Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Life Care Center Of St Louis during CMS and state inspections, most recent first.
Staff failed to follow infection control practices during EBP care, wound treatment, perineal care, and laundry handling. An NP, LPNs, CNAs, and laundry aides did not consistently wear gowns, change gloves, or perform hand hygiene between dirty and clean tasks, and clean linens were mixed with items that fell on the floor. The deficiencies involved residents with wounds, pressure injuries, incontinence, and severe cognitive impairment.
The facility failed to ensure five of 10 sampled CNA/CMT staff members with over 12 months of employment received the required 12 hours of annual in-service training. Records showed each of the five staff members had only 2.0 to 3.25 hours documented for the year, and the facility’s policy required annual competency education including dementia management and resident abuse training. An RN stated there were no more in-service hours available, and the Regional President said she would expect 12 hours to be completed and documented each year.
A resident with renal insufficiency, ESRD, obstructive uropathy, an indwelling catheter, and a left nephrostomy tube was admitted with hospital orders directing that the nephrostomy tube remain clamped and the dressing be changed every 24–48 hours and when soiled. Although these instructions appeared on transfer paperwork and in an early provider progress note, they were not timely transcribed onto the physician order sheet; only an order for nephrostomy output every shift was entered initially, and an order to keep the tube clamped was not added until weeks later, with no dressing-change order in place. During this time, documentation showed the nephrostomy tube draining to gravity with output recorded on multiple shifts, contrary to the clamping instructions. Interviews with nursing staff, the nurse manager, NP, and DON confirmed that the facility relied on the after-visit summary for orders, that nurses were responsible for entering and confirming provider orders, and that the clamping and dressing-change orders should have been placed at admission, but were not, resulting in services that did not meet professional standards of quality.
A resident with mild cognitive impairment, muscle weakness, cancer, and painful hidradenitis suppurativa required partial/moderate assistance with bathing and supervision for personal hygiene per MDS and care plan, which called for at least twice-weekly assisted bathing and personal hygiene support. Over several weeks, only a few showers or bed baths were documented, and repeated observations found the resident lying in bed with matted, unkempt hair and a persistent fecal odor in the room. The resident reported not receiving showers or bed baths since admission and not having hair washed, despite being unable to adequately clean themselves or wash their own hair. CNAs and an RN confirmed the resident needed assistance and that facility practice was to provide two showers weekly with hair care included, but one CNA relied strictly on the shower schedule and made a dismissive comment about the resident’s afro. Facility leadership acknowledged the resident should have been receiving at least two showers per week, including hair washing when requested, demonstrating a failure to follow the resident’s ADL care plan and hygiene needs.
A resident with hemiplegia, dysphasia, abnormal posture, and moderately impaired cognition repeatedly requested to get out of bed for meals, but staff relied on a get-up list that did not reflect the resident’s preference. The resident was observed eating breakfast in bed on multiple occasions, with the call light inaccessible and signs of difficulty positioning and eating, while staff said the resident was not consistently on the list and was often assisted up only after breakfast. Interviews confirmed staff knew the resident did not like being in bed, and an OT stated the resident’s choice about where to eat should be honored.
A resident with severe cognitive impairment and stroke-related deficits had $2,725.80 withdrawn from the trust account for medical equipment, but the resident and DPOA were not involved before the purchase. Staff later asked the resident to sign an incomplete trust fund authorization form after the fact, and the resident said he/she was unsure what was being signed and whether the wheelchair had been purchased by him/her. The DPOA said the facility notified him/her only after the wheelchair purchase.
Survey Results Not Readily Accessible: The facility failed to post the most recent survey and complaint investigation results in a location readily accessible to residents, families, and legal representatives without staff assistance. No posting or signage was found at the entrance, lobby, or receptionist area, and six alert and oriented residents said they did not know where the state survey results were located. The survey binder was found inside a dresser near the receptionist’s area and was not accessible to residents, families, or visitors.
A resident with a history of diabetes and heart failure fell from their bed and was ordered a stat x-ray for multiple areas. The x-ray was not completed for nine days, during which the resident experienced significant pain and refused care. Staff interviews revealed a lack of communication and follow-up regarding the x-ray orders, and the resident's physician was not informed of the delay. The mobile x-ray company attempted to contact the facility but received no response. The resident was eventually diagnosed with a possible fracture.
The facility failed to submit monthly transfer notifications to the Ombudsman since November 2022. The new Social Service Director and Administrator confirmed the lapse, with the last submission date unclear. A submission for April 2024 was made, and future submissions will be done monthly.
The facility failed to encode and transmit resident assessment data within 7 days after completing the assessments for 12 out of 19 residents investigated. The MDS Coordinator acknowledged being behind on assessments due to staffing shortages, leading to delays in completing and transmitting the MDS assessments as required by the RAI User's Manual.
