Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Quarters At Des Peres, The during CMS and state inspections, most recent first.
Failure to provide and document ordered wound care for a resident with a stage 4 sacral pressure ulcer and a right heel wound. The resident reported that after an incontinent episode the sacral dressing was removed and not replaced, and that the right ankle/heel wound had not been changed for several days. Observation found the sacral area uncovered with dried stool present, and the heel dressing still dated from several days earlier with dried drainage and adherence to the wound. The TAR showed wound care documented as completed even when the treatment had not been done.
A resident with ESRD, low blood pressure, and endometrial CA fell out of bed, hit their head, complained of pain, had markedly abnormal VS, and was sent to the hospital via EMT. Facility progress notes documented the fall, symptoms, abnormal VS, hospital transfer, and notification of the ADON and physician, but did not document any notification of the resident representative. Two adult relatives reported they were not informed of the fall or transfer until the following day, one learning this by phone and the other upon arriving to visit and being told by the receptionist, who initially gave the wrong hospital. The Administrator later confirmed his expectation that responsible parties be notified of changes in condition and that such notifications or attempts be documented, which did not occur in this incident.
A cognitively intact diabetic resident with orders for scheduled accuchecks, scheduled NovoLOG insulin, and sliding scale coverage had multiple blank MAR/TAR entries for early-morning blood glucose checks and insulin doses, with no documentation of results, administration, refusal, or unavailability. Nursing staff gave differing thresholds for when to notify the physician about abnormal blood sugars, which did not match the written order, and acknowledged that documentation was sometimes missed when they were busy. The resident reported frequent blood sugar fluctuations, concern that monitoring and insulin were not consistently provided, and perceived inconsistency among nurses, while the physician and administrator both stated that they expected orders to be followed and all blood sugars and insulin administrations or refusals to be documented.
A medication technician failed to administer multiple prescribed medications to two residents, including eye drops, nasal spray, diuretics, and a laxative, and inaccurately documented these as given in the eMAR. Both residents were cognitively intact and confirmed the omissions. The technician later admitted to forgetting the medications and initially provided false information about their administration. Facility policy requiring accurate medication administration and documentation was not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility failed to document the medical reason when residents were sent to the hospital after a change in condition. Records for residents with dialysis needs, SOB, hypoxia, falls, and neurologic impairment lacked progress notes, SBAR details, transfer forms, vital signs, or physician orders showing why the transfers occurred. Staff and the DON said the reason for transfer, notifications, and transport details should have been documented.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the affected area.
Two residents were not protected from accident hazards when staff failed to follow proper assessment and transfer protocols after a fall and during a mechanical lift transfer. One resident was manually lifted after an unwitnessed fall despite showing signs of injury, resulting in fractures, while another was unsafely transferred with a Hoyer lift without proper adjustment or support, contrary to facility policy.
Staff failed to follow infection prevention protocols, including not changing gloves, performing hand hygiene, or wearing gowns during high-contact care for residents on Enhanced Barrier Precautions, and placed soiled linens and gloves on the floor. Multi-use equipment such as blood glucose machines was not properly disinfected between residents. Additionally, most newly hired employees lacked complete documentation of the required two-step TB screening.
A resident with cognitive impairment and a history of multiple falls did not receive or have documented post-fall neurological assessments and every-shift follow-up as required by facility policy. Despite staff noting that checks were performed, the necessary documentation was missing or incomplete for most required intervals, as confirmed by interviews with nursing and administrative staff.
A resident with multiple pressure ulcers, including a Stage IV sacral ulcer and bilateral heel DTIs, did not receive timely wound assessments or documentation upon admission. Staff failed to consistently administer or document physician-ordered wound care treatments, with several missed entries on the TAR and no documentation of wound descriptions as required by facility policy. Interviews confirmed that these lapses were not communicated to the physician, and the facility's own policies for wound management and skin integrity were not followed.
A resident with HIV did not receive prescribed Triumeq for an extended period due to delays in insurance authorization and lack of timely follow-up by staff. Facility staff failed to consistently notify the prescribing ID physician or the resident's representative about the missed doses, and documentation of actions taken was incomplete. The resident's lab results later showed a high viral load and low CD4 count, confirming the medication was not administered as ordered.
Staff did not provide timely incontinence care or assistance with personal hygiene for several dependent residents, resulting in some being left wet for extended periods and not being checked every two hours. Additionally, fresh ice water was not provided to some residents as required.
Staff did not respond promptly to call lights, leading to one resident with a cardiac history calling 911 for chest pain after waiting 10 minutes without assistance, and EMS found a staff member asleep. Another resident returning from the hospital with EMS could not find staff available, and a third resident reported being left on the toilet for three hours, resulting in pain and stiffness.
The facility did not provide enough nursing staff to meet residents' needs, leading to delays in incontinence care for several residents, prolonged wait times for call light responses, and situations where EMS could not locate staff during emergencies. One resident with a cardiac history had to call EMS after staff failed to respond to chest pain, and another was left on the toilet for hours, resulting in pain.
Surveyors identified that the facility did not maintain a medication error rate below 5%, with eight errors observed out of 30 opportunities, resulting in a 26.66% error rate involving two residents.
The facility failed to provide adequate incontinence care and timely response to call lights, affecting multiple residents. Residents were found wearing saturated briefs, and staff shortages led to neglect in regular checks. One resident with chest pains called 911 after staff failed to respond, and EMS struggled to locate staff. Another resident was left on the toilet for hours, leading to pain. The ADON acknowledged inappropriate practices, and residents reported not receiving regular ice water. These issues had the potential to affect all residents.
