Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around September 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 Ignite Medical Resort St Peters during CMS and state inspections, most recent first.
A facility failed to manage pain effectively for two residents. One resident with cancer and fractures had repeated severe pain, inconsistent reassessment after PRN opioids, gaps in oxycodone availability, and no documented physician notification when pain remained uncontrolled; staff also documented PRN doses that were not supported by the MAR. Another resident with a left ankle fracture did not receive scheduled acetaminophen within the ordered timeframe, and records showed late doses, missing pain assessments, and missing effectiveness documentation.
The facility failed to follow its neuro assessment policy and provide appropriate EMS handoff for multiple residents. One resident on anticoagulation fell from bed, sustained a head laceration, and reported lying on the floor for a long time without staff present; no neuro checks were documented, no first aid such as pressure to the wound was provided, and EMS found the resident alone using clothing to control bleeding while the RN remained at the nurses’ station and did not give a report. Another resident on apixaban with complex cardiopulmonary history developed lower extremity discoloration, had Doppler-confirmed DVT, and was later emergently transferred for dyspnea; EMS and family reported that no staff were present in the room on EMS arrival, the family provided the clinical history, and the nurse who eventually appeared was unaware of the situation and minimized the resident’s respiratory distress. A third resident with stroke, dementia, severe cognitive impairment, and prior falls rolled out of bed, reported hitting the head, and had only a single neuro assessment documented, with no ongoing neuro checks recorded per facility protocol for unwitnessed falls.
A resident with osteomyelitis, peripheral vascular disease, and HTN was assessed as high risk for falls but had no fall care plan in place. The resident rolled out of a low bed while reaching for a phone charger, struck the head between the bed and a recliner, and required hospital evaluation with sutures placed. On return, documentation noted safety checks and a low bed, but record review showed no fall risk or post-fall care plan and the MDS inaccurately reflected no fall history. Observation later found the call light on the floor and out of reach, and the resident reported being unable to summon help and lying on the floor for a long time. Staff interviews revealed the fall was not correctly entered into the EMR, so required post-fall assessments and documentation were not triggered, and no individualized fall interventions were developed despite facility policy.
A resident with CHF, ESRD, and other comorbidities was admitted with documented superficial skin loss on the buttocks and a care plan for skin risk that included barrier cream and turning/positioning, but no Braden Scale was completed at admission and no weekly skin assessments or skin sheets were documented. The resident spent most of the time and slept in a recliner without a pressure-relieving cushion, reported a sore bottom, and stated that staff applied some cream but that no nurse had inspected the area. The pressure injury was only discovered when a CNA assisted with toileting and observed an open, draining area on the buttock, which an LPN then described as appearing to be a Stage 3 pressure ulcer, with no prior nursing documentation or notification of the wound.
The facility failed to complete a comprehensive facility assessment that identified the staffing and resources needed to meet resident care needs across all shifts. The assessment did not state the number of nursing staff required, omitted services and equipment needed for bariatric residents, had no completion signatures, and included inaccurate facility information. The resident matrix showed multiple care needs, including catheters, infections, falls, pressure ulcers, dementia, IV meds, enteral feedings, dialysis, hospice, therapy, and bariatric residents.
Surveyors found that the facility failed to administer ordered admission medications and to use available emergency medications for two residents with pneumonia, respiratory conditions, and chronic cardiac issues. One resident did not receive newly ordered antibiotics for pneumonia on the day they were prescribed, despite those drugs being listed in the emergency supply and no documentation of physician or pharmacy notification. Another newly admitted resident did not receive ordered anticoagulant, cardiac, antifungal, and nebulized bronchodilator doses on the evening of admission, even though some of these medications were present in the e-kit and the resident later reported not getting bedtime medications because they were unavailable. LPN interviews showed uncertainty about which drugs were in the e-kit, lack of access or use of the kit, and failure to obtain needed respiratory equipment from central supply, and the facility lacked a policy outlining how to obtain new medications or what to do when they were not available.
Surveyors found that medications were repeatedly left unsecured and unattended on a nurse’s station desk, on top of a treatment cart, and in unlocked medication and treatment carts, while residents and visitors passed nearby and no staff were in line of sight. Staff, including an LPN, RN, DON, and the Administrator, acknowledged that facility policy requires all medications and carts to be locked when unattended and that medications received from the pharmacy must be secured. In a separate finding, a resident recently admitted with influenza A pneumonia, bacterial pneumonia, COPD, and acute respiratory failure had four prescription inhalers from home lying on the bed without corresponding physician orders for all inhalers or an order to self-administer, and nursing leadership reported they were unaware of these bedside medications and stated that medications should be kept in a secure location.
The facility failed to provide needed bathing assistance to three dependent residents. Their records had no documentation of bathing preferences or bathing frequency, and bathing logs showed only limited showers or baths over the review period. Each resident said they had not been bathed as often as desired and wanted bathing at least twice weekly, while observations noted body odor and disheveled or greasy hair. An LPN reported there was only one aide on the hall and staff did not have time to provide showers as often as residents wished; the RDCS and DON stated the residents had not received showers as they should or as they desired.