The facility failed to complete quarterly resident assessments for nine residents, with the MDS Coordinator acknowledging delays due to staffing shortages. The assessments were either still in progress or needed to be signed off, affecting a significant portion of the resident population.
The facility failed to ensure that eight out of ten randomly selected CNAs received the required annual 12-hour resident care training. The absence of a Staff Development Coordinator led to a significant gap in tracking and completing the mandatory training hours, impacting the competency of the CNAs.
The facility failed to post the required daily nurse staffing information in a prominent place, with observations showing outdated or incomplete documentation of staffing details. The Administrator acknowledged the lapse, attributing it to the DON's absence.
The facility failed to follow infection control standards when an LPN did not change gloves or wash hands while administering G-tube medications, and a CNA left suction equipment uncovered. Additionally, the facility did not adhere to its TB testing policy for new hires, with incomplete documentation for eight employees.
The facility failed to complete a comprehensive resident assessment for a resident. The MDS Coordinator, who has been in the role for 5 years, acknowledged being behind on MDS assessments due to the facility being without a social worker for about a year and a half. As a result, the business office manager, director of rehab, and the MDS Coordinator herself have been filling the role, contributing to the delay in completing the assessments.
The facility failed to ensure that residents had complete, accurate, and individualized care plans. One resident's care plan lacked details on necrotizing fasciitis, discharge planning, and mental health concerns. Another resident's care plan missed focus on dietary status, difficulty swallowing, and PEG tube. A third resident's care plan was incomplete regarding dietary status, [NAME] tube, radiation treatments, and discharge planning.
The facility failed to ensure a safe discharge for a resident by not sending referrals to local contact agencies and orders for medical equipment in a timely manner. The resident, who had undergone significant surgical procedures, was discharged without the necessary support and equipment, leading to a potentially unsafe situation at home. Interviews revealed a lack of proper communication and documentation regarding the change in the discharge date.
The facility failed to provide necessary communication devices and ensure staff were knowledgeable about a deaf resident's communication needs. The resident's care plan included specific interventions, but these were not transferred to the Kardex, and staff lacked access to this information, leading to unmet needs.
A facility failed to provide timely wound care for a resident readmitted with chronic wounds. The resident's wounds were not fully assessed until several days after readmission, and treatment orders were delayed, contrary to the facility's policies. This resulted in inadequate care for the resident's wounds.
A resident missed a follow-up eye appointment due to the facility's failure to arrange transportation and reschedule the appointment. Staff interviews revealed a lack of communication and coordination regarding the resident's transportation needs.
A resident with diabetes did not receive their ordered routine insulin because an LPN decided to hold the medication without notifying the physician, contrary to the facility's medication administration policy. The ADON confirmed that the routine insulin should not have been held without physician notification.
The facility failed to ensure proper storage and labeling of medications and biologicals. Insulin pens in a medication cart were not labeled with the date they were removed from refrigeration, and ointments for two residents in a treatment cart were found with the caps off. Staff interviews confirmed non-compliance with storage policies.
The facility failed to ensure residents received care consistent with professional standards. One resident with vascular leg ulcers did not have treatments completed as per physician orders, and another resident with a blister on the right breast did not receive the prescribed treatment. Observations and interviews confirmed that treatments were not consistently documented or administered, and a systemic issue prevented weekly skin assessments from being completed.
The facility failed to ensure that two residents with pressure wounds received necessary treatments to promote healing. One resident's wound care was inconsistently documented, delaying their discharge, while another resident's existing skin issues were not properly managed, leading to worsening conditions. Interviews revealed systemic issues in documentation and execution of wound care.
Infection Control Failures During EBP Care, Perineal Care, and Laundry Handling
Penalty
Summary
The facility failed to maintain its infection prevention and control program during care for residents on enhanced barrier precautions (EBP) and during routine personal care. Staff did not consistently change gloves, perform hand hygiene, or wear gowns during high-contact care activities, and laundry staff did not keep dirty linens separated from clean linens. The report also documents that staff failed to change gloves and wash or sanitize hands during perineal care for one resident, and that clean and soiled linens were handled together in the laundry area. For one resident with right knee and sacral wounds and physician orders for daily and twice-weekly wound treatment, the NP and an LPN entered the room with gloves but no gowns while EBP signage was posted. The NP removed and cleaned the knee dressing, then used the same gloves to remove the sacral dressing and measure and clean the sacral area. The LPN entered and applied dressings without wearing a gown. For another resident with pressure ulcer injury and stump surgical wounds, staff entered the room without gowns, performed perineal care and dressing-related care, and a Duoderm dressing was visible on the sacrum. The RN and CNA also handled lift equipment and resident care without gowns while EBP signage was present. For a resident with a left thoracotomy wound and daily wound treatment orders, the NP and LPN entered without gowns, and clean wound supplies were placed on an overbed table inside a plastic trash bag. The NP removed old dressings, then did not perform hand hygiene before applying clean gloves and continuing wound care. For another resident with buttock wounds and treatment orders, the NP and LPN entered without gowns, placed clean supplies on a trash bag on the overbed table, and gloves that had fallen on the floor were picked up and placed with clean supplies. Both staff changed gloves without hand hygiene before applying new gloves, and the NP cleansed the wound without changing gloves before obtaining treatments. During perineal care for a severely cognitively impaired resident who was dependent for toileting and incontinent of bowel and bladder, a CNA did not change gloves after touching soiled areas and before touching clean areas. In the laundry area, clean linens were removed from the washer, a sheet and pillowcase fell on the floor, and the linens were still handled with the clean load and placed into the dryer, while the laundry aide stated stained pillowcases were discarded.