The facility failed to provide timely incontinence care and maintain personal hygiene for residents, leaving them in soiled briefs for extended periods. Observations revealed residents lying in urine-soaked sheets, sometimes wearing two briefs, which hindered proper care. Staff admitted to not changing residents during the night shift, citing inadequate staffing. Residents reported delayed call light responses and lack of fresh ice water. The administration acknowledged these issues, but no corrective actions were mentioned.
The facility failed to follow physician orders and perform wound treatments for residents, leading to deficiencies in care. A resident with peripheral vascular disease did not receive scheduled dressing changes, while another with a skin tear after a fall did not have the injury documented or treated properly. Additionally, a resident with severe cognitive impairment had undated dressings, and a resident with a hip fracture did not receive a proper assessment of a surgical wound upon admission.
The facility failed to provide sufficient nursing staff, resulting in delayed and inadequate care for residents. Several residents were left wet for extended periods, and it often took hours for staff to respond to call lights. One resident with a history of bypass surgeries experienced chest pains and contacted EMS after staff did not respond to his call light. Observations revealed residents wearing two soaked briefs and lying in urine-soaked bedding, with staff confirming the lack of adequate staffing made it difficult to provide necessary care.
A facility failed to provide adequate nursing coverage and falsely documented care on a specific hall. The DON was not present during the day shift but documented that they administered medications and treatments, affecting multiple residents. Blood glucose levels and insulin administration were also falsely recorded by the DON, impacting resident care.
A long-term care facility was found to have a medication error rate of 26.66% due to improper medication administration practices. A resident received medications that were improperly crushed and stored, while another resident was given an unprimed inhaler and incorrect aspirin form. Staff interviews revealed a lack of adherence to facility policies and proper documentation, contributing to the deficiencies.
A resident with severe cognitive impairment and dysphagia experienced a significant decline in health, including unresponsiveness and slow, shallow breaths. Despite the speech therapist's concerns about the resident's swallowing abilities and increased confusion, the facility staff failed to notify the physician in a timely manner. The resident was eventually transported to the hospital, but only after a significant delay in communication and action by the staff.
Two residents experienced discomfort due to cold room temperatures, with one resident's thermostat malfunctioning and the other experiencing continuous cold air despite the air conditioner being off. The maintenance staff was aware of the issues but delayed addressing them, causing prolonged discomfort for the residents.
A facility failed to re-admit a resident after hospitalization, violating its policy. The resident was transported to the hospital without a documented transfer order and was refused re-entry by facility staff upon return, despite being medically cleared. The facility's nurse cited system issues and lack of information as reasons for refusal. There was no documentation of the transfer, updates, or discharge notice, and the facility's administration was unaware of the resident's status.
A facility failed to develop a comprehensive and individualized care plan for a resident within the required timeframe. The resident, who was cognitively intact and had multiple medical conditions, did not have an updated care plan reflecting their current needs. The MDS/Care Plan Coordinator acknowledged the delay, and the DON and Administrator confirmed the expectation for timely care plan completion.
The facility failed to update care plans for two residents, one requiring aspiration precautions after returning from the hospital and another needing fall interventions. Staff were unaware of the necessary precautions, leading to inappropriate meal supervision and inconsistent fall prevention measures.
A facility failed to follow aspiration precautions for a resident with aspiration pneumonia, leaving them unsupervised during meals despite hospital discharge orders. Additionally, another resident with a history of falls did not have fall mats on both sides of the bed, and the bed was not kept in the lowest position when unattended. Staff were unaware of these precautions, and care plans were not updated accordingly.
A resident received two different blood thinners simultaneously due to a transcription error in physician orders. The resident, with multiple health conditions, was supposed to start apixaban on a specific date and receive Lovenox for a limited period, but these instructions were not followed. The DON and Medical Director were unaware of the error until after it occurred, and the LPN stated that orders should be transcribed as written.
Two residents receiving dialysis were served meals with restricted items like potatoes, despite clear dietary orders. The dietary restrictions were not reflected in care plans, and staff failed to adhere to menu slips specifying necessary substitutions. The facility's Administrator and DON expected compliance with physician orders, but this was not consistently practiced, leading to the deficiency.
A facility failed to maintain accurate medical records for a resident who was hospitalized due to a change in condition. The resident, admitted to skilled services, experienced chest pain and was sent to the ER without proper documentation of a hospital transfer order or physician notification. The Administrator and DON were unaware of the resident's status, and necessary documentation was missing, indicating a lapse in record-keeping standards.
Failure to Provide and Document Ordered Wound Care
Penalty
Summary
The facility failed to ensure ordered wound treatments were provided for one resident with multiple pressure injuries, including a stage 4 sacral pressure ulcer and wounds to the right medial heel and right second toe. The resident was cognitively intact and had diagnoses including diabetes, muscle weakness, acquired absence of the left leg below the knee, neurogenic bladder, spina bifida occulta, and pressure ulcer of the sacral region stage 4. The care plan directed staff to provide treatment per current orders, and the physician orders included daily wound care for the right medial heel and sacrum, with additional PRN sacral wound care orders. On observation, the resident reported that after an incontinent episode around 1:30 p.m. the previous day, the sacral dressing had to be removed and was not replaced. When surveyed the next morning, there was still no dressing on the sacral area, and the resident said staff had not yet checked the brief that morning. The resident also stated that the wound to the right ankle had not been changed since 5/15/26. During the observation, the resident had dried bowel movement covering the sacral area and shorts, and there was a foul odor noted in the hallway and room. Record review showed the TAR documented the right medial heel wound care as completed on multiple days, but the dressing on the heel was confirmed to still be dated 5/15/26 when the ADON removed it, with dried brown drainage and the dressing stuck to the open area. The sacral wound TAR showed daily treatment documented as completed on some days, but the PRN sacral wound TAR was blank on several dates, and the resident reported the dressing had not been replaced after it came off during incontinence care. The ADON stated nurses were responsible for wound care when the wound nurse was off and that the CNA should have notified the nurse if the dressing came off. An LPN and the DON both stated treatments should not be documented as completed if they were not done, and the DON said there should have been a note if the resident refused treatment.