Insufficient nursing staffing led to missed showers, lack of meal supervision, delayed breakfast assistance, and late medication administration. Residents who needed help with bathing went long periods without showers and had signs of poor hygiene. Several residents who required supervision with eating were left unsupervised during meals or had breakfast trays left out while asleep, and one resident’s medications were given late because the morning med pass was not completed on time. The DON also worked on the floor when census was over 60, and staff reported call-offs and too few aides and nurses to meet resident needs.
A resident with multiple comorbidities, severe cognitive impairment, dependence for ADLs, and an unstageable pressure ulcer experienced a significant weight loss of nearly 14% over two months. Facility policy required investigation and intervention for significant weight changes, but weights were not consistently documented, and no specific weight-loss interventions were added to the care plan. The RD identified increased nutrient needs, recommended supplements (Pro Heal, Juven) and later recommended adding Magic Cup BID, but this recommendation was not communicated to the physician, not entered as a diet order, and not provided with meals, as confirmed by observations and interviews with the resident, family, LPN, RD, and Dietary Manager. Leadership staff stated they expected RD recommendations to be reviewed and communicated, but this did not occur, resulting in failure to implement and evaluate appropriate nutritional interventions for the resident’s weight loss.
A resident admitted in the early evening with fracture pelvis, respiratory failure, and protein-calorie malnutrition, and ordered a regular mechanical soft diet, did not receive an evening meal from the facility. The family member reported that no staff offered food, a nurse stated the kitchen was closed, and the family had to purchase food from a local restaurant. The Dietary Manager stated that admission memos had prompted preparation of several trays, including one left in the kitchen window for this resident, but nursing never retrieved or delivered it. The tray remained in the window until the next morning, and the resident later reported being hungry and receiving little to eat for supper.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy for two residents with wounds and indwelling devices, including a urinary catheter, dialysis CVC, AV fistula, and multiple documented pressure and other wounds. Required EBP signage and PPE carts were absent from room entrances, and staff performed high-contact care activities such as transfers, toileting, linen changes, perineal care, catheter manipulation, and wound care wearing only gloves and no gowns, despite care plans and physician orders specifying EBP. Interviews with CNAs, an LPN, a nurse manager, the DON, the Administrator, and the Medical Director revealed uncertainty and lack of knowledge about which residents were on EBP and inconsistent implementation of the policy.
A resident with morbid obesity and a weight of 574 lbs was admitted without the needed bariatric equipment available. The resident’s bariatric WC would not fit through the bathroom or shower room doors, the facility had only a regular bed pan that spilled urine onto the bed, there were no bariatric shower chairs, and a mechanical lift could not raise the resident because the battery was dead. The ADM stated the facility had reviewed the resident’s records before admission and had ordered equipment, but the WC and lift were not delivered until after admission.
The facility failed to notify the physician about a resident’s significant weight changes and repeated missed doses of ordered diuretic medication when the medication was unavailable, despite CHF-related monitoring orders. The facility also failed to notify a resident’s family when the resident developed severe hypoglycemia, required glucagon, and was transferred by EMS to the ED. Records showed missing documentation of physician notification for the weight gains and medication omissions, and no documentation that the family was informed of the emergency transfer.
A resident with CHF, cardiomyopathy, AFib, and edema did not receive an ordered switch from Lasix to torsemide as prescribed by cardiology. The MAR continued to show Lasix administration, the new order was not promptly transcribed, and nursing notes documented the torsemide was unavailable for multiple days. The resident and family reported worsening swelling, leg drainage, weakness, and shortness of breath until the new medication was finally given.
Inadequate Pain Assessment, Timely Medication Administration, and Follow-Up
Penalty
Summary
The facility failed to provide effective pain management for two residents. One resident had diagnoses including anal cancer, a right hip fracture, and thoracic vertebral compression fractures, and frequently rated pain at 8 or higher on a 0-10 scale. The resident’s pain was documented as constant, throbbing, and burning, and staff noted that pain affected mood and emotions. The resident’s family reported the resident did not sleep well because of pain. The record showed repeated PRN opioid administration with inconsistent reassessment and documentation of effectiveness, including entries of unknown effectiveness, delayed follow-up, and periods when pain medication was not given despite continued reports of severe pain. For this resident, staff also failed to maintain access to oxycodone, and the resident was without the medication from 05/16/26 until 05/20/26. During that period, the resident continued to report severe pain, including pain rated 8 to 10 out of 10, and staff documented that hydromorphone and acetaminophen were sometimes ineffective or of unknown effectiveness. The record showed no documentation that the physician was notified when pain remained uncontrolled or when the resident was out of oxycodone. The resident and family reported long waits for pain medication, that hydromorphone alone did not control the pain, and that the resident had difficulty sleeping due to pain. Staff also documented PRN pain medication administration that was not supported by the MAR, and one note stated the resident was given PRN pain medication at times that were not documented in the medication record. The facility also failed to administer scheduled acetaminophen to another resident within an hour of the scheduled time. That resident had a displaced trimalleolar fracture of the left lower leg and reported pain that affected sleep. The physician ordered acetaminophen 500 mg, two tablets every eight hours scheduled for pain, but the MAR showed doses given late and sometimes without a documented pain assessment or effectiveness. The resident reported that the longest waits occurred on night shift, that PRN pain medication often took about two hours to receive, and that late scheduled medication contributed to breakthrough pain. The DON and Administrator stated staff were expected to assess pain, administer medications on time, and contact the physician if pain was not tolerable, but the records showed these expectations were not consistently met.
