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 Manchester Rehab And Healthcare Center during CMS and state inspections, most recent first.
A resident sustained a head injury when their wheelchair flipped over during transport due to improper securement. The maintenance worker and activity director involved lacked formal training in securing wheelchairs, and the regular transporter was on leave. The resident, who had a history of a humerus fracture and was on anticoagulants, was provided first aid for the injury.
A resident with a complex medical history was admitted to a facility without physician's orders, resulting in missed medications. The resident experienced two falls, and staff were unaware of the absence of medication orders. The facility lacked a policy for obtaining physician orders at admission, leading to deficiencies in care.
A resident sustained a fractured leg due to improper transfer by a CNA who lacked access to electronic medical records, violating facility policy. The facility also failed to ensure all nursing staff had access to care plans and did not adequately train staff on mechanical lift use. Additionally, a cognitively impaired resident exited the facility unnoticed, highlighting lapses in elopement prevention measures.
The facility failed to provide adequate hygiene care for several residents, as showers were not given according to their needs and preferences. Observations revealed poor hygiene conditions, such as greasy hair and body odor, in residents who required assistance with ADLs. The facility's shower schedule was based on room numbers rather than resident preferences, and there was a lack of proper documentation for showers provided.
A facility failed to maintain a medication error rate below 5%, resulting in a 9.52% error rate. Errors involved two residents, one cognitively impaired, where a CMT did not administer prescribed medications including aspirin, multivitamins, losartan, and metoprolol. The CMT believed medications were given but overlooked them, failing to follow the facility's medication policy.
A resident with pressure ulcers had incomplete clinical records due to missing physician notes, despite regular wound assessments and treatments documented by staff. The facility experienced management changes, and the absence of a wound nurse led to gaps in maintaining accurate medical records.
The facility failed to thoroughly investigate an allegation of a resident being hit in the head by a male nurse. The investigation did not include interviews with the resident or the resident's sibling, who reported the incident. Additionally, there was no documentation in the resident's medical record regarding the abuse allegation.
A facility failed to report an allegation of abuse to the DHSS within the required two-hour time frame. A resident mentioned being hit in the head by a male, but the state agency was not notified immediately. The resident's medical record lacked documentation of the abuse allegation or notification to the state agency. Interviews revealed that the facility did not follow the required reporting protocol.
Improper Wheelchair Securement Leads to Resident Injury During Transport
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not properly securing a resident's wheelchair during transport to another facility. This resulted in the wheelchair flipping over backwards during a turn, causing the resident to sustain a small gash on the back of their head. The incident occurred while the resident was being transported by a maintenance worker and an activity director, neither of whom were the regular transporters. The resident involved had a medical history that included a nondisplaced simple supracondylar fracture of the right humerus, muscle weakness, and was on anticoagulant medication. During the transport, the resident was strapped into the van using all available straps and a seatbelt. However, the seatbelt came undone or broke, leading to the resident falling backwards in the wheelchair. The maintenance worker and activity director attempted to assist the resident and provided first aid for the head injury. Interviews with the staff involved revealed that the maintenance worker had no formal training in securing wheelchairs and relied on the activity director's method. The activity director, who was CPR certified, also lacked specific training on securing residents in wheelchairs for transport. The facility's administrator was informed of the incident and noted that the regular transporter was on leave, and the facility was using a vendor for transportation until the regular driver returned.
Resident Admitted Without Physician Orders and Medication
Penalty
Summary
The facility failed to meet professional standards of practice when a resident was admitted without physician's orders and did not receive prescribed medications on the evening of admission. The resident, who had a complex medical history including Alzheimer's dementia, high blood pressure, diabetes, coronary artery disease, and seizure disorder, was admitted to the facility without the necessary discharge papers or orders from the hospital. This oversight led to the resident not receiving critical medications, including anticonvulsants and treatments for diabetes and high blood pressure. The resident experienced two falls within the facility, the first occurring on the day of admission and the second early the following morning. The first fall was documented by a nurse, but there was no record of the resident's arrival or verification of admission orders by the physician. The second fall resulted in the resident complaining of hip pain, and the resident was subsequently sent to the hospital without physician's orders. The facility's staff, including the LPN and CMT, were unaware of the absence of medication orders, and the resident's name did not appear in the electronic record for medication administration. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's admission status and medication needs. The DON was not aware of the admission without orders until questioned by the surveyor, and the Regional Corporate Nurse emphasized the importance of obtaining and transcribing physician's orders promptly. The facility did not have a policy for obtaining physician orders at the time of admission, contributing to the oversight and subsequent deficiencies in care.