Incomplete Annual In-Service Training for CNA/CMT Staff
Penalty
Summary
The facility failed to ensure that five of 10 randomly selected CNA/CMT staff members employed for over 12 months received the required annual 12 hours of in-service training. Review of the facility’s CNA 12 Hours of Inservice Training policy showed the Staff Development Coordinator was responsible for developing, implementing, and maintaining an effective in-service program so nurse aides received the required education, including dementia management and resident abuse training. Review of the Personal In-Service Records for in-service year 2025 showed CMT R had 2.0 hours, CMT S had 3.25 hours, CNA T had 2.0 hours, CNA U had 2.0 hours, and CNA V had 2.5 hours of in-service training. During interview, the RN stated the facility did not have any more in-service training hours, and the Regional President stated she would expect CNAs/CMTs to have 12 hours of education completed and documented annually.
Failure to Transcribe and Implement Nephrostomy Tube Orders per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards when a physician’s orders for a resident with complex renal conditions were not timely or accurately transcribed and implemented. The resident had moderately impaired cognition, an indwelling catheter, a left nephrostomy tube, and diagnoses including renal insufficiency, ESRD, and obstructive uropathy. Hospital transfer/after-visit orders specified that the left nephrostomy tube was to remain clamped and that the dressing was to be changed every 24–48 hours and when soiled, with instructions to contact the genitourinary provider if flank or back pain increased. These instructions were present on the transfer orders and reiterated in a physician progress note shortly after admission, which stated that the left nephrostomy tube should remain in place, be kept clamped, and have the dressing changed every 24–48 hours and when soiled. Despite these clear instructions, the physician order summary in use at the time of survey showed only an order for nephrostomy tube output every shift starting two days after admission, and did not include an order for dressing changes or for the tube to be clamped until several weeks later. Progress notes during the initial admission period documented that all orders were verified with the physician on the day of admission and that the nephrostomy tube was to remain in place until follow-up with urology, but there was no corresponding active order for clamping or dressing changes on the physician order sheet. Medication and treatment administration records showed that staff were documenting nephrostomy tube output on multiple shifts, which would not be expected if the tube had been clamped as ordered, and there were missed opportunities where output was not documented at all. Interviews with nursing staff and providers confirmed that the after-visit summary was the source for discharge orders and that nurses were responsible for entering and confirming orders in the electronic system. The nurse manager and NP stated that providers enter their own orders in the computer but nurses must confirm them, and that the general instructions and care of sites should be verified at admission. The NP and RNs interviewed stated that if the nephrostomy tube was properly clamped there would be no measurable output from the tube, and that the dressing should have been changed every 24–48 hours unless orders were changed during verification. Staff also reported that they did not routinely review provider notes unless told there were new orders, and that if a resident returned from an outside appointment without paperwork, the nurse would call the provider and document it. The DON stated that the resident’s orders were verified with the physician on admission, yet the clamping and dressing-change orders were not transcribed onto the physician order sheet in a timely manner, resulting in the nephrostomy tube draining to gravity instead of being clamped as ordered and the absence of a formal dressing-change order during the period reviewed.