Failure to Perform Neuro Checks and Communicate with EMS After Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its own neurological assessment policy and professional standards of practice after resident falls and changes in condition, and failure to provide pertinent information to EMS. For one resident with osteomyelitis, PVD, hypertension, and an active order for Eliquis, nursing notes documented that the resident rolled out of bed while reaching for a phone charger, was found on the floor with a gash to the right temple, swelling, and a reported headache, and that 911 was contacted. Vital signs were abnormal, and the dressing to the resident’s left foot was no longer intact. There was no documentation of a neurological assessment despite the head injury and the facility’s policy requiring neuro checks for unwitnessed falls and head injuries. The resident later returned from the hospital with a negative CT scan and sutures to the forehead, but no neuro checks were documented in the record. The same resident reported lying on the floor for a long time after the fall, yelling for help and being unable to find the call light. The resident stated that when staff arrived, they said they could not get the resident off the floor because of the head injury and that they had to call 911, then left the room. The resident reported that no one applied anything to the head to stop the bleeding, and that the resident used a pair of pants to apply pressure. EMS personnel later confirmed finding the resident alone on the floor with pants on the forehead to control bleeding and no staff present in the room. EMS staff reported having to leave the room to locate a nurse, finding the RN at the nurses’ station, and that the RN came to the room only after EMS had the resident on the gurney, handed over paperwork, stated they were going to get an ice pack, and left without giving a report or providing care. The RN later acknowledged not starting neuro checks because the resident was going to the emergency room, not applying pressure to the laceration, not recalling if the resident was on blood thinners, and knowing that neuro checks should be done for unwitnessed falls. Another resident with a history including fractured pelvis, toxic encephalopathy, acute respiratory failure, interstitial pulmonary disease, atrial fibrillation, anemia, and an order for apixaban had a care plan addressing anticoagulant therapy and monitoring for adverse reactions. A nurse practitioner documented bluish discoloration on the dorsum of both feet and ordered stat arterial and venous Doppler studies. The Doppler results showed acute DVT involving multiple veins in the left lower extremity, and the physician was notified. The medical record contained no further documentation of the resident’s condition, no additional physician orders related to the Doppler findings, and no documentation of transfer to the hospital, despite ambulance records indicating an emergent transfer for dyspnea. EMS documentation and family interviews indicated that when EMS arrived, no staff were in the room, the family provided the history including Doppler results and physician conversation, and staff only appeared about 20 minutes later as EMS was exiting with the resident. The nurse who entered the room did not know what was going on with the resident and told EMS that the resident’s shortness of breath was normal, and the corporate DON later stated that the nurse on duty should have documented and given report to EMS. A third resident with stroke, dementia, severe cognitive impairment (BIMS of 4), dependence on staff for ADLs and mobility, and a history of multiple falls had a documented fall in which the resident rolled out of bed from the side opposite the fall mat and stated they hit their head. Nursing notes recorded that ROM and a neuro assessment were within normal limits for the resident and that vital signs were taken, with the resident transferred back to bed and the physician and responsible party notified. However, there was no documentation that neurological checks were completed per the facility’s neurological flow sheet protocol after this unwitnessed fall with reported head impact. The ADON confirmed that neurological flow sheets should be completed for every unwitnessed fall, that these are to be uploaded into the EMR, and that no such documentation existed for this resident. The ADON also confirmed that the fall for the first resident was not entered correctly into the EMR, so no post-fall assessment, neurological assessment, or care plan interventions were generated.
Failure to Care Plan and Implement Interventions for High Fall-Risk Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess and care plan for a resident identified as high risk for falls, and to implement post-fall interventions after an actual fall. The resident was admitted with osteomyelitis of the left ankle and foot, peripheral vascular disease, and hypertension, and was assessed on 02/16/26 as being at high risk for falls. On 03/01/26 at 4:30 p.m., nursing notes documented that the resident rolled out of bed while reaching for a phone charger, landing on the right side of the body between the bed and a recliner, and sustaining a gash to the right temple with swelling and headache, requiring transfer to the emergency room. Later that evening, notes indicated the resident returned from the hospital with sutures to the forehead, a negative CT scan, and that safety checks were in place with the bed in a low position and instructions given to report dizziness or lightheadedness. Despite the high fall risk assessment and the documented fall with head injury, review of the medical record from 03/01/26 through 03/10/26 showed no care plan addressing the resident’s fall risk or the actual fall. The comprehensive MDS dated 03/03/26 documented the resident as cognitively intact, able to make self-understood, and at risk for falls with no history of falls, even though a fall had occurred on 03/01/26. Observation on 03/10/26 found the resident in a low bed with the call light on the floor and not within reach, and the resident reported having been unable to find the call light at the time of the fall and lying on the floor for a long time before help arrived. Interviews with the ADON, MDS coordinator, interim DON, and Administrator confirmed that the fall was not correctly entered into the EMR, which prevented triggering of post-fall assessments and documentation, and that no fall care plan or interventions had been developed for this resident despite facility policy requiring assessment and care planning for residents at risk for falls and after every fall.