Deficiencies in Resident Safety and Staff Training
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer, resulting in the resident sustaining a fractured leg. A staff member transferred the resident without using a Hoyer lift or additional staff assistance, contrary to the facility's policy. The resident, who had a history of traumatic brain injury, muscle weakness, and contractures, was dependent on a mechanical lift for transfers. The incident occurred when a CNA, who did not have access to the resident's electronic medical records, transferred the resident using a gait belt, leading to the resident's injury. Additionally, the facility did not ensure that all nursing staff had access to residents' electronic medical records through Point Click Care (PCC) before working with residents. This lack of access prevented staff from reviewing care plans and Kardex information, which are essential for understanding residents' care needs and transfer requirements. The CNA involved in the incident had not received access to PCC until after the transfer, and the facility had not adequately in-serviced staff on the use of mechanical lifts or updated care plans with current information. Furthermore, the facility failed to prevent a cognitively impaired resident from exiting through a secured door without staff knowledge, resulting in the resident leaving the facility property. The resident, who was at risk for elopement, walked 0.1 miles away from the facility towards a busy street. The facility did not implement additional interventions to ensure the resident's safety or in-service all staff on the facility's elopement policy, which would have enabled staff to identify residents at risk for elopement.
Failure to Provide Adequate Hygiene Care for Residents
Penalty
Summary
The facility failed to ensure that five residents who required assistance with activities of daily living (ADLs) received showers according to their needs and preferences. The facility's policy stated that residents should be offered a shower at least once weekly and as per their request. However, the review of the shower schedule revealed that showers were assigned by room number rather than resident preference, and there was no directive for staff to document when showers were given. This lack of documentation and adherence to resident preferences led to several residents not receiving showers as needed. Resident #4, who was cognitively impaired and required substantial assistance, was observed with greasy hair, a coated mouth, and long, dirty fingernails, indicating a lack of proper hygiene care. The resident's care plan did not specify their preferences for shower days or times, and the shower sheets showed inconsistencies in the provision of showers, with several instances of bed baths instead of showers. Similarly, Resident #5, also cognitively impaired and dependent on staff for personal hygiene, reported not receiving a shower in the past two weeks, and observations confirmed poor hygiene. Resident #7, who was non-verbal and cognitively impaired, was observed with greasy hair and a foul body odor, with shower sheets indicating a mix of bed baths and showers without proper documentation. Resident #11, cognitively intact but requiring assistance, often refused showers and preferred bed baths, yet staff did not assist with comprehensive hygiene during these baths. Lastly, Resident #2, who was cognitively impaired and required maximum assistance, had no shower sheets available, indicating a lack of documentation for hygiene care. Interviews with the DON and Administrator highlighted systemic issues with the shower scheduling and documentation process, which were not aligned with resident preferences or care plans.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 9.52% error rate. This was identified during a survey where 4 errors occurred out of 42 medication administration opportunities. The errors involved two residents, one of whom was cognitively impaired and dependent on staff for all activities of daily living. The errors included the failure to administer chewable aspirin and a multivitamin to one resident, and the failure to administer losartan potassium and metoprolol succinate to another resident. During an interview, the Director of Nursing revealed that the Certified Medication Technician (CMT) responsible for the errors believed they had administered the medications but overlooked the over-the-counter medications. The CMT could not provide an explanation for why the other prescribed medications were not administered. The facility's medication policy emphasizes the importance of the seven rights of medication administration and the Rule of 3, which involves multiple checks to ensure accuracy, but these procedures were not followed in these instances.
