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 Fountain Care At Sunset Hills during CMS and state inspections, most recent first.
Surveyors found that staff failed to administer and manage medications according to professional standards for three residents. One resident with ESRD, CHF, and hypertension repeatedly did not receive multiple 8:00 A.M. medications because the CMT documented the resident as sleeping and did not escalate the ongoing refusals to the DON or physician or attempt to adjust administration times. Another resident with dementia and bipolar disorder had a new order for Azithromycin for pneumonia, but the first dose was delayed many hours despite the drug being available in the E‑Kit, and this resident also went several days without amphetamine‑dextroamphetamine and Valium when bubble cards ran out and staff did not timely secure new prescriptions and refills. A third resident admitted with C‑diff did not receive ordered Vancomycin doses for days even though the pharmacy had delivered the medication, and there was inadequate documentation explaining the omissions, demonstrating systemic failures in timely medication administration, communication, and documentation.
A resident was admitted with multiple documented skin issues, including open lesions on the right lower leg and calf, a diabetic foot ulcer on the right great toe, and peri-anal redness. An LPN performed the admission skin check, applied basic dressings and barrier cream, but did not notify the physician, did not obtain treatment orders, and did not enter the skin issues or treatments on the TAR. Other LPNs and the wound care nurse reported that they rely on the TAR to identify residents needing wound assessment and treatment, and the POS and TAR contained no orders or entries for these wounds. As a result, through the time of the resident’s death, the skin issues were not supported by physician orders and were not documented for ongoing monitoring and assessment.
A resident admitted with cognitive impairment, total dependence for care, incontinence, and a high-risk Braden score was found on admission to have an open, reddened coccyx pressure ulcer along with other skin issues. The admitting LPN measured and documented the coccyx ulcer in a progress note and applied barrier cream but did not notify the physician, did not obtain or document any treatment orders, and did not enter the ulcer or a treatment on the POS or TAR. The LPN reported an undocumented attempt to contact the physician on the day of admission and made no further attempts on subsequent worked days, and no other nurses were aware of the ulcer because it was not listed on the TAR. As a result, up to the time of the resident’s death, the coccyx pressure ulcer had no physician orders and was not included in the facility’s ongoing monitoring and treatment system.
A facility failed to communicate care plans and implement proper transfer methods, resulting in a resident sustaining multiple fractures after being transferred without a mechanical lift. Another resident experienced multiple falls and significant swelling, but staff failed to notify the physician of the change in condition. The lack of communication and adherence to care plans led to immediate jeopardy for the residents.
The facility failed to investigate resident-to-resident altercations in a timely manner, involving residents with cognitive impairments and other medical conditions. Staff interviews revealed a lack of communication and understanding of the facility's abuse policy, resulting in delayed investigations and notifications to the state agency.
The facility failed to report resident-to-resident altercations to the Department of Health and Senior Services within the required timeframe. In two separate incidents, residents with cognitive impairments were involved in altercations, but no immediate investigation or report to the state agency was made. Staff members were aware of the incidents but did not initiate an investigation, believing it was management's responsibility. The new Administrator expected the facility's policy to be followed, but the report was delayed.
A resident with severe cognitive impairment and a history of stroke experienced significant weight loss due to the facility's failure to implement a Registered Dietitian's recommendation for a revised g-tube feeding schedule. The recommendation was not communicated to the resident's physician, hospice nurse, or family, leading to continued weight loss. Interviews revealed that facility staff were unaware of the recommendation, and the facility lacked a nutritional policy.
A resident in an LTC facility developed a Stage III pressure ulcer due to inadequate care and prevention measures. Initially, a small breakdown on the buttocks was identified, but it was not staged, and no treatment order was obtained. Weekly skin assessments were not completed, leading to the ulcer's progression. The facility's policies were not followed, and documentation was inconsistent, contributing to the deficiency.
A facility failed to prevent the unauthorized removal of controlled medications by an LPN, who tampered with medication cards for two residents. The LPN was observed on video replacing oxycodone pills with Claritin. Both residents involved were on scheduled pain medication regimens but did not experience a lapse in medication administration.
A facility failed to follow its policy when an injury of unknown origin was discovered on a resident and was not reported, assessed, or investigated. The resident indicated the injury occurred when an aide hit their leg with a wheelchair foot pedal, but no documentation or incident report was initiated. Staff interviews confirmed awareness of procedures, but these were not followed, leading to the deficiency.
