There was no documentation in the resident's care plan or medical record indicating an assessment for self-administration of medications. Despite having orders for several medications, the resident was not supervised during administration, as evidenced by the observation of medications left at the bedside. Similarly, Resident #128, with moderate cognitive impairment and diagnoses including stroke, anxiety, and depression, was also found with medications left at their bedside. An assessment dated prior to the incident indicated that the resident was not capable of self-administration. Interviews with facility staff, including a CNA/CMT, LPN, and the ADON, confirmed that residents should be supervised during medication administration and that it is not acceptable to leave medications with residents and walk away. Both residents were identified as needing supervision during medication administration, yet this protocol was not followed, leading to the deficiency.
Failure to Timely Complete TPL Forms for Deceased Residents
Penalty
Summary
The facility failed to ensure that third party liability (TPL) forms were completed within 30 days for the final accounting of residents who had passed away. This deficiency affected three residents who had expired and still had money in their accounts. The facility's Business Office - Resident Trust Fund Policy and Procedure requires that upon the discharge or passing of a resident, funds should be disbursed according to regulatory requirements, particularly for Medicaid residents. These funds must be reported to the State for estate recovery and can only be released by the State or made payable directly to a mortuary for unpaid funeral expenses. The Business Office Manager (BOM) acknowledged her responsibility for submitting the TPL to Medicaid within the required timeframe but admitted to being behind on this task due to her recent start at the facility and the need to learn the procedures for fund reconciliation. The Administrator expressed an expectation for TPLs to be submitted within the state-regulated timeframes and for accounts to be closed out promptly. The report highlights that the TPLs for the three residents were not completed within the 30-day requirement, indicating a lapse in the facility's adherence to its own policies and state regulations.
Failure to Maintain a Safe and Homelike Environment Due to Water Damage
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents sharing a room, as evidenced by water stains on the ceiling, peeling wallpaper, and flaking paint due to water damage. Observations revealed yellow ring stains on the ceiling above the window, and the wall next to the bathroom had bubbled, peeled, and flaked paint. The ceiling near the doorway also showed flaked and bubbled paint. Family members and staff reported that the room had been leaking water for at least a couple of months, with staff placing bedspreads and bath blankets to catch the leaking water. Interviews with staff indicated a lack of timely maintenance response. A CNA mentioned that the room always leaks water, and staff verbally inform maintenance staff about issues. An LPN stated that not all staff have access to place maintenance requests in the computer and was unaware of the water leaking issues. The Maintenance Director acknowledged the ceiling stains and water leaking, attributing it to a flat roof that does not drain well, and was waiting for the walls and ceiling to dry before making repairs. The Administrator expected repairs to be made in a timely manner and for residents to have a homelike environment.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of resident transfers and discharges, as required. The facility's policies on both involuntary and voluntary discharges, revised on 10/7/21, lacked guidance on notifying the Ombudsman. This oversight was identified during a review of the facility's policies and interviews with staff. The Ombudsman reported not receiving monthly notifications of transfers and discharges for approximately five to six months. The Social Services Director (SSD), who began working at the facility in May 2024, was responsible for notifying the Ombudsman but admitted to not sending any notifications since starting her role. The Administrator expected the SSD to send these notifications monthly, but this did not occur. The facility census at the time was 83, indicating a significant number of potential unreported transfers and discharges.
Failure to Provide Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure that transportation was provided for two residents, resulting in missed medical appointments. Resident #66, who has multiple health issues including diabetes, morbid obesity, and obstructive sleep apnea, missed appointments with both a pulmonary doctor and a neurosurgeon. The resident requires a special transportation unit due to their size, which the facility did not arrange. The Social Service Director was unaware of the missed appointments and noted that the transportation company requires at least three days' notice. Similarly, Resident #12, who has Parkinson's disease and Alzheimer's, missed three neurology appointments. The Director of Social Services was not informed of these missed appointments by the nursing staff. The report also highlights systemic issues with the facility's transportation scheduling process. During a group interview, residents expressed that it takes a long time for staff to schedule appointments, and some have missed appointments due to lack of transportation. The transportation driver indicated that nurses are responsible for filling out transportation paperwork and require 24-hour notice. However, the Social Service Director found the transportation logbook empty, indicating a breakdown in communication and documentation. The facility administrator expected timely transportation arrangements, but the current process failed to meet this expectation.