Failure to Provide Required Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, to a resident who required help. Facility policy required that residents unable to perform ADLs receive needed assistance and that any change in ADL ability be reported to nursing, ensuring residents maintained good grooming and personal hygiene. The resident’s MDS documented mild cognitive impairment, no behaviors, and a need for partial/moderate assistance with showering/bathing and supervision or touching assistance with personal hygiene. The care plan in effect identified an ADL self-care performance deficit related to impaired balance, limited mobility, and pain, and directed staff to provide moderate assistance for bathing at least twice weekly and as necessary, along with personal assistance for hygiene. The resident’s diagnoses included hidradenitis suppurativa with painful boils on the buttocks and around the anus, muscle weakness, and cancer. The shower calendar showed only five showers or bed baths documented from admission through mid-January, despite the care plan requirement. During multiple observations over several days, the resident was repeatedly found lying in bed on their stomach with matted, unkempt hair and a persistent odor of bowel movement in the room. The resident reported significant pain from boils that leaked and caused odor and discomfort, stated they had not had a shower since admission, and consistently reported not being offered showers or bed baths, including after wound treatments when only the wound area was cleansed. Staff interviews confirmed that the resident needed assistance with showers or bed baths and that facility practice was to offer two showers per week. A CNA acknowledged the resident needed hair washed and treated and that staff were expected to offer two showers weekly. Another CNA, assigned to the resident, stated the resident was scheduled for showers on specific days and was not due for a shower on the day in question, and made a remark about the resident’s hair, saying the resident “has an afro” and questioning expectations, adding that if the resident wanted hair washed, they would wash it. An RN confirmed the resident needed assistance with showers and personal care and that hair care was part of shower or bed bath, but was unsure what was being done about the resident’s hair. Facility leadership stated the resident should have received at least two showers per week, including hair washing if requested, indicating that the resident’s documented needs and care plan interventions for ADL assistance, bathing frequency, and hair care were not consistently implemented.
Resident Choice for Morning Wake-Up and Meals Not Honored
Penalty
Summary
The facility failed to create an environment that supported and respected a resident’s right to make choices about significant aspects of daily life. The deficiency involved one resident who requested to get out of bed for meals, but the facility used a get-up list to decide which residents would be assisted out of bed in the morning without considering the resident’s stated preference. The resident had hemiplegia following a cerebral infarction affecting the left non-dominant side, dysphasia following cerebral infarction, abnormal posture, and moderately impaired cognition, and required extensive assistance with ADLs and staff assistance for transfers out of bed. The resident’s care plan addressed ADL self-care deficits related to hemiplegia, impaired balance, and stroke, but did not include the resident’s preference for wake-up time. During observation, the resident was found in bed at various times eating breakfast in bed or waiting to get up, with the call light inaccessible and food crumbs or spilled coffee present. The resident stated he/she did not like eating in the room and requested to get up, but was told to wait until after breakfast or was not assisted when requested. The resident also stated eating in bed was difficult because of the stroke and that he/she slid down in bed or leaned to one side while eating. Staff interviews showed the resident was not consistently placed on the get-up list, and several staff members knew the resident did not like being in bed but still relied on the night shift or later staff to get the resident up. One CNA stated the resident was usually gotten up after breakfast if not already up, and another CNA said the resident was not on the night get-up list. An OT stated residents have the right to decide whether to eat in their room or in the dining room and that choice should be honored. The Operation Specialist later stated resident rights should be honored regarding when a resident gets up in the morning.
Resident trust funds withdrawn for wheelchair purchase without prior resident or DPOA involvement
Penalty
Summary
The facility failed to ensure the resident and the resident’s DPOA-Healthcare were invited to participate in person-centered care planning and were informed before a withdrawal was made from the resident’s trust account for medical equipment in the amount of $2,725.80. The resident’s quarterly MDS showed diagnoses of diabetes, stroke, difficulty with speech and swallowing, and severe cognitive impairment. The care plan identified impaired cognitive ability and difficulty performing ADLs, with interventions including asking yes/no questions to determine needs and providing substantial assist of one for wheelchair mobility. The resident’s quarterly resident fund statement showed a beginning balance of $2,618.26, a withdrawal on 10/7/25 for medical equipment in the amount of $2,725.80, and an ending balance of $101.60. During observation, the Business Manager Assistant and Activity Director asked the resident to sign a Trust Fund Disbursement Authorization Form that was visibly incomplete, with only the resident’s name, amount, and payee completed. The resident stated he/she was having problems holding the pen to sign and later said he/she was not sure what he/she was asked to sign and did not know whether the wheelchair was new or whether he/she had purchased it. The packet presented to the resident included the incomplete authorization form, the medical equipment invoice, a copy of the facility check for $2,725.80, a withdrawal record created by the Business Manager Assistant, and the resident’s quarterly fund statement marked with an X. The Business Manager Assistant stated the Business Manager directed staff to have the resident sign a new authorization form because the original form from October 2025 was misplaced. The Operations Specialist said the facility did not communicate with the family prior to the purchase to discuss the resident’s needs, and the resident’s DPOA said the facility informed him/her about the wheelchair after the fact and that he/she would have wanted a discussion before the purchase.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the results of the most recent survey and complaint investigations in a place readily accessible to residents, family members, and legal representatives without requiring staff assistance. Observations on 1/12/26 through 1/15/26 showed no survey results posted at the entrance, in the lobby, or at the receptionist’s desk, and no signs were posted to indicate where the survey results or complaint investigation information could be found. During a group interview on 1/13/26, six residents identified by the facility as alert and oriented stated they were unaware of where the state survey results were located. On 1/15/26, the most recent survey and complaint investigations were found inside a binder stored in a dresser diagonal from the receptionist’s area, with no sign indicating the binder’s availability. The receptionist stated the binder was always kept in the dresser, and the binder was not accessible to residents, families, or visitors. During an interview on 1/16/26, the Regional Nurse, Regional [NAME] President, and Operations Specialist stated the survey binder should have been available and accessible for residents, families, and visitors.