Failure to Notify Resident Representative of Fall and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition, as required by its own Notification of a Change in Condition Policy. The policy, revised 2/6/25, states that the attending physician/physician extender and the resident representative will be notified of a change in condition, including accidents/incidents, and that such notifications will be documented in the IDT notes. Resident #4, admitted with diagnoses including low blood pressure, ESRD, and endometrial cancer, fell out of bed late in the evening, hit their head, and complained of left eye pain, right shoulder pain, and abdominal discomfort. Vital signs at that time were significantly abnormal, with a blood pressure of 51/31 and pulse of 40, and the resident was sent to the hospital via EMT transport. Progress notes documented the fall, the resident’s complaints, the abnormal vital signs, the transfer to the hospital, and that the ADON and physician were made aware, but there was no documentation that the resident representative was notified. Interviews with the resident’s family members confirmed that the responsible parties were not informed at the time of the fall or transfer. One adult relative reported not learning of the fall or hospital transfer until the following day when calling to speak with the social worker. Another adult relative stated they were not notified of the fall or hospital transfer until arriving at the facility the next day, when the receptionist informed them the resident was in the hospital and provided the wrong hospital name. That relative then spoke with the Administrator, who did not know which hospital the resident was in and only called back with the correct location 2–3 hours later. The Administrator stated he would expect staff to notify the responsible party of any change in condition, including when a resident is sent out and when they return, and to document notification attempts or messages, which did not occur in this case.
Failure to Document and Follow Insulin and Blood Glucose Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing services were provided and documented in accordance with professional standards of practice for a resident with diabetes. The resident was cognitively intact and had diagnoses including diabetes, arthritis, and respiratory failure. Physician orders included accuchecks three times daily with meals and at bedtime, with additional checks as needed, and scheduled NovoLOG insulin doses before meals and at bedtime, along with a detailed sliding scale for additional insulin coverage. The orders also required physician notification if blood sugar was less than 70 or greater than 200. Review of the April 2026 MAR/TAR showed multiple blank entries for the 0600 scheduled insulin doses and corresponding sliding scale doses on numerous dates, as well as missing 0600 blood sugar values on those same dates. There were no documented accucheck results or insulin administrations for those times, and no documentation of refusals or resident unavailability. Progress notes showed episodes of very high blood sugars (e.g., 598 and 538) with physician notification and additional insulin orders on specific dates, but there were no other progress notes documenting physician notification for blood sugars between those dates, despite the standing order to notify for values greater than 200. Interviews with nursing staff revealed inconsistent understanding of when to notify the physician about abnormal blood sugars, with one LPN stating the physician should be called if blood sugar was greater than 400 and another stating less than 60 or greater than 300, which differed from the written order of less than 70 or greater than 200. Staff acknowledged that blood sugars and insulin administration should be documented when performed but sometimes were not due to being busy. The resident reported that blood sugars were constantly fluctuating, expressed concern that blood sugars were not being checked as often as prescribed, and believed not all ordered insulin was being administered. The physician stated an expectation that staff follow orders and document blood sugars, insulin given, or refusals. The administrator stated that blank MAR/TAR entries could mean the resident was not available but that there should be a note, and also stated that for a very high blood sugar, the nurse should have called and attempted contact again and could have reached out to the onsite nurse practitioner.
Medication Error Rate Exceeds 5% Due to Omitted Doses and Inaccurate Documentation
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a 13.2% error rate with 7 errors out of 53 observed opportunities. Certified Medication Technician (CMT) X was observed on one morning medication pass to have omitted several prescribed medications for two cognitively intact residents. For one resident, the omitted medications included artificial tears, Fluticasone Propionate nasal spray, Furosemide, MiraLAX, and Omeprazole. For the second resident, artificial tears and MiraLAX were not administered. Despite these omissions, the electronic Medication Administration Record (eMAR) was marked as if the medications had been given. Interviews with the residents confirmed that the omitted medications were not administered as scheduled. One resident specifically stated that the morning eye drops were not provided. CMT X later admitted during an interview that the medications, including MiraLAX for both residents, were not given due to nervousness and forgetfulness. CMT X also initially provided inaccurate information regarding the administration of eye drops and Flonase, later admitting dishonesty when questioned by surveyors and facility leadership. The facility's policy requires that medications be administered as prescribed, with accurate documentation on the MAR, and that any omissions or refusals be properly documented and communicated. In these instances, the required documentation and communication did not occur. The Regional Director of Operations confirmed that the MARs did not accurately reflect the omission or administration of medications and that the staff member involved did not follow established medication administration procedures.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Missing Transfer Documentation for Hospital Sends
Penalty
Summary