Incomplete Documentation of Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident with pressure ulcers. The resident was admitted with a Stage II pressure ulcer on the coccyx and a Stage IV pressure ulcer. The care plan noted the resident's refusal to turn, reposition, and accept treatments, with goals to prevent further skin breakdown. Despite this, the treatment administration records indicated that staff documented treatments for the coccyx/buttock area. Throughout February to May, the facility's wound reports consistently listed the resident, including measurements, treatment orders, and interventions. However, the resident's progress notes repeatedly showed that the resident was seen by a wound physician, yet the physician's notes were missing from the medical record. This pattern of missing documentation persisted over several weeks, even as the resident was hospitalized and later not expected to return to the facility. The Director of Nursing (DON) acknowledged that the wound nurse, along with the wound physician, was responsible for measuring wounds weekly and ensuring the information was transcribed into the resident's medical record. However, due to management changes and the termination of the wound nurse, the Assistant Director of Nursing (ADON) had been filling in, and the facility's wound reports were not integrated into the resident's medical records. The DON could not explain why the wound reports were completed but not included in the medical record, highlighting a significant gap in maintaining accurate and complete clinical documentation.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to follow their abuse policy by not thoroughly investigating an allegation of a resident being hit in the head by a male nurse. The incident was reported by the resident's sibling to the facility's Marketing Director while visiting the resident in the hospital. The facility's investigation did not include interviews with the resident or the resident's sibling, who initially reported the allegation. Additionally, there was no documentation in the resident's medical record regarding the abuse allegation. The facility's Abuse Prevention and Prohibition Program mandates a thorough investigation of abuse allegations, including interviews with the resident, witnesses, and family members. However, the investigation conducted by the facility only included interviews with the four male staff members and ten other residents, all of whom reported feeling safe and not witnessing any abuse. The Marketing Director, DON, and Administrator failed to follow up with the resident and the resident's sibling for further details, which was a critical step in the investigation process. The resident involved had no cognitive impairment and was dependent on activities of daily living, with diagnoses including diabetes, osteoporosis, and Down Syndrome. The failure to interview the resident and the resident's sibling, as well as the lack of documentation in the medical record, indicates a significant lapse in the facility's adherence to their abuse prevention policy. This deficiency highlights the need for a more comprehensive and thorough investigation process to ensure resident safety and compliance with federal and state requirements.
Failure to Report Allegation of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of resident abuse to the Department of Health and Senior Services (DHSS) within the required two-hour time frame. The incident involved a resident who mentioned to the Marketing Director that they had been hit in the head by a male. The Marketing Director informed the Administrator and the Director of Nursing (DON), but there was no immediate report made to the state agency as required by the facility's Abuse Prevention and Prohibition Program. The resident's medical record also lacked documentation regarding the allegation of abuse or notification to the state agency. The resident involved had no cognitive impairment, no moods or behaviors, and was dependent on activities of daily living. The resident had diagnoses including diabetes, osteoporosis, and Down Syndrome. The incident came to light when the resident was discharged to the hospital due to swelling of the left hand, and during a visit by the Marketing Director, the resident mentioned the abuse incident. Interviews with the Marketing Director, DON, and Administrator revealed that the facility did not follow the required protocol for reporting the abuse allegation. The DON and Assistant Administrator suspended all male nurses and interviewed other residents, but the state agency was not notified within the required time frame. The Administrator acknowledged that an FYI notification should have been made to the state agency immediately upon learning of the abuse allegation.
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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 Ballwin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Senior Services At Meramec Bluffs | 1 mi | ★★★★★ | 2 | 0 |
| Delmar Gardens On The Green | 2.1 mi | ★★★★★ | 1 | 0 |
| Athene Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 46 | 0 |
| Big Bend Woods Healthcare Center | 3.1 mi | ★★★★★ | 22 | 0 |
| Garden View Care Center At Dougherty Ferry | 3.2 mi | ★★★★★ | 0 | 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.