Failure to Complete Ordered X-rays for Resident After Fall
Penalty
Summary
The facility failed to follow physician orders for x-rays for a resident who had fallen from their bed. The resident, who had a history of diabetes, heart failure, and peripheral vascular disease, fell on 9/6/24 and was ordered a stat x-ray for multiple areas including the left shoulder, left arm, left hip, right hip, and chest. Despite the order, the x-ray was not completed for nine days, during which the resident experienced significant pain and refused care, behaviors that were not typical for them prior to the fall. The resident's progress notes indicated multiple instances of pain and requests for medication, yet there was no documentation showing the completion of the x-rays as ordered. Staff interviews revealed a lack of communication and follow-up regarding the x-ray orders. The Assistant Director of Nurses (ADON) obtained the x-ray orders but did not ensure their completion, and the Director of Nursing (DON) was unaware of the situation until a week later. The resident's physician was also not informed of the delay in completing the x-rays. The mobile x-ray company attempted to contact the facility to recommend hospital transfer due to high radiation exposure but received no response. The resident continued to suffer from pain, requiring increased assistance for care, and was eventually diagnosed with a possible fracture. The deficiency highlights a significant lapse in the facility's process for following physician orders and ensuring timely medical interventions for residents.
Failure to Submit Monthly Transfer Notifications to Ombudsman
Penalty
Summary
The facility failed to submit facility-initiated transfer notifications to the Ombudsman on a monthly basis. The census was 92. During an interview, the Ombudsman stated that the facility had not sent their monthly transfer notifications since November 2022. Email communication between the facility's Social Service Director and the Ombudsman office showed an admission/discharge log dated April 1, 2024, through April 18, 2024. The Administrator confirmed that the social worker would be responsible for submitting hospital transfer logs monthly to the Ombudsman, but it had not been done since the new Social Service Director started two weeks ago. The last submission date was unclear, but a submission for April 2024 was made, and future submissions will be done at the end of each month.
Failure to Encode and Transmit MDS Data Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data within 7 days after completing the assessments for 12 out of 19 residents investigated. The Minimum Data Set (MDS) assessments for these residents were found to be in progress beyond the required timeframe. The MDS Coordinator, who has been in the role for 5 years, acknowledged being behind on MDS assessments due to the facility being understaffed, particularly lacking a social worker for about a year and a half. This has led to the business office manager, director of rehab, and the MDS Coordinator herself filling in the role, contributing to the delay in completing and transmitting the MDS assessments as required by the Resident Assessment Instrument (RAI) User's Manual. The residents affected by this deficiency include those with quarterly and annual MDS assessments that were not completed or signed off on time. Specific examples include residents with assessment reference dates ranging from late December to early April, all showing their MDS assessments in progress. The MDS Coordinator confirmed that these assessments either needed to be completed or signed off, indicating a significant backlog in the facility's assessment process. This failure to adhere to the mandated timelines for encoding and transmitting MDS data highlights the operational challenges faced by the facility due to staffing shortages and increased workload on the existing staff members.
Failure to Complete Quarterly Resident Assessments
Penalty
Summary
The facility failed to complete quarterly resident assessments for nine out of 19 residents investigated. The Minimum Data Set (MDS) assessments for these residents were found to be in progress and not completed within the required timeframe. The MDS Coordinator acknowledged being behind on assessments due to staffing shortages, including the absence of a social worker for about a year and a half. This has led to the business office manager, director of rehab, and the MDS Coordinator herself filling in the role, contributing to the delay in completing the assessments. The residents affected by this deficiency include Resident #54, #6, #53, #43, #2, #7, #29, #14, and #23. Each of these residents had quarterly MDS assessments that were not completed within the mandated period. The MDS Coordinator, who has been in the role for five years, confirmed that the assessments were either still in progress or needed to be signed off. The facility's census at the time was 92, indicating a significant portion of the resident population was impacted by this oversight.