Deficiencies in Wound Care and Skin Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards for two residents, leading to deficiencies in wound care and skin treatment. Resident #14, who has dementia and diabetes, was found to have a wound on the left flank that was not identified or documented in the medical record, and no treatment order was obtained for this wound. Observations revealed a wound dressing on the resident's left flank that was not dated, and interviews with staff indicated a lack of awareness and proper documentation regarding the wound. Resident #66, who is cognitively intact but requires substantial assistance for daily activities, was found to have extremely dry skin with multiple layers of thick flaky skin on the lower legs and feet. Despite having treatment orders for Urea cream and warm towel applications, the resident reported that the treatment was ineffective, and the condition of the skin had not improved. The resident had not received a shower in three weeks, and staff interviews confirmed that the treatment had remained unchanged despite its ineffectiveness. Interviews with facility staff, including LPNs and the ADON, revealed expectations for wound treatments to be in accordance with physician orders and for skin assessments to be accurate and comprehensive. However, there was a lack of follow-up and adjustment of treatment plans when current treatments were ineffective, as well as a lack of understanding of certain documented conditions, such as foot erosion.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents by not adhering to physician orders for oxygen use. Resident #46, diagnosed with acute respiratory failure and hypoxia, had a physician order for oxygen at 2L as needed for shortness of breath. However, observations showed the resident receiving oxygen at 5L without documentation of oxygen saturation levels or physician notification. The resident expressed uncertainty about the correct oxygen setting, and staff confirmed the discrepancy between the physician's order and the administered oxygen level. Resident #14, with diagnoses including dementia and diabetes, had a physician order for oxygen at 2L per nasal cannula as needed, with an additional order for a humidifier. Observations revealed the resident receiving oxygen at 3L initially and later at 2L, but without the required humidifier attached. Staff interviews confirmed the expectation for physician orders to be followed, including the use of a humidifier, which was not adhered to in this case. Interviews with facility staff, including the LPN, ADON, and Administrator, highlighted the expectation that physician orders for oxygen should be followed precisely. The staff acknowledged the inappropriate administration of oxygen at levels higher than ordered and the lack of physician notification when deviations occurred. The facility's failure to adhere to these orders and protocols resulted in deficiencies in providing safe and appropriate respiratory care for the residents involved.
Deficiency in Dialysis Care Documentation and Monitoring
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for residents receiving dialysis, specifically for two residents out of a sample of 19. Resident #70, who is cognitively intact and diagnosed with end-stage kidney disease, was receiving hemodialysis three times a week. The care plan included interventions such as checking and changing the dressing at the access site daily and avoiding blood pressure measurements in the right arm. However, there was no documentation in the Medication Administration Record/Treatment Administration Record (MAR/TAR) from 11/1/24 to 11/18/24 to show that staff monitored the dialysis access site every shift or reported any absence or weak thrill or bruit to the dialysis provider and primary medical doctor. Similarly, Resident #275, also cognitively intact and diagnosed with kidney failure, was receiving hemodialysis three times a week. The care plan noted the potential for infection, bleeding, and pain related to the internal jugular catheter, but there was no documentation for an AV fistula in the care plan. Physician's orders required checking the AV site for thrill/bruit and signs of infection every shift, but the care plan did not reflect these orders. Interviews with staff revealed that vital signs and weights were taken before dialysis and documented on a communication sheet, but there was a lack of reassessment and documentation upon the residents' return from dialysis.