The facility failed to ensure nursing staff documented the reason for residents’ transfer or discharge in the medical record. Survey review found that for 3 residents who were transported to the hospital after a change in condition, the records did not contain the medically justified reason for the transfer, and the required documentation was incomplete or absent. For one resident with renal dialysis, diabetes, cognitive communication deficit, weakness, and need for assistance with personal care, the record showed the resident was sent to the hospital, but there was no progress note documenting the medical reason, no SBAR assessment, no transfer form, and no documentation explaining why the resident was transported. The resident remained active in the census and was not discharged, and there was no physician order on the dates of transfer to send the resident to the hospital. Staff interviewed said they did not know why the resident was sent out, and the DON stated the resident was sent out on night shift due to shortness of breath. For another resident with renal dialysis and cognitive communication deficit, the record showed the resident was sent to the hospital after dialysis treatment, but the progress notes did not document the reason for transfer. The SBAR form was incomplete, with “unable to determine” marked under situation, no vital signs documented, appearance left blank, and no medical reason recorded. The dialysis clinic record noted shortness of breath, labored breathing, lethargy, hypoxia with oxygen saturations in the 80s, and that treatment was discontinued and the resident was referred back to the facility for further evaluation. There was no physician order in the resident’s record to send the resident to the hospital. For a third resident with cerebral infarction, PRES, hemiplegia/hemiparesis, anemia, and muscle weakness, the record showed a fall with pain complaints and x-rays ordered, but there was no documentation that the resident was transported to the hospital. The DON stated staff complete change-in-condition and transfer forms when a resident is transported, notify the resident representative or family, and expected a progress note to include vital signs, notifications, and the time of transport if not documented in real time.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Accident Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. In the first incident, a cognitively intact resident with significant mobility assistance needs experienced an unwitnessed fall while attempting to reach an item from the bedside table. After the fall, the resident was found on the floor, expressed pain, and refused the use of a mechanical lift for transfer. Despite showing signs of injury and vocalizing pain, staff, including agency CNAs, manually lifted the resident by the arms and legs to return them to bed, without performing a full assessment or obtaining vital signs. The resident later was found to have sustained fractures to the left humerus and femur, with ongoing complaints of pain and repeated refusals for hospital transfer until eventually agreeing to be sent out for further care. Interviews with staff and the resident confirmed that the transfer was performed without the use of a mechanical lift, contrary to facility policy, and that the resident's pain was not adequately assessed prior to movement. Staff present at the time, including agency personnel, did not perform range of motion checks or vital signs, and the nurse on duty failed to call EMS despite the resident's complaints of pain and visible distress. Facility leadership, including the DON and Medical Director, later confirmed that the appropriate response would have been to contact EMS and not move the resident if injury was suspected. In a separate observation, another resident with moderate cognitive impairment, paraplegia, and total dependence for transfers was not transferred safely using a mechanical lift. During a Hoyer lift transfer, staff failed to properly adjust the resident in the sling, did not position the wheelchair correctly, and allowed the resident to dangle and spin in the air without adequate support. Only one staff member operated the lift and attempted to adjust the resident simultaneously, while the other did not provide necessary spotting or support. Interviews with staff and facility leadership confirmed that these actions were not in accordance with the facility's mechanical lift policy, which requires two staff to ensure resident safety and proper technique during transfers.
Failure to Maintain Infection Control and Employee TB Screening
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to established protocols for Enhanced Barrier Precautions (EBP) and general infection control. Staff were observed failing to change gloves, perform hand hygiene, and wear gowns during high-contact care activities for residents on EBP, including those with multidrug-resistant organisms, wounds, catheters, and feeding tubes. In several cases, staff placed soiled gloves and linens directly on the floor rather than in designated bags, and did not consistently use required personal protective equipment (PPE) such as gowns during resident transfers, wound care, and hygiene assistance. Specific observations included a certified nurse aide providing peri care and handling soiled briefs without wearing a gown and placing contaminated items on the floor. A nurse was seen changing wound dressings and handling linens without a gown, and also placed dirty linens on the floor. In another instance, both a nurse and a CNA transferred a resident using a mechanical lift without donning gowns, and staff were observed touching multiple surfaces and resident care items with the same pair of gloves, including after contact with urinary catheters and resident faces. Additionally, a blood glucose testing machine was used on multiple residents without proper disinfection between uses or placement of a barrier on the medication cart, contrary to facility expectations. The facility also failed to ensure that newly hired employees completed the required two-step Mantoux tuberculin skin test (TST) for latent tuberculosis infection. Review of employee records revealed missing documentation for both the dates and results of the first and second steps of the TST for the majority of sampled new hires. The infection control preventionist indicated that human resources was responsible for notifying nursing staff about TB testing needs, but records were incomplete or missing for nine out of ten sampled employees.
Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice by not performing and documenting post-fall neurological assessments and completing post-fall assessments according to its own policy for a resident with a history of multiple falls. The facility's Fall Management policy required a complete neurological evaluation after unwitnessed falls or potential head injuries, as well as post-fall evaluation and documentation on every shift for 72 hours. However, review of the resident's records showed that, following several unwitnessed falls, neurological checks and every-shift documentation were either missing or incomplete for the majority of required intervals. The resident involved had moderately impaired cognition, was frequently incontinent, required substantial to maximal assistance for activities of daily living, and used a wheelchair. The care plan identified the resident as being at risk for falls due to confusion, deconditioning, and gait/balance problems, with multiple falls documented over a two-month period. Despite these risks and repeated incidents, the facility did not consistently document the required post-fall neurological assessments or every-shift follow-up as outlined in their policy. Interviews with staff, including an LPN, the Administrator, the DON, and a Corporate Nurse, confirmed that neurological checks were expected to be completed and documented per policy after unwitnessed falls. The Administrator acknowledged that neurological check sheets for the resident could not be found, and staff had only documented that checks were done without providing the required detailed documentation. This lack of adherence to policy and incomplete documentation constituted the deficiency identified by surveyors.