Deficiency in CNA Annual Training Compliance
Penalty
Summary
The facility failed to ensure that eight out of ten randomly selected Certified Nurse Aides (CNAs) received the required annual 12-hour resident care training. The facility's census was 92. The review of the facility assessment indicated that staff training, education, and competencies were provided through various methods, including new employee orientation, in-house in-services, webinars, and other educational arrangements. However, the individual in-service records for the CNAs showed significant deficiencies in training hours. For instance, CNA L, hired in 1998, had no documentation of in-service education, and several other CNAs hired between 2002 and 2023 had either zero or insufficient hours of in-service education. This lack of training was confirmed during interviews with the Administrator, who acknowledged that the facility did not have a Staff Development Coordinator (SDC) responsible for tracking the in-service training for CNAs, leading to the deficiency in training compliance. The Administrator further explained that the Healthcare Academy would typically send a report, and the SDC would pull the report to see what training was due. However, due to the absence of an SDC, the facility failed to track and ensure the completion of the required training hours for the CNAs. This oversight resulted in a significant gap in the mandatory annual training for the CNAs, which is essential for maintaining their certification and ensuring the quality of care provided to the residents. The deficiency highlights a critical lapse in the facility's training and education system, directly impacting the competency and preparedness of the CNAs in delivering resident care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information in a prominent place, readily accessible to residents and visitors on a daily basis. Observations from 4/17/24 through 4/19/24 and 4/22/23 and 4/23/24 showed that the board behind the front desk reception contained outdated information or incomplete documentation of the total number and actual hours worked by RNs, LPNs, and CNAs per shift. The census was consistently recorded as 92, but the necessary staffing details were missing. During an interview, the Administrator acknowledged that the information should be posted daily and attributed the lapse to the Director of Nursing (DON) placing the information on a paper copy to be framed, which was not completed in the DON's absence.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control. Specifically, a Licensed Practical Nurse (LPN) did not change gloves or wash hands while administering medication via a G-tube, moving from the medication cart to the resident's room and back without proper hand hygiene. Additionally, a Certified Nursing Assistant (CNA) left suction equipment uncovered at the bedside after use, which was observed on multiple occasions. These actions were contrary to the facility's policies and professional standards of practice, as confirmed by interviews with the Registered Nurse (RN) and Assistant Director of Nursing (ADON). The facility also failed to adhere to its Tuberculosis (TB) testing policy for new hires. Eight employee files were reviewed, and none had complete documentation of the required two-step TB test. Some employees had no TB test documentation at all, while others had only completed the first step. The ADON confirmed that the facility's policy requires a two-step TB test to be completed within one to three weeks, and the lack of compliance was acknowledged during the interview. Resident #1, who required medications via a G-tube and had a care plan to remain free of complications related to tube feeding, was directly affected by the LPN's failure to follow proper hand hygiene protocols. The resident also experienced improper handling of suction equipment by the CNA, which was left uncovered, increasing the risk of infection. These deficiencies highlight significant lapses in infection control practices within the facility, as observed and documented by the surveyors.
Failure to Complete Comprehensive Resident Assessment
Penalty
Summary
The facility failed to complete a comprehensive resident assessment for one of 12 residents investigated for comprehensive assessment completion. The resident was admitted on an unspecified date, and an annual MDS assessment dated 4/1/24 with an ARD date of 2/24/24 was still in progress. The MDS Coordinator, who has been in the role for 5 years, acknowledged being behind on MDS assessments due to the facility being without a social worker for about a year and a half. As a result, the business office manager, director of rehab, and the MDS Coordinator herself have been filling the role, contributing to the delay in completing the assessments.
Incomplete and Inaccurate Care Plans
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #175, the care plan did not include focus, goals, and interventions related to the resident's diagnosis of necrotizing fasciitis of the lower left extremity, discharge planning goals, and mental health concerns. Additionally, the location of pain was not documented. Observations revealed that the resident had a bandage wrapped around the left leg with visible drainage, and the resident expressed ongoing pain and uncertainty about future care plans. The resident had not had a care plan meeting with staff. For Resident #59, the care plan lacked focus, goals, and interventions related to the resident's dietary status, difficulty swallowing, and PEG tube. The care plan also did not document the resident's rehospitalization, falls, and bowel incontinence focus, goals, and interventions. Observations showed the resident being served a puree meal and having a Jevity 1.5 bottle on the bedside table. The resident's medical record indicated multiple orders related to enteral feeding and dietary needs, but these were not reflected in the care plan. Resident #174's care plan was also incomplete, lacking focus, goals, and interventions related to the resident's dietary status, [NAME] tube, current radiation treatments, and discharge planning. The care plan did not document the resident's rehospitalization and fall goals. The resident's medical record showed multiple orders for enteral feeding and other care needs, but these were not included in the care plan. Interviews with the Administrator and MDS Coordinator confirmed that the care plans were expected to meet the residents' medical, nursing, and mental psychosocial needs but were not completed timely or comprehensively.