Failure to Prevent and Timely Identify Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services, including individualized interventions, to prevent the development and identification of a Stage 3 pressure ulcer on a resident’s buttock. The facility’s skin policy required a full-body skin assessment within 6 hours of admission, weekly skin assessments, quarterly Braden Scale risk assessments, and use of skin sheets by direct care staff to report abnormalities. For this resident, admitted with diagnoses including CHF, ESRD, heart failure, anemia, and depression, there was no Braden Scale completed upon admission and no documented weekly skin assessments after the initial admission assessment. The admission note documented normal skin color and temperature with no open areas but did note superficial skin loss on the buttocks, and the care plan identified risk for alteration in skin with interventions such as barrier cream and turning/positioning every two to three hours, yet there was no documentation that barrier cream was applied. In the days following admission, the resident was repeatedly observed sitting and sleeping in a recliner without a pressure-relieving cushion. The resident reported sitting in the recliner all the time, sleeping there because of fear of rolling out of bed, and primarily lying on his/her back. The resident stated that his/her bottom was sore and that staff had applied “some type of cream,” but also reported that no nurse had looked at the area. Observations on consecutive evenings and early mornings showed the resident in the recliner on his/her back, still without a pressure-relief cushion, despite the facility policy that staff should encourage bed use and provide a cushion for the recliner as needed. The pressure ulcer was identified only when a CNA responded to the resident’s call light for toileting and the resident complained of pain in the bottom while sitting on the toilet. The CNA observed an open area on the inner left buttock about the size of a quarter with bloody drainage and white tissue in the center surrounded by red to pink tissue, and reported not having seen it before. An LPN then assessed the area and described the larger open area as deep with white tissue and some drainage, with the appearance of a Stage 3 pressure ulcer, and also noted a superficial open area on the left buttock. The LPN stated he/she had not been notified of these open areas prior to that day. Review of the medical record showed no completed skin assessments after admission and no skin sheets per facility policy, and interviews with leadership confirmed expectations that Braden assessments, weekly skin checks, and prompt identification and reporting of skin issues should have occurred but did not in this case.
Incomplete Facility Assessment and Staffing Determination
Penalty
Summary
The facility failed to complete a comprehensive facility assessment specific to the facility and failed to ensure the assessment determined the appropriate number of staff and resources needed to care for residents competently during day-to-day operations and emergencies. The facility census was 70. The facility policy dated 8/01/24 stated the assessment was to evaluate the resident population, identify needed resources, inform staffing decisions across day, evening, and night shifts, and address staffing competencies, contingency planning, and resident care needs based on assessments and care plans. Review of the facility assessment dated 06/21/24 showed resident care needs such as assistance with eating, toileting hygiene, transfers, and bed mobility, and stated staffing across all shifts and units would be adjusted based on acuity. However, the assessment did not include the number of nursing personnel required to provide care and meet resident needs, did not include services or equipment needed for bariatric residents, and contained no signatures showing completion. The assessment also included inaccurate information about the facility age and contractors used for services, and the staffing resources listed in the Recruitment and Retention Plan were designated for another facility in another city. The resident matrix dated 4/14/26 showed residents with urinary catheters, infections, falls, pressure ulcers, dementia or Alzheimer’s disease, IV medications, enteral feedings, dialysis, hospice services, therapy services, and bariatric needs. During interview, the Administrator stated he was responsible for the facility assessment and that the amount of staff required to meet resident needs should be indicated on it. The Assistant Administrator stated the 6/21/24 completion date was a clerical error and said the facility opened in August 2025, with the assessment completed shortly thereafter, though he did not know the exact date.