Failure to Timely Administer and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for pressure ulcer management for one resident. Upon admission, staff did not document a description of the resident's wounds, including location, stage, size, or other required characteristics, as outlined in the facility's wound management and skin integrity policies. The baseline care plan for the resident was left blank regarding skin issues, and progress notes lacked any wound description upon admission. The resident was admitted with significant medical conditions, including paraplegia, diabetes, heart failure, and multiple pressure ulcers: two suspected deep tissue injuries (DTIs) on the heels and a Stage IV pressure ulcer on the sacrum, all present on admission. Physician orders for wound care were not timely administered or documented. The Treatment Administration Record (TAR) showed multiple missed or undocumented treatments for the resident's wounds, including the sacral pressure ulcer and both heel DTIs. There were no entries for some ordered treatments on specific dates, and staff failed to document reasons for missed treatments. Interviews with nursing staff, the wound nurse, and the DON confirmed that a blank on the TAR indicated the treatment was not done, and there was no documentation that the physician was notified of delays or missed treatments. The wound doctor and corporate nurse both stated that staff were expected to follow physician orders and facility policies, but were unaware of the lapses in documentation and administration until after the fact. The facility's policies required comprehensive skin assessments and timely documentation of wound characteristics and treatments, as well as prompt notification of the physician and other relevant parties when wounds were identified or when treatment orders were absent. Despite these policies, the resident's wounds were not properly assessed or documented on admission, and there were significant gaps in the administration and documentation of prescribed wound care treatments. These failures were confirmed through record review, staff interviews, and review of the facility's own policies and procedures.
Failure to Administer HIV Medication and Notify Physician and Responsible Party
Penalty
Summary
A resident with a diagnosis of HIV and impaired immunity was admitted to the facility and had a physician order for Triumeq, an antiretroviral medication critical for managing HIV. Upon admission, the resident did not receive Triumeq as ordered for an extended period due to issues with medication availability, insurance authorization, and lack of timely follow-up by facility staff. Documentation shows that the medication was not administered on multiple occasions, with staff marking 'not administered' (NA) on the Medication Administration Record (MAR) but failing to consistently document actions taken to resolve the issue or notify the prescribing Infectious Disease (ID) physician, the resident, or the resident representative (RR) about the missed doses. The facility's policies required staff to notify the physician and document actions taken when a vital medication was not available, but interviews and record reviews revealed that these procedures were not followed. Staff often did not document communication with the physician or RR regarding the medication gap, and there was no evidence that the ID physician was informed in a timely manner about the ongoing lack of medication. The resident's care plan identified the risk of infection due to immune deficiency, but interventions to monitor and report complications were not effectively implemented in relation to the missed medication. The facility also lacked a process to ensure timely follow-up on prior authorizations, resulting in prolonged delays in obtaining the medication. As a result of these failures, the resident missed multiple doses of Triumeq over a period of more than a month, which was confirmed by laboratory results showing a significantly elevated viral load and low CD4 count, indicating the medication was not being administered as required. The ID office and RR were not made aware of the medication gap until after the resident's condition had deteriorated. Interviews with facility staff, pharmacy, and the ID office confirmed that communication and documentation were insufficient, and the facility did not provide evidence of timely notification or adequate follow-up to ensure the resident received the prescribed medication.
Failure to Provide Timely Incontinence Care and Personal Hygiene Assistance
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living for residents who were dependent, specifically in the areas of toileting and incontinence care. Four residents who were incontinent of bowel and/or bladder did not receive timely incontinence care, as staff did not provide care as needed to maintain good personal hygiene. Additionally, two other residents reported that staff frequently did not check them for incontinence every two hours and did not respond to their call lights in a timely manner when they needed to be changed, resulting in them being left wet for extended periods. The facility also did not provide fresh ice water to three residents, as observed during the survey. These deficiencies were identified through observation, interviews, and record review, affecting multiple residents with a census of 118. The report documents that the facility did not ensure dependent residents received timely and adequate care for incontinence and personal hygiene, and failed to provide fresh ice water to some residents, as required.
Failure to Respond Timely to Call Lights and Resident Needs
Penalty
Summary
Facility staff failed to respond promptly to residents' call lights, resulting in delayed care for multiple residents. One resident with a history of bypass surgeries experienced chest pain, activated the call light, and after waiting 10 minutes without a response, called 911. Emergency Medical Services (EMS) arrived and were unable to locate facility staff until they found one staff member asleep on a couch. The resident was subsequently admitted to the hospital with atrial fibrillation. At the same time, another resident was returning from the hospital with EMS, and the EMS crew also could not find staff readily available. Additionally, a hospital Emergency Department report indicated that another resident called 911 after being left on the toilet for three hours, resulting in stiffness and pain.
Insufficient Nursing Staff Resulting in Delayed and Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delayed and inadequate care. Four residents who were incontinent of bowel and/or bladder did not receive timely incontinence care. Three other residents reported that staff did not check on them every two hours, leaving them wet for extended periods, and that call lights often went unanswered for hours. One resident with a history of bypass surgeries experienced chest pain, used the call light, and did not receive a response from staff for 10 minutes, prompting the resident to contact EMS. When EMS arrived, they could not locate facility staff until they found one staff member asleep on a couch. Another resident returned from the hospital with EMS at the same time and that EMS crew also could not find staff readily available. Additionally, a hospital emergency department report indicated that a resident called 911 after being left on the toilet for three hours, resulting in stiffness and pain. The facility census was 118 residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During observation, interview, and record review, eight medication errors were identified out of 30 opportunities, resulting in a 26.66% error rate. These errors involved two residents while the facility census was 118. The deficiency was identified through direct observation and review of medication administration practices, which revealed multiple errors affecting the residents involved.