A resident with Type 2 diabetes mellitus and diabetic chronic kidney disease sustained a skin tear from an aide hitting their leg with a wheelchair foot pedal. The facility failed to obtain a physician's order for wound care, document the incident, or notify the responsible parties, contrary to their policy.
Failure to Administer and Manage Medications in Accordance With Professional Standards
Penalty
Summary
The deficiency involves multiple failures in medication administration and communication that did not meet professional standards of quality. One resident with ESRD on hemodialysis, CHF, hypertension, atrial fibrillation, and other comorbidities had numerous 8:00 A.M. medications, including cardiac, anticoagulant, renal, and vitamin therapies, documented as not given on multiple days because the resident was sleeping. The electronic MAR showed that on ten separate days in January, eight of eight scheduled 8:00 A.M. medications were not administered, and a weekly vitamin D dose was also missed on two of three scheduled Wednesdays, all coded as the resident sleeping. The CMT who typically passed these medications stated the resident preferred to sleep until around noon and did not want 8:00 A.M. medications, but also stated they had not informed the DON or the physician, had not asked the resident about changing medication times, and had only told a nurse that the resident was not taking the morning medications. The nurse who checked the resident’s blood glucose and administered insulin around 8:00 A.M. reported not being aware of the missed 8:00 A.M. medications and indicated that, if informed, they would have attempted to administer the medications or discuss alternate times with the resident. Another deficiency involved a cognitively intact resident with non‑Alzheimer’s dementia, anxiety, depression, and bipolar disorder who had new orders for Azithromycin for pneumonia and was also prescribed amphetamine‑dextroamphetamine and Valium. A chest x‑ray impression showed focal pneumonia, and a physician order for Azithromycin was obtained that evening. The MAR showed the first Azithromycin dose was not administered until the following day at midday, approximately 15 hours after the order, despite Azithromycin being stocked in the facility’s E‑Kit. The resident reported not feeling well due to pneumonia and stated staff told them the antibiotic had not yet been received. The same resident’s MAR and progress notes documented that amphetamine‑dextroamphetamine and Valium doses were repeatedly not given over several days because the medications were on order or a new prescription was needed. Nursing notes repeatedly indicated the medications were on order or awaiting pharmacy delivery, and that a new script was needed, but one LPN acknowledged not contacting the pharmacy or physician personally and assumed another nurse had done so. Pharmacy records showed that new prescriptions were not received until several days after the medications began running out, and that delivery occurred only after those prescriptions were obtained. A third deficiency involved a newly admitted resident with C‑diff who had a hospital order for Vancomycin 125 mg daily for four days. The facility MAR contained an order for Vancomycin at 6:00 A.M. for four days, but staff documented code 9 (other/see progress notes) for the first two scheduled doses. The progress notes contained no explanation for the missed dose on the first day and documented on the second day that Vancomycin was pending delivery. A pharmacy representative reported that four doses of Vancomycin were delivered to the facility late morning on the first day, but the first dose was not administered until three days after delivery. The DON stated that when medications are delivered, the receiving nurse is responsible for ensuring medications for residents on other halls are promptly distributed, and that if Vancomycin was delivered that morning, she would have expected it to be administered that day. Across these three residents, the survey identified failures to administer ordered medications as scheduled, to use the E‑Kit for timely initiation of antibiotics, to prevent medications from running out by timely reordering and obtaining new prescriptions, and to document and communicate medication refusals and omissions in accordance with facility policy.
Failure to Obtain Physician Orders and Document Treatment for Admission Skin Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and obtain treatment orders for multiple skin issues identified at admission, and to document these issues on the treatment administration record (TAR) for ongoing monitoring. The facility’s Skin Program Policy required that all residents be fully assessed on admission, that residents admitted with skin areas/pressure ulcers have treatment orders initiated upon admission, and that an individualized skin plan of care be developed. The resident was admitted on 12/19/25 with documented dependence in multiple ADLs, cognitive impairment, and incontinence, and the baseline care plan noted current skin integrity issues and referenced a skin assessment. On the evening of admission, an LPN completed a skin check and documented several skin issues in the progress notes: an open lesion on the front right medial lower leg, an open lesion on the right lateral calf, a diabetic foot ulcer on the right great toe, and redness in the peri-anal area. A subsequent admission note the same night described redness to the groin and shearing areas on the front right shin, back of right ankle, and right big toe. However, there was no documentation that the resident’s physician was contacted for treatment orders for these identified skin issues, and the physician order sheet contained no corresponding treatment orders. The TAR for the period from 12/1/25 through 12/23/25 contained no entries to monitor or treat these specific skin issues. In interviews, the admitting LPN stated that dressings were removed, the areas were cleaned with soap and water, and protective dressings and barrier cream were applied, but acknowledged forgetting to place the skin issues and any treatments on the TAR and not documenting attempts to contact the physician. The LPN reported only one undocumented attempt to contact the physician on the day of admission and no further attempts on the following days, despite working that weekend and changing dressings without documentation. Other LPNs and the wound care nurse indicated that they rely on the TAR to know which residents have skin issues requiring assessment or treatment, and that if a treatment is not on the TAR, they would not know to perform it. The DON and wound care nurse both stated that the admitting nurse should have contacted the physician for treatment orders, documented those orders on the POS and TAR, and documented multiple attempts to reach the physician. As of 12/23/25, when the resident died, the facility still had not contacted the physician regarding the identified skin issues, had not obtained treatment orders, and had not documented the skin issues on the TAR for ongoing monitoring and assessment.