Failure to Administer Admission Medications and Use Emergency Supply for New Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered on admission and to follow procedures when medications were not available. For one resident with diagnoses including type 2 diabetes mellitus, pneumonia, and COVID, a stat chest x-ray on 1/13/26 showed pneumonia, and the physician ordered doxycycline 100 mg BID for five days and Augmentin 500/125 mg daily for five days. These orders were entered on the POS and MAR on 1/13/26 at 4:30 P.M., but there was no documentation that staff administered either antibiotic that day. The facility’s emergency medication supply list showed Augmentin 500/125 mg and doxycycline 100 mg were available, yet there was no documentation that staff notified the physician or pharmacy when the medications were not given or if they were not obtained from the emergency supply. For another resident admitted from the hospital with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, acute respiratory failure with hypoxia and hypercapnia, and chronic atrial fibrillation, hospital discharge orders included atorvastatin 80 mg at bedtime, Eliquis 5 mg BID, metoprolol 12.5 mg BID, nystatin suspension QID, and DuoNeb every six hours, with next doses due the evening and bedtime of the admission date. The POS reflected these orders, but the MAR showed staff did not administer the bedtime doses of atorvastatin, Eliquis, or metoprolol, nor the scheduled nystatin doses at 4:00 P.M. and 8:00 P.M., nor the DuoNeb dose at 8:00 P.M. The resident reported not receiving bedtime medications because the facility did not have them. The emergency medication supply list showed Eliquis 5 mg and metoprolol 25 mg were available, but they were not used. Staff interviews revealed confusion and inaction regarding medication availability and use of the emergency kit. One LPN stated the pharmacy delivered the resident’s medications the following morning, claimed no doses were due the prior night, and said he/she did not have access to the emergency kit, later acknowledging that Eliquis was in the kit and could have been administered. Another LPN stated there was an e-kit for after-hours or new admission medications but was unsure which medications it contained, confirmed the resident did not receive medications because the pharmacy had not yet delivered them, and reported the resident still had not received DuoNeb due to waiting on a nebulizer, despite central supply maintaining medical equipment such as nebulizers. The facility did not provide a policy related to obtaining newly ordered medications from the pharmacy or procedures to follow when medications were not available.
Unsecured Medications and Unauthorized Bedside Inhalers
Penalty
Summary
The deficiency involves the facility’s failure to secure medications in locked locations and to prevent medications from being left unattended, contrary to facility policy and professional standards. Surveyors observed multiple instances where medication cards and medication bottles delivered by the pharmacy were left on the nurse’s station desk and on top of a treatment cart for an extended period without any staff present or in line of sight, while residents and visitors walked past the area. The treatment cart was not in use and was positioned in front of the nurse’s station counter, making the unsecured medications easily accessible. Staff later confirmed that medications were not to be left unlocked or unattended and acknowledged that the medications had been left out since delivery because staff had not yet put them away. Additional observations showed that both the treatment cart and the medication cart, which contained medications, were left unlocked and unattended at the nurse’s station on another occasion, again with no staff in the area or in line of sight. Nursing staff, including an LPN and an RN, stated that medication and treatment carts should always be locked when unattended and that medications should never be left unattended at the nurse’s station or on carts. The DON and the Administrator both stated that staff were expected to lock medication and treatment carts when unattended and to secure medications with a lock upon receipt from the pharmacy, consistent with facility policies on medication labeling, storage, and administration. The facility also failed to secure medications for one resident by allowing prescription inhalers to remain at the bedside without appropriate orders or assessment for self-administration. A resident recently admitted with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, and acute respiratory failure reported having inhalers at the bedside that they self-administered and had brought from home. Observation revealed four prescription inhalers lying on top of the bed covers at the foot of the resident’s bed. Review of physician orders showed an order for a fluticasone furoate inhaler but no orders for tiotropium or albuterol inhalers and no order permitting bedside self-administration. Nursing leadership stated they were unaware of the inhalers at the bedside, confirmed that residents must be assessed and have an order to self-administer medications, and stated that even with such an order, medications should be kept in a secure location rather than on the bed. The Medical Director stated that all medications should be secured behind at least one locked door or drawer.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary care and services to maintain good hygiene for three residents who were dependent on staff for bathing. Review of the bathing policy showed residents were to receive a bath or shower in accordance with their preferences, and if no preference was provided, staff were to offer one. However, the medical records for the three residents contained no documentation of bathing preferences or how often bathing was to occur, and the Point of Care bathing records showed only limited showers or baths during the 30-day review period. During interviews, each of the three residents stated they had not been bathed or showered as often as they wanted and each said they wanted bathing at least two times per week. Observations showed one resident had slight body odor, while the other two had body odor and disheveled or greasy hair. An LPN stated there was only one aide for the hall where the residents lived and that staff did not have time to give showers as often as the residents wished. The Regional Director of Clinical Services said the residents had not received showers as they should or as they desired, and the DON said he expected residents to receive at least two showers per week.
Insufficient Nursing Staffing Led to Missed Hygiene, Meal Assistance, and Late Medications
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs, and the report describes multiple care failures tied to staffing shortages. The facility census was 70, and the unsigned Facility Assessment did not identify the number of nursing personnel needed to provide care and services. During interviews, staff stated there was only one aide for the hall where Residents #4, #5, and #6 lived, and that aides did not have time to complete showers as often as residents wanted. The DON said he expected residents to receive at least two showers per week, and the Regional Director of Clinical Services said the residents on the Sparkle hall had not received showers as they should or as they desired. Residents #4, #5, and #6 were dependent on staff for bathing, but record review showed very limited bathing documentation over a 30-day period. Resident #4 received showers/baths only on 03/20/26 and 04/03/26, Resident #5 received a bath only on 03/21/26, and Resident #6 received showers on 03/20/26, 03/24/26, and 04/03/26. Each resident told the surveyor they had gone a long time without a shower or bath and wanted bathing at least two times per week. Observations showed body odor, disheveled hair, and greasy hair on these residents. The report also documented missed supervision and delayed assistance during meals. Residents #2, #4, and #8 had care plans requiring supervision with eating, but observations showed residents eating without staff present in the dining room or at the bedside. Resident #4 was served a grilled cheese sandwich that was not cut into bite-size pieces as ordered. Residents #7, #10, and #12 were left with breakfast trays in their rooms while asleep or unable to reach the food, and staff did not assist them until 30 to 64 minutes later; in one case, a family member had to help the resident eat. In addition, medications for Resident #1 were administered late, with the LPN stating the morning medication pass was not completed until after 1:00 P.M. and that later doses were also delayed that day. Staffing concerns were further supported by observations that only one nurse and one CNA were on the rehab hall for 28 residents, while dietary staff and the BOM were passing trays because nursing staff were unavailable. The DON was observed performing finger sticks and stated he had worked floor shifts because a scheduled nurse called off. The Staffing Coordinator said several staff called off and one trainee left, leaving the facility short-staffed. The DON also stated he was not aware he could not work the floor when census was over 60, and he was not aware there was only one nurse and one aide on the hall during the morning when residents were waiting for care and meals.