Neglect in Incontinence Care and Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure residents were free from neglect, as evidenced by inadequate incontinence care and delayed response to call lights. Four residents were observed wearing two saturated incontinence briefs, emitting strong odors of urine and feces, indicating they had not been changed for extended periods. Interviews with residents and staff revealed that residents were not checked every two hours as required, and staff shortages were cited as a reason for the neglect. Additionally, residents reported that call lights were not answered promptly, sometimes taking hours for a response. One resident with a history of bypass surgeries experienced chest pains and activated their call light, but when staff did not respond within 10 minutes, the resident called 911. Emergency Medical Services (EMS) arrived but could not locate facility staff immediately, eventually finding one staff member asleep on a couch. Another resident returned from the hospital with EMS at the same time, and the EMS crew again struggled to find staff readily available. Another resident's hospital Emergency Department report indicated they called 911 after being left on the toilet for three hours, resulting in stiffness and pain. The facility's staffing issues were further highlighted by interviews with staff, who admitted to being unable to perform regular checks due to insufficient personnel. The Assistant Director of Nursing (ADON) acknowledged that it was inappropriate to check residents' briefs through their clothing and that staff should provide privacy and visually check for soiling. The report also noted that residents were not offered fresh ice water regularly, and some residents had to rely on family members to provide it. These deficiencies had the potential to affect all residents, with a census of 118.
Inadequate Incontinence Care and Hygiene Maintenance
Penalty
Summary
The facility failed to provide timely incontinence care and maintain personal hygiene for residents who were unable to perform activities of daily living independently. This deficiency affected several residents who were incontinent of bowel and/or bladder. Observations revealed that residents were left in soiled briefs for extended periods, sometimes wearing two briefs, which made it difficult to determine if the inner brief was wet. This practice led to residents lying in urine-soaked sheets and experiencing discomfort and potential skin integrity issues. Interviews with staff and residents highlighted that the facility did not adhere to its policy of checking residents every two hours for incontinence. Staff admitted to not changing residents during the night shift and acknowledged the inappropriate practice of placing two briefs on residents. Residents reported that call lights were not answered promptly, often taking over an hour, and that they were not provided with fresh ice water regularly. The lack of adequate staffing was cited as a reason for the delay in providing care, with only two CNAs available for 58 residents during the night shift. The facility's failure to provide necessary care and services resulted in residents being left in unsanitary conditions, with some experiencing redness and potential moisture-associated skin damage. The administration and DON acknowledged the issues with call light response times and the inappropriate practice of checking briefs through clothing. However, the report does not mention any corrective actions or plans to address these deficiencies.
Failure to Follow Physician Orders and Perform Wound Treatments
Penalty
Summary
The facility failed to provide care consistent with professional standards by not following physician orders and performing wound treatments for three residents. Resident #10, who was cognitively intact and had multiple diagnoses including peripheral vascular disease and diabetes, did not receive wound dressing changes as ordered. The resident's dressings were not changed according to the schedule, and the care plan did not address the treatment for the resident's lower extremities. Observations confirmed that the dressings were not dated correctly, and interviews with staff revealed a lack of adherence to the physician's orders. Resident #8, admitted with cellulitis and malignant melanoma, experienced a skin tear after a fall. The skin tear was not documented in the resident's medical record, and no physician's order was obtained for the treatment. The dressing applied to the skin tear was not changed as it should have been, and the resident was later admitted to the hospital. Interviews with staff indicated that the necessary steps to document and treat the skin tear were not followed, leading to a lapse in care. Resident #1, with severe cognitive impairment and diagnoses including Alzheimer's Disease, had undated dressings on the right lower and upper extremities. The treatments were documented as completed, but observations showed that the dressings were not dated. Additionally, Resident #18, who was cognitively intact and admitted with a hip fracture, did not receive a proper assessment of a surgical wound upon admission. The dressing on the surgical incision was not changed, and there was no physician's order for the dressing. Interviews with staff highlighted the failure to perform a complete skin assessment and obtain necessary treatment orders for surgical wounds.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure residents received prompt and adequate care, affecting multiple residents. Several residents reported that staff did not check on them every two hours, leaving them wet for extended periods, and it often took hours for staff to answer call lights. One resident with a history of bypass surgeries experienced chest pains and contacted EMS after staff did not respond to his call light for 10 minutes. When EMS arrived, they found a staff member asleep on the couch, and another EMS crew could not find staff readily available when another resident returned from the hospital. The facility's staffing levels were inadequate, particularly during the night shift, as observed during the initial tour. There were only two nurses and five CNAs on duty for 118 residents, with one nurse and two CNAs assigned to each floor. Interviews with staff revealed that this staffing level was insufficient to provide timely care, with some residents not being checked or changed for incontinence throughout the night. The facility's assessment indicated a need for more staff, but the facility failed to meet these staffing expectations on multiple occasions. Specific residents were observed to be wearing two briefs, both soaked with urine, and lying in urine-soaked bedding. These residents had not been changed for several hours, leading to potential skin integrity issues. Staff interviews confirmed that the lack of adequate staffing made it difficult to provide necessary care, and some staff were unaware of the facility's policies regarding resident care. The facility's failure to provide adequate staffing and timely care had the potential to affect all residents.