Failure to Obtain Physician Orders and Document Treatment for Admission Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and obtain treatment orders for a coccyx pressure ulcer identified on admission, and failure to place the ulcer and its treatment on the Treatment Administration Record (TAR) for ongoing monitoring. The facility’s own Skin Program Policy required that all residents be fully assessed on admission, that residents admitted with skin areas/pressure ulcers have treatment orders initiated upon admission or readmission, and that an individualized preventative and active skin plan of care be developed. The resident was admitted with cognitive impairment, total dependence for mobility and hygiene, constant moisture, chairfast status, friction and shear problems, and a Braden score of 11, indicating high risk for pressure injuries. On the evening of admission, the admitting LPN documented a coccyx pressure ulcer/pressure injury measuring 4.0 cm x 0.3 cm x 0.5 cm, with redness and an open area, along with other skin issues to the groin, right shin, back of right ankle, and right big toe. Despite identifying the coccyx pressure ulcer, the admitting LPN did not obtain or document any physician orders for treatment of this wound and did not enter a treatment on the physician order sheet or TAR. The LPN reported cleaning the ulcer and applying barrier cream but acknowledged forgetting to place the treatment on the TAR and not documenting the care provided. The LPN stated they attempted to contact the physician on the day of admission but did not document this attempt and made no further attempts to contact the physician on the following two days worked, even though the resident remained under their care. There was no documentation in the progress notes that the physician was notified about the coccyx pressure ulcer or that any treatment orders were received. Other nursing staff and the wound care nurse confirmed that, per facility practice, any pressure ulcer or skin treatment should appear on the TAR so that nurses on all shifts know to assess and treat the area. Multiple LPNs stated that if a pressure injury or treatment is not on the TAR, they would not know it existed or required care. The wound care nurse and DON both indicated that the admitting nurse was responsible for completing the admission skin check, notifying the physician, obtaining treatment orders, and documenting the ulcer and orders on the POS, TAR, and in progress notes, including any attempts to contact the physician. As of the date the resident died, there were still no physician orders or TAR entries for the coccyx pressure ulcer, and the ulcer had not been incorporated into the facility’s ongoing monitoring and treatment systems.
Failure to Communicate Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure proper communication and implementation of care plans for residents, leading to significant injuries. In one instance, a resident with a history of stroke and cognitive impairment required a mechanical lift for transfers, as indicated in their care plan. However, an agency CNA, who did not receive a proper report or instructions, attempted to transfer the resident using a gait belt instead of a Hoyer lift. This resulted in the resident falling and sustaining multiple fractures, including to the ribs, legs, and ankle. The incident was not promptly communicated to the resident's physician, and the resident was not transferred to the hospital until several hours later, during which time they became lethargic and hypotensive. Another resident, who was cognitively intact but had a history of falls and multiple medical conditions, experienced several falls over a short period. Despite showing signs of significant injury, including facial swelling and black eyes, the facility staff failed to notify the physician of the resident's change in condition. The resident was left sitting on the toilet for extended periods, refusing care, and eventually required emergency medical attention due to severe swelling and confusion. The lack of timely medical intervention and failure to follow the facility's policy for notifying physicians of changes in condition contributed to the resident's deteriorating health. The facility's policies for change in condition and fall prevention were not adequately followed, as evidenced by the lack of communication and documentation regarding the residents' conditions and care needs. Agency staff did not receive proper orientation or instructions, and there was no system in place to ensure they reviewed the care instructions binder. These deficiencies in communication and adherence to care plans resulted in immediate jeopardy to the residents' health and safety.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to adhere to its abuse policy by not thoroughly investigating in a timely manner allegations of resident-to-resident altercations. The incidents involved two separate pairs of residents. In the first incident, a resident with no cognitive impairment and a history of congestive heart failure, high blood pressure, and dementia was involved in an altercation with another resident who had moderate cognitive impairment and delusions. The altercation was witnessed by a nurse, but there was no documentation of the Administrator, Director of Nursing (DON), or Assistant Director of Nursing (ADON) being notified, and it was unclear if an investigation was initiated. In the second incident, a resident with no cognitive impairment and a history of stroke was assaulted by their roommate, who had severe cognitive impairment and dementia. The assault was witnessed by a nurse