Expired Medications and Improper Labeling in Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored in accordance with currently accepted professional principles, as expired medications were found in the nurse medication carts and medication supply rooms. Observations revealed that a FreeStyle Libre sensor kit, which expired on 9/23/23, was still present in the South medication room. Additionally, the North nurse medication cart contained Assure Platinum Strip containers that were not dated when opened, despite having expiration dates of 2/26/26 and 3/20/26. The South nurse medication cart also had an Assure Platinum Strip container without an opening date and a CoaguChek bottle of strips that expired on 10/31/24. Interviews with facility staff, including an LPN and the ADON, confirmed that glucose strip containers should be dated when opened and that expired devices should be removed and discarded. The facility's Medication Storage policy mandates that outdated or expired medications be immediately removed from inventory and disposed of according to procedures. The Administrator also stated that she expected staff to label glucose strip containers when opened and to remove expired medications or equipment from the medication cart and rooms.
Deficiencies in Resident Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of resident records, leading to deficiencies in the handling of two residents' medical records. For one resident, there was no documentation of the circumstances surrounding their discharge from the facility. The resident, who had a history of seizures, diabetes, heart failure, atrial fibrillation, dementia, schizophrenia, and bipolar disorder, left the facility with a family member and did not return. Staff interviews revealed that the resident's leave of absence was not documented, and there was no record of the resident signing out against medical advice or any other documentation regarding the discharge. In another case, a resident with a history of falling had neurological assessments documented as completed by an LPN who was not on duty during the shifts in question. The neurological evaluation flow sheet showed assessments signed with the LPN's initials, despite the LPN not working those shifts. Interviews with staff confirmed that the documentation was inaccurate, as the assessments should have been recorded by the nurse who performed them. The facility lacked a policy related to complete and accurate medical record documentation, as confirmed by the Administrator.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the necessary competencies and skills to manage the food and nutrition service. This deficiency occurred because the facility did not designate a person to serve as the Director of Food and Nutrition Services after the Dietary Manager was terminated. This oversight had the potential to affect all 76 residents in the facility.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen by not adhering to their established cleaning schedules, which included monthly, weekly, and daily tasks. Observations revealed that kitchen equipment was not kept clean, and floors were not free of debris, grease, and grime. Additionally, the facility did not store food in a safe and sanitary manner, leading to potential cross-contamination. Food items were also not labeled and dated properly. These deficiencies had the potential to affect all 76 residents who consumed food from the facility kitchen.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in the kitchen. This deficiency was identified through observation and interview during a survey. The facility had a census of 76 at the time of the survey, indicating the number of residents potentially affected by this issue.
Deficiency in Food and Nutrition Services Management
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to manage the food and nutrition services after the termination of the Dietary Manager (DM) on 7/30/24. This resulted in the absence of a designated Director of Food and Nutrition Services, which affected the cleanliness and safety of the kitchen environment. Observations on 8/12/24 revealed that staff did not maintain kitchen cleanliness, proper food storage, or food safety, and failed to document temperatures and cleaning schedules. Additionally, there was no pest control in the kitchen, which posed a risk of foodborne illnesses to residents. Interviews with the Dietary Cook (DC) and the Administrator highlighted that the former DM had not performed sanitation inspections or maintained a clean and safe kitchen environment. The Administrator, who started on 7/8/24, terminated the DM due to poor job performance and was unsure if any sanitation inspections were completed during the DM's tenure. The facility's Registered Dietician (RD) conducted a sanitation survey on 5/15/24, scoring 61%, but no other surveys were available. The Administrator found the former DM's office disorganized and could not locate prior sanitation surveys, indicating a lack of adherence to facility policies and procedures.