Failure to Implement and Communicate RD-Recommended Nutritional Interventions After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement, evaluate, and modify nutritional interventions to prevent significant weight loss for one resident. The facility’s own policy required a weight change investigation for significant weight changes of 5% or more in one month, 7.5% or more in three months, and/or 10% or more in six months, with subsequent contact of the dietician and physician, updating of interventions, and ongoing monthly investigation until weight stabilized. The resident’s care plan for nutrition and hydration, initiated in early December, identified potential for alterations in nutrition and hydration and directed staff to evaluate weight changes, determine percentage change, follow facility protocol for weight change, and monitor for signs and symptoms of malnutrition. The comprehensive MDS documented severe cognitive impairment, dependence for ADLs, an unstageable pressure ulcer, and increased nutritional needs, but no difficulty swallowing and no nutritional approaches at that time. The resident was admitted with multiple significant diagnoses including acute respiratory failure, pulmonary edema, CHF, diabetes, protein-calorie malnutrition, osteoporosis, and osteomyelitis of the left ankle and foot. Weights recorded in the EMR showed 192 lbs on 12/06, 185 lbs on 12/11, and 185.2 lbs on 12/13. On 12/16, the RD evaluated the resident, noted a weight of 185.2 lbs and increased nutrient needs related to a large chronic unstageable pressure ulcer to the left heel, and recommended discontinuing certain diet restrictions, changing to a regular no added salt diet with sugar-free beverages and diet condiments, and adding Pro Heal 30 ml BID and Juven BID. The January POS reflected the NAS diet, Juven BID, and ProHealth 30 ml BID, but there were no documented weights from 12/14 through 01/21, and a weight of 159.8 lbs was then recorded on 01/22, representing a 25.4 lb loss since 12/13. The RD’s 01/29 note identified this as a significant weight loss, noted the resident reported not being interested in food, and recommended adding Magic Cup BID at lunch and dinner, to be included as dietary fluids. Despite this recommendation, the January POS contained no order for Magic Cup, and no weights were documented from 01/22 through 02/22, with the next weight of 163.8 lbs recorded on 02/23. The February POS also showed no order for Magic Cup, and the resident’s nutrition/hydration care plan contained no interventions specifically addressing weight loss. Multiple meal observations on 02/23 and 02/24 showed the resident receiving meals without Magic Cup, and both the resident and a family member reported that Magic Cups had not been provided. The RD stated that recommendations were emailed to the Administrator, DON, DM, and Care Plan Coordinator, that she had noted significant weight loss and recommended Magic Cup BID, and that she did not know why these recommendations were not communicated to the physician. The DM acknowledged receiving RD emails and changing diet cards based on recommendations, but stated the resident did not have Magic Cup in the diet order and that he must have missed that RD recommendation. The Interim DON, Administrator, and Medical Director each stated they would expect RD recommendations to be reviewed and communicated to the physician for residents with weight loss, but this did not occur, and the facility failed to implement and integrate the RD’s recommended intervention for Magic Cup or to update the care plan with weight-loss interventions while the resident experienced a 13.98% weight loss in two months. Additionally, the facility did not consistently obtain and document weights per its policy and the resident’s care plan. There were gaps in weight documentation between mid-December and late January, and again from late January to late February, despite the resident’s known risk factors, existing pressure ulcer, and documented significant weight loss. The RD reported having noted weight discrepancies that had not been addressed. The MDS also showed that dental status was not assessed. Collectively, these inactions—failure to consistently monitor weights, failure to initiate and document weight change investigations as required by policy, failure to communicate and obtain physician orders for RD-recommended interventions, and failure to update the care plan with specific weight-loss interventions—led to the resident’s unaddressed significant weight loss. The facility’s own staff interviews confirmed that the process for handling RD recommendations was not effectively carried out. The LPN reported not seeing any Magic Cup recommendations in the resident’s record. The RD described a practice of emailing recommendations but not participating in IDT meetings, and acknowledged that her recommendation for Magic Cup BID was not communicated to the physician. The DM confirmed that he relies on RD emails to change diet cards and admitted that he must have missed the Magic Cup recommendation, resulting in no diet order for Magic Cup. Leadership staff, including the Interim DON, Administrator, and Medical Director, each stated expectations that RD recommendations be reviewed and communicated to the physician for residents with weight loss, but these expectations were not met in this case, contributing to the failure to implement appropriate nutritional interventions for the resident experiencing significant weight loss.