False Documentation and Lack of Nursing Coverage
Penalty
Summary
The facility failed to provide services that meet professional standards of clinical practice on the day shift of 12/15/24 on [NAME] Hall. There was no Licensed Practical Nurse (LPN) or Registered Nurse (RN) available to administer medications, perform gastrostomy (g-tube) flushes, provide treatments, complete assessments, or monitor residents as ordered. The Director of Nursing (DON) falsely documented that they administered medications and g-tube flushes, completed treatments, and assessments for residents from 7:00 A.M. through 3:00 P.M. This affected 41 residents on the hall, with specific issues identified in 15 sampled residents. Additionally, LPN FF and/or Certified Medication Technician (CMT) GG obtained resident blood glucose levels and administered insulin but were unable to record these in the Medication Administration Record (MAR). The DON entered these blood glucose levels and insulin administration into the MAR using their electronic signature, falsely indicating they had performed these tasks. This affected 17 residents who received blood glucose monitoring and/or insulin, with problems identified in 10 sampled residents. Interviews with staff and the facility's Medical Director revealed that the DON was not present during the day shift and did not perform the documented tasks. The DON admitted to initialing several day shift medications, treatments, assessments, and monitoring as completed, despite not performing them. The facility's policies require that medications, treatments, and assessments be documented accurately and completed at the time they are done. The DON's actions were not in line with these policies, leading to a significant deficiency in the facility's care standards.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 26.66% error rate during the survey. This was observed through multiple medication administration errors involving two residents. For Resident #41, the Certified Medication Technician (CMT) prepared medications by crushing them and mixing them with pudding, despite some medications being on the facility's 'Do Not Crush' list. The medications were then stored improperly in the medication cart for over an hour before administration, which posed an infection risk and could affect the efficacy of the medications. Additionally, there was no documented order allowing for the crushing of medications, and the resident's preference for receiving medications in pudding was not properly documented or communicated. For Resident #42, the CMT administered a new inhaler without priming it first, as required by the manufacturer's instructions, and failed to provide the correct dosage of two puffs. The resident was also not instructed to rinse their mouth after using the inhaler, which is necessary to prevent fungal infections. Furthermore, the CMT administered a chewable aspirin instead of the prescribed delayed-release form, indicating a lack of awareness of the differences between medication forms. Interviews with facility staff, including the Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON), revealed expectations for proper medication administration practices that were not followed. These included ensuring medications are administered as ordered, documenting resident preferences and refusals, and adhering to facility policies and guidelines. The failure to follow these protocols contributed to the high medication error rate and the deficiencies observed during the survey.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to adhere to its change of condition policy for a resident who experienced a significant decline in health. The resident, who had severe cognitive impairment and a history of dysphagia, was found unresponsive with slow, shallow breaths. Despite the speech therapist's observations of the resident's deteriorating swallowing abilities and increased confusion, the physician was not notified in a timely manner. The resident was eventually transported to the hospital after being found in a critical state, but this was only after a significant delay in communication and action by the facility staff. The facility's policy required that any change in a resident's condition be promptly communicated to the attending physician and the resident's representative. However, the staff failed to notify the physician about the resident's worsening condition, as reported by the speech therapist. The speech therapist had noted the resident's increased risk of aspiration and had communicated these concerns to the nursing staff, who were supposed to inform the physician. Despite multiple attempts by the LPN to contact the physician, no message was left, and the information was inadequately passed on to subsequent shifts. Interviews with the facility staff revealed a breakdown in communication and adherence to protocol. The primary care physician and medical director were not informed of the resident's condition change, which they expected to be notified about. The administrator and director of operations also confirmed that staff were expected to follow the facility's policies and procedures, which included documenting changes in condition and notifying the appropriate parties. This failure to follow established protocols resulted in a delay in the resident receiving necessary medical evaluation and treatment.
Failure to Maintain Comfortable Room Temperature for Residents
Penalty
Summary
The facility failed to maintain a comfortable room temperature for Resident #6, who reported that the cold temperature in his/her room was causing discomfort and affecting his/her sleep. Despite the resident's repeated complaints to the maintenance staff, nurses, and the Administrator, the issue persisted for nine weeks without resolution. The Maintenance Supervisor acknowledged the problem but cited delays due to other tasks, such as moving furniture, and the need for a replacement part, which was only purchased the day before the surveyor's observation. Resident #6's medical history includes moderate cognitive impairment and chronic lung conditions, which could be exacerbated by the cold environment. The resident's temperature readings consistently showed low body temperatures, indicating the room's coldness was affecting his/her physical state. The Maintenance Supervisor was unaware of the thermostat's malfunction, which was set to 78 degrees but only reached 71 degrees, and had not taken timely action to address the issue. Similarly, Resident #19 also experienced discomfort due to the cold air blowing continuously in his/her room, despite the air conditioner being turned off. The resident, who is on blood thinners, expressed frustration and concern about the cold environment. The Maintenance Supervisor and Assistant were aware of the issue but had not communicated any updates or resolved the problem, leaving the resident to cope with the cold by using extra blankets and wearing a sweater to bed.
Facility Fails to Re-Admit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its written policy by not permitting a resident to return after hospitalization, despite the absence of a proper discharge order or documentation. The resident, who was admitted for skilled services, was transported to the hospital without a documented physician's order for transfer. Upon the resident's return, the facility staff refused to accept the resident back, citing a lack of information and system issues, despite the hospital's insistence on the facility's legal obligation to do so. The Emergency Medical Service (EMS) report indicated that the facility's nurse refused to sign a transfer of care for the resident, who was medically cleared to return. The nurse claimed the resident did not want to be there and that it was not their problem, further stating that the facility's system was down, and they had no information on the resident. The EMS had to return the resident to the hospital after the facility's refusal to accept them back. There was no documentation in the resident's progress notes regarding the transfer to the hospital, updates on the resident's status, or the refusal to readmit the resident. Additionally, there was no record of a bed-hold, a 30-day discharge notice, or any physician order to discharge the resident. The facility's Administrator and Director of Nursing were unaware of the resident's status and expected the nursing staff to have documented the necessary information and updates.
Failure to Develop Timely and Individualized Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive, accurate, and individualized care plan was developed for a resident, identified as Resident #10, within the required timeframe. The facility's policy mandates that a comprehensive care plan should be developed within seven days after the completion of the Admission Minimum Data Set (MDS). However, the MDS/Care Plan Coordinator acknowledged that a comprehensive care plan was not present in the resident's chart, despite the expectation that it should be completed within 14 days of admission. The Director of Nursing and Administrator confirmed this expectation during an interview. Resident #10, who was cognitively intact, had a history of high blood pressure, peripheral vascular disease, diabetes, high cholesterol, and stroke, and was admitted with wounds. The care plan in use at the time of the survey included outdated information from a previous admission and did not reflect the resident's current needs. The MDS/Care Plan Coordinator admitted to making changes to the care plan at a later time, indicating a delay in updating the care plan to address the resident's specific needs and conditions.