Failure to Ensure Safe Resident Discharge
Penalty
Summary
The facility failed to ensure a safe discharge for a resident by not sending referrals to local contact agencies and orders for medical equipment in a timely manner. This deficiency was identified for a resident who was discharged without home health setup or durable medical equipment after a change in the discharge date. The resident, who had undergone significant surgical procedures including a total laryngectomy and pharyngectomy, was discharged without the necessary support and equipment, leading to a potentially unsafe situation at home. The resident's medical record showed that the discharge plan did not include focus, goals, and interventions related to the resident's discharge planning. Despite the resident's complex medical needs, including the need for tracheostomy and PEG tube care, the facility did not update the home health referral with the new discharge date. This oversight resulted in the resident being sent home without the required medical equipment and home health services, which were crucial for the resident's post-discharge care. Interviews with facility staff revealed that there was a lack of proper communication and documentation regarding the change in the discharge date. The Social Services Director, who had only been at the facility for three weeks, stated that there was no Social Services Director at the time of the incident. The Administrator confirmed that referrals should have been resent if the discharge date was changed. This failure in the discharge planning process had the potential to affect all residents discharging from the facility, as it demonstrated a systemic issue in ensuring safe and well-coordinated discharges.
Failure to Provide Communication Assistance for Deaf Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident who is deaf by not supplying necessary speech assistive devices and ensuring staff were knowledgeable about the resident's communication needs. The resident's quarterly assessment indicated severe hearing impairment and a preference for an American Sign Language (ASL) interpreter, but no hearing aids or other communication devices were provided. The care plan included specific interventions to aid communication, but these were not transferred to the Kardex, a report used by direct care staff. During observations and interviews, it was evident that the resident struggled to communicate effectively, and staff were unaware of how to access or use communication resources for the resident. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) reported that they received information about resident care during shift reports but did not have access to the computer to review the Kardex. The Assistant Director of Nursing (ADON) acknowledged that some CNAs lacked computer access and expected them to report this issue so that access could be created. The Administrator confirmed that the care plan interventions were not being transferred to the Kardex and stated that this issue would be addressed. The lack of proper communication tools and staff awareness led to the resident's needs not being fully met, as staff were unable to effectively communicate with the resident to understand their needs and preferences.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure that a resident with chronic wounds received treatment and care in accordance with professional standards of practice. The resident was readmitted from the hospital with wounds on the left knee and lower extremities on 3/29/24. However, a full wound assessment was not completed until 4/3/24, and treatment orders for the left plantar foot and left knee were not obtained until 4/11/24 and 4/19/24, respectively. This delay in assessment and treatment was contrary to the facility's policies, which require immediate and comprehensive skin assessments upon admission or readmission and timely treatment orders for any identified wounds. The resident's medical history included high blood pressure, paraplegia, diabetes, and weakness. Upon readmission, the resident had open areas on the left knee and lower extremities, but no wound measurements or descriptions were documented until 4/3/24. The resident's Treatment Administration Record (TAR) showed no treatment orders for the left knee wound or the left lower extremity open areas until 4/11/24 and 4/19/24, respectively. This lack of timely documentation and treatment orders resulted in a failure to provide appropriate care for the resident's wounds. Interviews with the Wound Nurse revealed that the resident was readmitted on a weekend by an agency nurse, and the Wound Nurse had just accepted the position and was not yet fully in the role. The Wound Nurse assessed the wounds on 4/3/24 and obtained treatment orders, but the orders were missed when adding them into the computer. The facility's policies require that wounds be assessed upon arrival and that treatment orders be obtained immediately, but these procedures were not followed, leading to a delay in the resident's wound care.
Failure to Arrange Transportation for Follow-Up Eye Appointment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision by not making transportation arrangements for a follow-up appointment after eye surgery. The resident, who was cognitively intact and had diagnoses including heart disease, Parkinson's disease, and depression, missed the scheduled ophthalmology appointment due to the facility's failure to arrange transportation. Despite the resident's care plan indicating the need for assistance with activities of daily living and therapy services, the necessary transportation was not provided, and the appointment was not rescheduled after being missed. Interviews with staff revealed a lack of communication and coordination regarding the resident's transportation needs. The nurse responsible for setting up appointments and the receptionist responsible for scheduling transportation were both unaware of the missed appointment and the need to reschedule it. The optometrist's office confirmed that the resident was marked as a no-show and no follow-up appointment was made. The facility's administrator acknowledged that physician's orders should be followed and transportation provided, but could not explain why the resident missed the appointment.
Failure to Administer Ordered Insulin
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Practical Nurse (LPN) did not administer the resident's ordered routine insulin. The resident, who has diabetes, had an order for Admelog SoloStar insulin to be administered twice daily before breakfast and dinner. On the day of the incident, the LPN checked the resident's blood sugar, which was within normal limits, and decided not to administer the insulin without notifying the physician or obtaining an order to hold the medication. This action was contrary to the facility's medication administration policy, which requires medications to be administered as ordered unless a physician is notified and provides an alternative directive. The Assistant Director of Nursing (ADON) confirmed that the routine insulin should not have been held without physician notification, especially since insulin is considered a high-risk medication. The ADON also noted that the resident is a brittle diabetic, and administering insulin too far from meal times could cause blood sugar levels to drop. Despite this, the LPN did not follow the proper protocol, leading to a significant medication error. The facility's policy emphasizes the importance of adhering to the 10 rights of medication administration, which were not followed in this instance.