Failure to Provide Evening Meal to Newly Admitted Resident
Penalty
Summary
The facility failed to provide an evening meal to a newly admitted resident whose diagnoses included fracture of the pelvis, respiratory failure, and protein-calorie malnutrition. The resident was admitted to the facility in the early evening with a physician’s order for a regular diet with mechanical soft foods. According to the resident’s family member, they arrived at approximately 5:55 P.M., and no staff offered or brought any food to the resident. The family member reported seeing only one nurse, who stated the kitchen was closed for the day, leading the family member to go to a local restaurant to obtain food for the resident. The resident later stated that they were hungry, did not get much to eat for supper, and that their daughter had to bring food because the facility did not provide a meal tray. The Dietary Manager reported that they are notified of expected admissions via memo and that on the day in question they had prepared three or four meal trays for anticipated admissions, including a tray intended for this resident. The Dietary Manager explained that they must wait for nursing to enter the resident’s information into the EMR before entering diet information into the dietary system, and that if a resident is admitted before 7:00 P.M., nursing is expected to inform dietary of the admission and ask the resident what they would like for the meal. On this occasion, dietary staff were not informed that the resident had arrived, so they left a tray in the kitchen window for nursing to take when the resident came in. The next morning, the tray was still in the kitchen window and had not been passed to the resident. The Dietary Manager stated this was not the first time such an occurrence had happened. The DON, Administrator, and Medical Director each indicated in interviews that they would expect new or late-returning residents to receive some type of nourishment, such as a meal tray or sandwich.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds and Indwelling Devices
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy for residents with wounds and indwelling medical devices, resulting in staff not using required gowns and gloves during high-contact care activities. The facility’s March 2024 EBP policy required EBP for all residents with wounds or indwelling medical devices, regardless of MDRO status, and specified that gowns and gloves must be used for high-contact care such as dressing, bathing, transferring, toileting, changing linens and briefs, and device and wound care. The policy also required clear EBP signage on or near the resident’s door, availability of PPE near or outside the room, and staff education and competency regarding EBP. For one resident with an indwelling urinary catheter, the comprehensive MDS documented the catheter, and the care plan directed staff to provide EBP and use gowns and gloves during high-contact care. However, observations showed there was no EBP sign on the door and no gowns available inside or outside the room. A CNA entered the room without a gown or gloves, applied a gait belt, transferred the resident from a recliner to a wheelchair, handled the urinary catheter collection bag, and pushed the resident into the bathroom. In the bathroom, the CNA donned gloves but no gown, assisted the resident to stand, pulled down pants, removed an unsoiled incontinence brief, manipulated the catheter tubing, and attached it to the handrail. After the resident complained of a sore on the bottom, the CNA removed gloves and exited the room without handwashing. Subsequently, an LPN and the same CNA entered the bathroom wearing gloves but no gowns; the CNA assisted the resident to stand while the LPN wiped the resident’s bottom, noted blood on the tissue, and left after removing gloves. Another LPN then entered with gloves but no gown, cleansed and dressed an open wound on the buttock, and left after removing gloves and using hand sanitizer. The CNA then completed perineal care, catheter manipulation, clothing adjustment, transfers, and linen changes wearing only gloves and no gown. Interviews showed the LPN believed EBP should be used when applying creams, and the CNA was unsure what EBP was used for and stated he/she only wore gloves when caring for residents. For another resident with end stage renal disease, dependence on dialysis, multiple documented wounds (coccyx, left buttock, right arm, right heel), and a dialysis CVC and AV fistula, the care plan and physician orders specified EBP for wounds and dialysis CVC, with daily wound cleansing and dressing changes. Despite this, repeated observations showed no EBP sign on the door and no PPE cart or PPE door hanger outside the room. Staff, including an LPN and CNA, entered the room and performed high-contact care such as changing linens while the resident was in bed, and other care activities, wearing only gloves and no gowns. A guest and the resident’s spouse both reported that staff only wore gloves when providing care and wound care. In interviews, a CNA stated they relied on door signage to know when to wear a gown, an LPN stated uncertainty about whether the resident was on EBP and confirmed only glove use, and a nurse manager acknowledged that residents with dialysis access and/or wounds should be on EBP, that every such resident should have PPE outside the room, and that the EBP sign likely was never placed on the door. The DON stated that EBP was required for residents with MDRO history, draining wounds, or indwelling devices including catheters, IV lines, dialysis access, and central lines, and that nurse managers were responsible for setting up EBP, while the Administrator and Medical Director both stated they expected staff to know which residents should be on EBP and to use all required PPE.
