Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Lemay Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant increase in pain, but the facility delayed obtaining an x-ray order for over 12 hours. The delay was due to waiting for hospice to return a call, despite the resident's evident pain. The x-ray revealed a right hip fracture, and the resident was sent to the hospital for further evaluation. The facility's policy requires timely assessment and intervention, which was not followed in this case.
A nurse in an LTC facility pre-pulled medications, documented them as administered, but did not give them to residents, affecting nine individuals with conditions like osteoarthritis, epilepsy, and anxiety. The medications, including narcotics, were left on a cart, and another staff member refused to administer them. This breach of protocol led to residents not receiving critical medications.
The facility failed to prevent physical abuse when one resident punched another in the head three times, despite a previous altercation between the same residents. Both residents have severe cognitive impairments, and staff were aware of the need to keep them apart but failed to do so effectively.
A resident with dementia and behavioral disturbances struck another resident twice, causing injury. Despite an order for a psychiatric consult, the facility delayed implementing it and updating the care plan, leading to repeated aggressive behavior.
Delay in Obtaining X-ray Order for Resident in Pain
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who experienced a significant increase in pain, which was identified on 12/18/24. The resident, who had severe cognitive impairment and multiple diagnoses including heart failure, end-stage renal disease, and Alzheimer's disease, had to wait over 12 hours for an x-ray order to be obtained. The delay in obtaining the x-ray order was due to the facility waiting for hospice to return a call with the order, despite the resident showing signs of being in pain. The x-ray, completed on 12/19/24, revealed a right hip fracture, and the resident was subsequently sent to the hospital for further evaluation and treatment. The facility's Change in Condition Nursing Intervention policy requires timely assessment and documentation of changes in a resident's condition, with appropriate interventions to prevent hospitalization whenever possible. However, in this case, there was no documentation of the circumstances that led to the need for an x-ray order on 12/18/24, nor was there an assessment of the resident's condition. The Administrator later stated that the staff should have called the physician directly to obtain the x-ray order instead of waiting for hospice, which did not respond in a reasonable time frame. Interviews with facility staff revealed that there was a misunderstanding regarding the process for obtaining the x-ray order. The Administrator initially believed that the delay was due to the x-ray company being unable to come out, but upon reviewing the progress notes, it was clear that the delay was due to waiting for hospice. The Administrator acknowledged that the nurse should have taken more immediate action to obtain the x-ray order, given the resident's pain and the lack of timely response from hospice.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice when a nurse pre-pulled medications for residents, documented them as administered, and did not actually administer them. This resulted in nine residents not receiving their ordered medications. The medications involved were primarily narcotics and other controlled substances, which require strict handling and documentation procedures. The incident was discovered when a nurse found medication cups with pills left on a cart, indicating that the medications had not been given to the residents. The residents affected had various medical conditions requiring medication management, including osteoarthritis, epilepsy, anxiety disorders, fractures, chronic pain, dementia, and diabetes. The medications that were not administered included tramadol, lorazepam, oxycodone, hydrocodone-acetaminophen, clonazepam, diazepam, and Ultram. These medications were critical for managing the residents' pain, anxiety, and other health conditions. The failure to administer these medications as ordered could have had significant implications for the residents' health and well-being. The issue arose when LPN A pre-pulled the medications and left them on the cart, expecting CMT B to administer them. However, CMT B refused to pass the medications, and they were left unattended. Despite this, LPN A documented the medications as given. The facility's policy clearly states that medications should be administered at the time they are pulled and that only the person who pulls the medications should administer them. This breach of protocol was compounded by the fact that the medications were narcotics, which require even more stringent handling and documentation procedures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical abuse when one resident punched another resident in the back of the head three times. This incident occurred despite a previous altercation between the same two residents, where one resident hit the other in the eye, causing a laceration. The facility's policy mandates that each resident must be free from abuse by anyone, including other residents, but this was not upheld in this case. Resident #1, who has dementia and depression, was sitting in the dining room when Resident #2, who has severe cognitive impairment and Alzheimer's dementia, struck them. The medical records show that after the first incident, Resident #1 had a laceration over their left eyebrow, and after the second incident, there was no documented skin or neurological assessment performed. Despite the facility's policy and care plans for both residents, the measures to prevent further incidents were insufficient. Interviews with staff revealed that they were aware of the need to keep the two residents apart, yet the second incident still occurred. Staff members described the events and their immediate actions, but it was clear that the interventions were not effective in preventing the second altercation. The facility's investigation concluded that the residents should be kept separated, but the failure to do so led to repeated physical abuse of Resident #1 by Resident #2.
Failure to Provide Timely Psychiatric Care for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia and exhibiting behavioral disturbances received appropriate treatment and services. The resident, who had a history of self-neglect and potential self-harm, was involved in two separate incidents where they struck another resident in the head, causing a laceration in the first incident. Despite an order for a psychiatric consult on 2/9/24, the consult was not implemented until after the second incident on 4/24/24. The resident's care plan was also not updated until after the second incident, indicating a delay in addressing the resident's behavioral issues. The resident's medical records showed severe cognitive impairment and diagnoses including non-traumatic brain dysfunction and Alzheimer's dementia. The resident had a history of depression and was on medication for Alzheimer's disease. Despite these known issues, the facility did not take timely action to address the resident's behavioral disturbances. The first incident occurred on 3/4/24, and although the physician and family were informed, no immediate psychiatric evaluation or care plan update was conducted. The resident continued to exhibit behavioral issues, including crying and refusing meals, but these were not adequately addressed. After the second incident on 4/24/24, the facility finally reached out to the psychiatrist for an urgent evaluation. The psychiatric evaluation confirmed the resident's major neurocognitive disorder with agitation and recommended monitoring and potential medication adjustments. However, the delay in implementing the psychiatric consult and updating the care plan contributed to the recurrence of the aggressive behavior. Interviews with staff revealed that they were aware of the resident's behavioral issues but did not take sufficient measures to prevent further incidents, such as keeping the residents apart or closely monitoring the aggressive resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 897 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sherbrooke Village | 1.6 mi | ★★★★★ | 6 | 0 |
| St Louis Altenheim | 2.8 mi | — | 20 | 0 |
| Carrie Elligson Gietner Health Care Center | 3 mi | ★★★★★ | 8 | 0 |
| Bluebird Wellness And Rehabilitation | 3.3 mi | ★★★★★ | 1 | 0 |
| Lansdowne Village | 3.7 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lemay Nursing.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.