Failure to Update Care Plans for Aspiration Precautions and Fall Interventions
Penalty
Summary
The facility failed to ensure timely revisions to resident care plans, resulting in deficiencies in care for two residents. One resident returned from the hospital with a diagnosis of aspiration pneumonia and required aspiration precautions during meals. However, these precautions were not added to the resident's care plan. Observations revealed that the resident was left unsupervised during meals, and staff were unaware of the aspiration precautions, leading to the resident being served food and drink inappropriately. Another resident, who had a history of falls, was found under the bed during routine rounds and was subsequently hospitalized. Upon readmission, new orders for bilateral fall mats were received, but these interventions were not added to the resident's care plan. Observations showed inconsistencies in the placement of fall mats and the height of the bed, which was not always in the lowest position as required. Interviews with the MDS/Care Plan Coordinator and facility administration confirmed that the necessary updates to the care plans were not made. The facility's policies and procedures for fall management and care plan updates were not followed, leading to these deficiencies in resident care.
Failure to Follow Aspiration Precautions and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure staff followed aspiration precautions for a resident with a recent diagnosis of aspiration pneumonia. The resident, who had unclear speech, severely impaired cognition, and required partial assistance with eating, was observed without supervision during meals. The resident's care plan was not updated to include the aspiration precautions ordered upon discharge from the hospital, which included sitting at a 90-degree angle, alternating liquids and solids, and requiring 100% supervision. Staff, including CNAs and LPNs, were unaware of these precautions and left the resident unsupervised, contrary to the hospital's discharge instructions. Another deficiency involved a resident with a history of falls who did not have a mat on both sides of the bed and whose bed was not kept in the lowest possible position when unattended. The resident, who had no speech and was dependent on others for mobility, was found under the bed during routine rounds. Although new orders were received for bilateral fall mats, observations showed that the resident's bed was not consistently equipped with mats on both sides, and the bed height was not maintained at the lowest position when staff were not present. The facility's policies on fall management and staff responsibilities were not adhered to, as evidenced by the lack of updated care plans and failure to implement necessary safety measures. The Administrator and DON acknowledged that the policies provided were current and expected to be followed, yet the deficiencies in supervision and safety precautions for both residents were evident during the survey observations.
Medication Error: Simultaneous Administration of Blood Thinners
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident received two different blood thinner medications simultaneously. The resident, who was cognitively intact and had diagnoses including anemia, heart failure, low blood pressure, kidney disease, and high cholesterol, was admitted with physician discharge orders for apixaban and heparin. However, the orders were not correctly transcribed, leading to the resident receiving apixaban earlier than intended and Lovenox instead of heparin due to pharmacy issues. The Director of Nursing was unaware of the discrepancy in the orders until after the error occurred, and the Medical Director expected the nurses to have clarified the orders. The Licensed Practical Nurse involved stated that medication orders should be written as per the admission orders. The error was discovered when it was noted that the apixaban was not to be started until a specific date, and the Lovenox was only to be administered for four days, which was not followed as per the orders.
Failure to Adhere to Dietary Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to ensure that residents receiving dialysis were provided with diets as ordered by their physicians. Two residents, both receiving in-house dialysis, were served meals that included restricted food items such as potatoes, despite clear dietary orders to avoid them. The dietary restrictions were not reflected in the residents' care plans, and the dietary aides and CNAs did not adhere to the menu slips that specified the necessary dietary substitutions. Resident #5, who had severe cognitive impairment and required partial assistance with eating, was served breakfast and lunch that included potatoes, a restricted item. The CNAs responsible for serving and feeding the resident did not read the menu slip, which clearly stated the dietary restrictions. The LPN and CNA involved acknowledged the oversight but did not take immediate corrective action to replace the restricted food items. Resident #17, who was cognitively intact and aware of their dietary restrictions, also received meals containing potatoes. Despite knowing the restrictions, the resident consumed the potatoes due to the lack of available substitutes. The Dietary Manager confirmed that the dietary aides should have followed the menu slips and provided appropriate substitutions. The facility's Administrator and DON expected staff to follow physician orders and ensure dietary compliance, but this was not consistently practiced, leading to the deficiency.
Failure to Maintain Accurate Medical Records for Hospitalized Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced a change in condition and was admitted to the hospital. The resident, who had been admitted to skilled services, showed signs of confusion and dependency in self-care and mobility. On the day following their admission, the resident experienced chest pain and was advised by their primary care provider to be sent to the emergency room. However, there was no documentation of a hospital transfer order, physician notification, or updates on the resident's status in the facility's records. During an interview, both the Administrator and the Director of Nursing (DON) were unaware of the resident's whereabouts and lacked documentation regarding the resident's hospital transfer. The DON did not recall completing the necessary hospital transfer form, and the Administrator discovered only during the interview that the resident had been transferred to another facility. The absence of documentation, including admission notes and progress notes, led to the inability of the facility staff to provide information about the resident's status, highlighting a significant lapse in maintaining medical records according to professional standards.
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What surveyors actually found near you
We read the 843 citations issued within 25 miles in the last 12 months — including the 14 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Des Peres
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden View Care Center At Dougherty Ferry | 2.5 mi | ★★★★★ | 0 | 0 |
| Aberdeen Heights | 2.8 mi | ★★★★★ | 1 | 0 |
| Athene Nursing And Rehabilitation | 3 mi | ★★★★★ | 46 | 0 |
| Big Bend Woods Healthcare Center | 3.3 mi | ★★★★★ | 22 | 0 |
| Manchester Rehab And Healthcare Center | 3.5 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.