Failure to Provide Needed Bariatric Equipment on Admission
Penalty
Summary
The facility failed to ensure the necessary equipment was available upon admission for one resident with morbid obesity, who weighed 574 pounds on hospital discharge records dated 04/14/26. The resident’s face sheet showed admission to the facility on [DATE]. Observation and interview showed the resident had a bariatric wheelchair measuring 35 inches across the seat, but it would not fit through the bathroom door in the resident’s room. The resident also had a regular-sized bed pan, and the resident stated the bed pan was not large enough and urine spilled onto the bed when used. The resident said he/she had not been out of bed since admission, was not able to bear enough weight to walk, thought he/she might be able to pivot but had not tried, and therapy staff had not evaluated him/her. Further observation showed the main shower room doors on the [NAME] and Kindle hallways measured 37 inches wide, while the resident’s wheelchair would not fit into the shower room doors. There were no bariatric shower chairs in either shower room. When staff attempted to transfer the resident using a mechanical lift, the lift would not raise the resident off the bed because the battery was dead and would take several hours to charge. The Assistant Administrator stated the battery should have been charged when the lift was delivered. The Administrator stated regional staff reviewed the resident’s medical documentation before admission and determined the facility could meet the resident’s needs, and that equipment had been ordered before admission, but the wheelchair and mechanical lift were not delivered until the day after admission. The Administrator also stated he did not realize the wheelchair would not fit into the bathroom or shower room doors and that there was not a shower chair large enough for the resident to use.
Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician when Resident #17’s condition changed in relation to fluid management and medication administration. The resident had diagnoses including cardiac pacemaker, ischemic cardiomyopathy, atrial fibrillation, hypertension, chronic CHF, and a history of heart attack. The care plan directed staff to monitor weight changes, intake and output, signs of dehydration, and to administer medications as ordered. The physician’s progress note documented leg edema, daily weights, and assessment for diuretic need, and Lasix was increased to 40 mg daily. The resident’s record showed ordered daily weights with instructions to notify the physician for a weight gain greater than 2 pounds in 24 hours or 5 pounds in one week. Staff did not document weights on two days, then documented a weight of 191 pounds after a prior weight of 175 pounds, but there was no documentation that the physician was notified of the 16-pound gain. Later weights showed additional gains of 3.7 pounds in one day and 3 pounds in one day, with no documentation that the physician was notified of those changes. The record also showed torsemide 40 mg twice daily was ordered after Lasix was discontinued, but the medication was not documented as administered on multiple days because it was unavailable and on order, and there was no documentation that the physician was notified that the medication was not being given as ordered. The facility also failed to notify a resident’s family when Resident #15 was transferred to the emergency department for hypoglycemia. The resident had diabetes, was cognitively intact, and received insulin. The care plan directed staff to monitor blood glucose and report hypoglycemia. On the day of the event, the resident’s blood glucose was documented as 26, with the resident cool and clammy. Staff administered glucose gel and glucagon, notified the physician, and the resident was sent to the hospital by ambulance. The record contained no documentation that the family or responsible party was notified of the low blood sugar or the transfer to the hospital. The resident’s family member later stated they were not aware of the event until the resident was returning to the facility from the hospital.
Delay in Administering Ordered Diuretic Medication
Penalty
Summary
The facility failed to administer diuretic medications as ordered for one resident with a history of cardiac pacemaker, ischemic cardiomyopathy, atrial fibrillation, hypertension, chronic congestive heart failure, and prior heart attack. The resident’s care plan directed staff to administer medications as ordered and monitor for changes in nutrition and hydration. The resident had been admitted after hospitalization for CHF exacerbation and acute on chronic kidney disease, and the physician note documented persistent lower leg edema, daily weights, intake and output monitoring, and an increased Lasix dose for fluid management. On 03/20/26, the cardiologist ordered torsemide 40 mg twice daily and discontinued Lasix 40 mg twice daily. The resident’s POS was not transcribed to reflect the torsemide order or the discontinuation of Lasix at that time. The MAR showed Lasix 40 mg twice daily was still administered on multiple days after the cardiology visit, and there was no documentation that torsemide 40 mg twice daily was administered as ordered during that period. Nursing notes later documented that the torsemide medication was not available and was on order on several dates. The resident’s family member stated the resident’s legs were weeping, the resident became weaker and declined overall, and it took over two weeks before the new medication was provided. The resident stated staff did not give the new medication for swelling, the legs were swollen and draining, and the resident was huffing and puffing and did not want to get out of bed for therapy. The resident also stated that after taking the new medication, the swelling was gone and shortness of breath improved. Observation showed the resident in bed with lower extremities without swelling at the time of the observation. The physician stated staff did not inform him that torsemide had not been administered as ordered for two weeks, and that the medication changes were made because of edema and CHF.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 732 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Peters
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Peters Post Acute | 0 mi | ★★★★★ | 7 | 0 |
| St Peters Rehab And Healthcare Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Mcclay Senior Care | 3 mi | ★★★★★ | 1 | 0 |
| Garden View Care Center | 4.2 mi | ★★★★★ | 2 | 0 |
| Aspen Point Health And Rehabilitation | 4.6 mi | ★★★★★ | 9 | 0 |
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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.