Facility Fails to Maintain Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by observations of unclean kitchen equipment, floors covered in debris, grease, and grime, and improper food storage practices. The facility did not adhere to its own cleaning schedules, as there were no monthly, weekly, or daily cleaning task sheets posted, and the kitchen was found to be in disarray. The kitchen's back hall was cluttered with semi-frozen food items on the floor, uncovered trash cans, and dirty mop buckets, all of which contributed to an unsanitary environment. In the dry storage area, food items were improperly stored, with open sacks of rice on the floor and undated boxes of food spilling out. The area was disorganized, making it difficult for staff to rotate stock or determine when items were opened. The kitchen's prep and food service areas were also found to be unsanitary, with sticky, greasy surfaces, dirty equipment, and improperly stored food items. The freezers lacked proper temperature monitoring, and food items were not dated or organized, increasing the risk of foodborne illness. Interviews with the Dietary Coordinator (DC) and the Administrator revealed a lack of adherence to cleaning protocols and food safety practices. The DC admitted to not knowing how to properly monitor freezer temperatures and acknowledged that the kitchen was not a clean or safe environment for food preparation. The Administrator confirmed that the former Dietary Manager was terminated due to poor performance and that the current DC had not implemented necessary cleaning duties or maintained proper food storage and preparation. The facility's failure to follow its own policies and procedures for kitchen cleanliness and food safety posed a significant risk to the health and safety of the residents.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in the kitchen. During an observation on August 12, 2024, at 9:42 A.M., several flies and gnats were noted throughout the food preparation areas, outside the walk-in cooler, and inside the dry food storage room. The pests were also observed in the dishwasher area, outside the ice machine, and swarming over the steam table, dining room pass-through window, and under the disinfecting sinks around the grease trap. Additionally, gnats were found floating in and swarming around a large, clear rectangular container filled with approximately three inches of cloudy water, located underneath a large industrial food steamer. Interviews conducted on the same day revealed that the Dietary [NAME] (DC) acknowledged the kitchen's dirty condition, which attracted the flies and gnats, and expressed an expectation for the kitchen to be free of such pests. The Administrator also stated an expectation for the kitchen to be free of flies and gnats. Despite these expectations, subsequent observations at 11:00 A.M. and 2:00 P.M. confirmed the continued presence of flies and gnats in the same areas, indicating a failure to address the pest issue effectively.
Failure to Conduct Required Background Checks for Rehired Staff
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy regarding employee screening, specifically in the case of a registered nurse (RN) who was rehired after termination. The facility's policy mandates conducting criminal background checks and checking the federal indicator through the state nurse aide registry for all employees, including those returning after termination. However, the facility did not perform these checks for RN A before allowing them to return to work. RN A was initially hired on February 27, 2023, and terminated on April 26, 2024. Despite this termination, RN A worked an overnight shift on June 21, 2024, without the required background and registry checks being completed. During an interview, the Area Director of Operations confirmed that the necessary background checks should have been completed before re-employment. The oversight in conducting these checks represents a failure to follow the facility's established procedures designed to protect residents from potential abuse, neglect, or mistreatment by staff. This deficiency highlights a lapse in the facility's commitment to ensuring the safety and well-being of its residents by not thoroughly vetting returning employees.
Failure to Prevent Pressure Ulcers Due to Inadequate Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers for a resident who was at risk. The resident, who was cognitively intact but had impairments in both upper and lower extremities, was always incontinent of bowel and bladder and required substantial assistance for personal hygiene and mobility. Despite these needs, the resident was not frequently repositioned, nor was incontinence care provided in a timely manner, leading to the development of new pressure ulcers. Observations revealed that the resident was left lying on a pressure-reducing mattress with a visibly soaked brief and bedding saturated with urine, which had not been changed since the previous day. The resident expressed discomfort and embarrassment due to the lack of care. A CNA confirmed the resident's condition and noted that it was common for residents to be found wet with urine or feces at the start of their shift. The CNA also reported the issue to supervisors, but the resident's condition was not addressed adequately. The Wound Nurse and Wound Physician were not aware of the resident's new skin issues until they were alerted by the CNA. Upon examination, the Wound Physician identified a Stage II pressure ulcer on the resident's left buttock and coccyx. The facility's leadership acknowledged that staff were expected to follow policies, complete skin assessments promptly, and check on incontinent residents every two hours. However, these expectations were not met, contributing to the resident's skin breakdown.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 970 citations issued within 25 miles in the last 12 months — including the 28 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Florissant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowcreek Wellness & Rehabilitation | 0.7 mi | ★★★★★ | 12 | 0 |
| St Sophia Health & Rehabilitation Center | 1.7 mi | ★★★★★ | 27 | 0 |
| Bentwood Nursing & Rehab | 2 mi | ★★★★★ | 29 | 0 |
| Oak Knoll Skilled Nursing & Rehabilitation Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Arbor Hills Care & Rehab Center | 3 mi | ★★★★★ | 28 | 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.