and a Certified Medication Technician (CMT), but again, there was no documentation of the Administrator, DON, or ADON being notified. The CMT noted that an investigation should have been started immediately, but it was not until the surveyor's inquiry that any action was taken. Interviews with staff revealed a lack of communication and understanding of the facility's abuse policy. The ADON received a text message about the incident but did not initiate an investigation or report it to the state agency until prompted by the surveyor. The Social Service Director (SSD) also did not start an investigation, citing a lack of knowledge on how to report to the state agency. The DON admitted to not starting the investigations until the day after the surveyor's inquiry, indicating a systemic failure to follow the facility's abuse policy and ensure timely investigations.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to report allegations of abuse to the Department of Health and Senior Services (DHSS) within the required timeframe following resident-to-resident altercations. The facility's policy mandates immediate reporting of such incidents, but this was not adhered to in two separate incidents involving four residents. In the first incident, Resident #15, who had no cognitive impairment but was diagnosed with dementia, was involved in an altercation with Resident #16, who had moderate cognitive impairment and delusions. The altercation involved Resident #15 hitting Resident #16, but no injuries were noted. Despite the incident, there was no immediate investigation or report to the state agency. In the second incident, Resident #10, who had no cognitive impairment but was dependent on activities of daily living due to a stroke, was assaulted by their roommate, Resident #11, who had severe cognitive impairment and dementia. Resident #11 hit Resident #10 in the face, breaking their glasses. Although the residents were separated and sent to the hospital, the incident was not reported to the state agency until the following day when a surveyor inquired about it. Staff members, including a Certified Medication Technician and a Licensed Practical Nurse, were aware of the incident but did not initiate an investigation or report it, as they believed it was the responsibility of management. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the incidents through a group text message, but no immediate action was taken to report the incidents to the state agency. The new Administrator, who had been with the facility for less than 24 hours, expected the facility's policy to be followed, but the report to the state agency was delayed. The lack of timely reporting and investigation of these incidents constitutes a deficiency in the facility's adherence to its abuse, neglect, and exploitation policy.
Failure to Implement Dietitian's Recommendation for Resident with Weight Loss
Penalty
Summary
The facility failed to address a recommendation from the Registered Dietitian (RD) for a resident experiencing significant weight loss. The resident, who had severe cognitive impairment, was dependent on activities of daily living, and had a history of stroke, was at risk for pressure ulcers and had a gastronomy tube (g-tube) for nutrition. Despite the RD's recommendation to change the g-tube feeding schedule to prevent further weight loss, there was no documentation of this recommendation being communicated to the resident's physician, hospice nurse, or family. Consequently, the resident continued to lose weight, dropping from 151.7 lbs to 132.1 lbs over a three-month period, representing a 12.2% weight loss. Interviews with facility staff, including the RD, Hospice Nurse, Wound Nurse Practitioner, Director of Nursing (DON), and the resident's physician, revealed that none were aware of the RD's recommendation. The DON indicated that the previous Assistant Director of Nursing was responsible for following up on such recommendations, but the process was not completed. The facility also lacked a nutritional policy, which contributed to the oversight. The failure to implement the RD's recommendation and communicate it to relevant parties resulted in the resident's continued weight loss and potential impact on their health.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development of a Stage III pressure ulcer. Initially, a small breakdown on the resident's buttocks was identified, but it was not staged, and no treatment order was obtained. Despite documentation indicating treatments were provided, licensed nursing staff did not complete weekly skin assessments between mid-June and early July. Consequently, the pressure ulcer progressed to Stage III before being identified and treated. The facility's Skin Program Policy and Procedure, implemented in April 2023, mandates comprehensive skin assessments upon admission and regular follow-ups. However, the resident's Braden skin risk assessment, completed in November 2023, indicated a high risk, yet no further assessments were conducted. The resident's care plan did not include the presence of pressure ulcers, and there was a lack of documentation for treatment orders for the sacrum wound throughout May and June. Interviews with facility staff revealed inconsistencies in skin assessment practices and documentation. The Administrator acknowledged the failure to complete and document skin assessments as ordered, and the wound care company Nurse Practitioner expressed expectations for earlier intervention. The facility's oversight and lack of adherence to its own policies contributed to the resident's pressure ulcer progressing to a more severe stage.