Failure to Properly Store and Label Medications and Biologicals
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored per acceptable standards of practice for one of four medication carts and one of one treatment cart reviewed. Specifically, the medication cart contained insulin pens that were not labeled with the date they were removed from refrigeration or their expiration date after being removed from refrigeration. The treatment cart contained ointments for two residents with the caps off. The facility had a total of 10 medication/treatment carts and a census of 92 residents. During an observation, it was noted that the insulin pens in the medication cart were not currently in use and were still unopened, but the staff did not know when they were removed from the refrigerator. Manufacturer recommendations for the insulin pens indicated that they should be discarded after a certain period once removed from refrigeration, which was not adhered to in this case. Additionally, the treatment cart contained an opened tube of clotrimazole-betamethasone cream for one resident and an opened tube of gentamicin ointment for another resident, both without their lids. The facility's policy on the storage and expiration dating of medications and biologicals required that opened medications be labeled with the date opened and stored with their lids on. Interviews with the staff, including a Registered Nurse and the Assistant Director of Nursing, confirmed that the facility's practices did not align with these requirements. The Assistant Director of Nursing acknowledged that insulin pens should be dated when removed from refrigeration and that ointments and creams should be stored with their lids on.
Failure to Administer and Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards. One resident with vascular leg ulcers did not have treatments completed as per physician orders. The resident's Treatment Administration Record (TAR) showed multiple instances where the required daily treatments were not documented as administered. Observations confirmed that the dressings on the resident's lower extremities were not changed daily as required, with dressings dated several days prior still in place during the survey. The resident's care plan also did not address the vascular leg ulcers, indicating a lack of comprehensive care planning for the resident's condition. Another resident with a history of stroke, tracheostomy, and hemiplegia did not receive the prescribed treatment for a blister on the right breast. The resident's care plan included interventions such as applying Inter-dry between the breasts and arms, but observations showed that these treatments were not in place. The resident's wound observation tool indicated the presence of a blister, but no follow-up skin assessments were completed to monitor the healing process. The resident's TAR also showed that the prescribed treatments were not consistently documented as administered. Interviews with staff, including the Director of Nursing (DON), revealed that there were expectations for staff to follow physician orders and document treatments on the TAR. However, the DON acknowledged that a glitch in the system prevented weekly skin assessments from appearing for nurses to complete. This systemic issue contributed to the failure to provide consistent and documented care for the residents' wounds, leading to deficiencies in the facility's care standards.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that two residents with pressure wounds received the necessary treatments and services to promote healing. Resident #5, who was cognitively intact and had multiple diagnoses including diabetes and chronic pain syndrome, had a physician's order for wound care that was not consistently followed. The treatment administration record (TAR) showed multiple instances where the prescribed wound care was not documented as completed. Observations confirmed that the resident's dressing had not been changed for several days, and the resident expressed concern that this was delaying their discharge. The Assistant Director of Nursing (ADON) and an LPN confirmed the presence of pressure wounds that were not being properly managed according to the physician's orders. Resident #1, who had a history of diabetes, stroke, and other significant health issues, was admitted with existing skin issues including a small red open area on the sacrum. Despite being at high risk for developing pressure sores, there were no documented orders for skin or wound treatments in the resident's records. The resident's condition worsened, and they were found with non-blanching redness and an open area on the left buttocks upon discharge to the hospital. Interviews with staff revealed that CNAs did not consistently report skin issues to the nurses, and the nurses were unaware of the resident's skin condition. Interviews with the facility's nursing staff, including the DON, revealed systemic issues in the documentation and execution of wound care. Weekly skin assessments were not consistently completed, and there was a known glitch in the system that prevented skin assessments from appearing for the nurses to complete. The facility lacked a dedicated wound nurse, placing the responsibility on floor nurses who did not always follow through with the required treatments. The DON confirmed that blank boxes on the TAR indicated missed treatments, and that all skin issues should be addressed with the physician and documented properly.
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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) |
|---|---|---|---|---|
| Beauvais Rehab And Healthcare Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Bernard Care Center | 1.4 mi | ★★★★★ | 31 | 0 |
| Grand Manor Health Care Center | 1.4 mi | ★★★★★ | 7 | 1 |
| Blue Circle Rehab And Nursing | 1.8 mi | ★★★★★ | 3 | 0 |
| Magnolia Wellness Center | 3 mi | ★★★★★ | 10 | 1 |
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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.