Unauthorized Removal of Controlled Medications
Penalty
Summary
The facility failed to prevent the unauthorized removal of Schedule II controlled medications, specifically oxycodone, for two residents. The incident involved a Licensed Practical Nurse (LPN) who was observed tampering with medication cards. The LPN was seen on video footage using tape to cover missing pills and replacing them with Claritin, an over-the-counter allergy medication. This tampering was discovered during a routine medication count by another LPN. Resident #1, who was cognitively intact and had diagnoses including end-stage renal disease and heart failure, was on a scheduled pain medication regimen. The resident's medication card was found to have been tampered with, although the resident did not experience a lapse in pain medication administration. Similarly, Resident #2, who was also cognitively intact and had conditions such as diabetes and quadriplegia, was on a scheduled pain medication regimen. Their medication card was also found to be tampered with, but they did not experience a lapse in medication. The incident was initially discovered by an LPN who noticed tampering during a shift change. The LPN reported the issue to the Director of Nursing (DON), who then conducted an audit of the medication carts. The DON discovered that several oxycodone pills were missing and had been replaced with Claritin. The facility's investigation revealed that the LPN involved had access to the medication cart keys for several hours during the night shift, which allowed for the tampering to occur.
Failure to Follow Policy for Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its policy when an injury of unknown origin was discovered on a resident and was not reported, assessed, or investigated. The resident, who was cognitively intact and required partial to moderate assistance for transfers, was observed with a bandage on their right lower leg. The bandage was dated two days prior, and the resident indicated that the injury occurred when an aide hit their leg with the foot pedal of their wheelchair. However, there was no documentation in the resident's progress notes regarding the injury, assessment, or notification of the responsible party or physician. The Assistant Director of Nursing (ADON) confirmed that there was no documentation available in the resident's medical record regarding the injury. The initials on the resident's dressing belonged to the Director of Nursing (DON), but no incident report or assessment had been initiated. Interviews with various staff members, including Certified Nursing Assistants (CNAs) and nurses, revealed that they were aware of the procedures to follow when discovering an injury of unknown origin, but these procedures were not followed in this case. The Administrator was made aware of the incident by the ADON and acknowledged that the facility's policies were not followed. The Administrator expected the DON to have documented the incident, performed a skin assessment, and notified the appropriate parties. The lack of documentation and failure to follow the facility's Accident and Incident Protocol and Abuse, Neglect, Misappropriation of Resident Property policy led to the deficiency.
Failure to Obtain Physician's Order for Skin Tear
Penalty
Summary
The facility failed to follow its policy by not obtaining a physician's order for a skin tear of unknown origin for a resident, potentially increasing the risk of a negative outcome related to the healing process. The resident, who has a diagnosis of Type 2 diabetes mellitus with diabetic chronic kidney disease, was observed with a bandage on their right lower leg that was stained and dated two days prior. The resident reported that the injury occurred when an aide hit their leg with the foot pedal of their wheelchair, and they were unsure about the dressing change schedule. Upon review, it was found that there were no physician orders for wound care or treatment documented for the resident. Additionally, there was no documentation in the resident's progress notes regarding the injury, assessment, accident/incident report initiation, or notification of the responsible party or physician. The Assistant Director of Nursing confirmed the lack of documentation and stated that the incident should have been assessed, the physician notified, and an order obtained for treatment, all of which should have been documented. Interviews with staff revealed that the expected protocol for handling such incidents was not followed. The nurse stated that they would have assessed the resident, notified the physician and family, and documented the incident, but this was not done. The Administrator also confirmed that the incident was not documented as expected and that the dressing should have been changed since the initial date. The Administrator indicated that the incident should have been discussed with risk management and the team, and that in-service training should have been completed to prevent such occurrences.
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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 Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Sunset Hills | 0.4 mi | ★★★★★ | 0 | 0 |
| Fieser Nursing Center | 2.2 mi | ★★★★★ | 22 | 0 |
| Delmar Gardens South | 3 mi | ★★★★★ | 0 | 0 |
| Grove At Kirkwood, The | 3.3 mi | ★★★★★ | 29 | 0 |
| Bluebird Wellness And Rehabilitation | 3.5 mi | ★★★★★ | 1 | 0 |
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