Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 St Johns Place during CMS and state inspections, most recent first.
The facility failed to submit complete and accurate PBJ staffing data to CMS and failed to enter nursing hours in the PBJ, resulting in a quarter with no data submitted, a one-star staffing rating, and suppressed staffing metrics. The PBJ report and CMS interviews showed that the validation report only confirmed receipt of a file, while the facility’s staffing data lacked RN hours and had no LPN hours entered after the identified point, despite the facility stating it had been submitting PBJ information without errors.
The facility did not provide required notifications to the State LTC Ombudsman regarding the transfer of a resident to the hospital due to respiratory distress and the discharge of another resident who was taken out by family. Review of records and staff interviews confirmed that no notifications were sent to the Ombudsman for any resident transfers or discharges over several months, and there was no documentation to support that such notifications occurred.
The facility did not ensure care plans were updated and individualized to reflect residents' current needs, including documentation of falls, transfer status, and the use of side rails. For example, a resident who fell and fractured a hip did not have this event or related interventions documented in the care plan, and two residents using side rails did not have this reflected in their care plans, despite physician orders and staff observations.
Surveyors identified a medication error rate of 25.8% due to multiple failures in medication administration and documentation. Errors included staff not administering prescribed medications, not following manufacturer instructions for inhalers and insulin pens, and inaccurately documenting medications as given. Nursing staff confirmed that proper procedures were not followed in these cases.
The facility failed to provide ongoing resident-centered activities on weekends and failed to offer one-on-one activities to residents who needed them. Residents and staff reported that structured activities were generally limited to weekdays, with weekends mostly self-directed except for occasional church services or monthly bingo. The Activity Director said there was no weekend activity staff, no structured weekend program, and no documentation of one-on-one activities. One cognitively intact resident on COVID isolation was left in bed with a nonworking TV and no activities offered, and another resident with cognitive impairment was also found with a nonworking TV/radio while staff and family were aware of the issue.
The facility failed to ensure four NAs were certified within the required four-month timeframe after hire. Staffing records showed the NAs continued to work past the limit, and interviews with the DON, CNA staffing supervisor, and Administrative Assistant confirmed that the facility knew NAs must complete CNA testing within four months but had difficulty tracking and scheduling the tests. One NA had been separated, one had a test scheduled, and another had completed part of the testing process, but all four had already worked beyond four months.
Unlabeled and improperly stored medications were found in a nurse cart. Surveyors observed an open, undated insulin pen, a cup with two green tablets that had no resident name or medication label, and an open Senna bottle with no lid. RN B said the insulin pen had no name and he/she did not know when it was opened, and the DON stated medications should not be in an unlabeled cup and bottles should have lids.
Failure to Use EBP and Proper Infection Control During Resident Care: The facility did not implement EBP for two residents with indwelling devices, including a resident with a urinary catheter and a resident with a feeding tube, and staff provided direct care without gowns despite the facility’s EBP policy. In addition, during peri care for another resident with bowel and bladder incontinence, a CNA placed soiled items on the floor and did not perform hand hygiene or change gloves between dirty and clean tasks.
Staff failed to maintain resident dignity and privacy by using profanity during personal care with the door open and not drawing the privacy curtain, exposing two residents to inappropriate language and lack of privacy. In a separate incident, a nurse aide provided peri-care to a resident with impaired cognition and incontinence without pulling the privacy curtain, despite the roommate being present and the resident's stated preference for privacy.
Staff failed to accurately document medication administration for two residents, recording medications as given on the MAR when they were not actually administered. Additionally, a resident's fall and subsequent hospital transfer were not documented in the medical record or care plan, despite verbal reports and assessment by nursing staff.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
The facility did not ensure that three NAs completed their certification training within the required four months of hire. The DON was aware of the requirement, but the facility faced challenges in accessing an approved clinical testing site for the final exam. The nearest site was 15-20 miles away, and some staff lacked transportation, causing delays in scheduling the exam.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for Fiscal Year Quarter Three 2025 and failed to enter nursing hours in the PBJ from 9/16/25 through 9/30/25, with a census of 56. The facility’s PBJ Staffing Data Report for the quarter showed that no data was submitted for the quarter, which triggered the “no data submitted” result, and the report also showed a one-star staffing rating. Other metrics were suppressed, including excessively low weekend staffing, no RN hours, and failure to have licensed nursing coverage 24 hours/day. The facility’s PBJ policy stated that staffing and census information would be reported electronically to CMS using payroll-based or other verifiable and auditable data, and that staffing data includes hours worked each day by each staff member. The validation report dated 10/17/25 showed one file was received and accepted with no rejected files or messages, but a CMS representative stated that the validation report did not confirm the data submitted was complete or accurate. During interviews, the Administrative Assistant said he had been submitting PBJ information and had not received errors, but he was unable to access the job code report for April 1 through June 30, 2025. A CMS representative later stated that the provider did not enter LPN hours after 9/16/25 and no RN hours were provided from 9/16/25 through 9/30/25 in the PBJ.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required notification to the Office of the State LTC Ombudsman regarding resident transfers and discharges. Specifically, for two residents, there was no documentation that the Ombudsman was notified when one resident was transferred to the hospital after experiencing severe respiratory distress, and when another resident was discharged after being taken out of the building by family members. Review of facility records for a four-month period revealed that no discharge or transfer notifications were sent to the Ombudsman for any residents during that time. Interviews with facility staff confirmed that the Ombudsman was not consistently notified of resident discharges or transfers, and there was no documentation to support that notifications were made. Staff described inconsistent practices, such as sometimes handing notifications to the Ombudsman in person, sending them by email, or notifying by phone, but could not provide evidence of these actions for the months in question. The Ombudsman representative also confirmed not receiving any notifications during the specified period.
Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were updated and accurately reflected the current needs of residents, as evidenced by the lack of documentation regarding recent falls, transfer status, and the use of side rails for three residents. For one resident, after experiencing a fall that resulted in a hip fracture while being weighed, there was no documentation in the care plan about the fall, fall risk, or the resident's transfer status. The MDS nurse confirmed that care plans should be updated to include such incidents and interventions, but this was not done. Additionally, two other residents had physician orders and assessments indicating the use of side rails for mobility and self-care, yet their care plans did not include any information about side rail use. Observations confirmed that side rails were in use for these residents, and staff interviews indicated that side rails were used for positioning and transfers. The MDS nurse and DON both acknowledged that care plans should reflect the use of side rails and be individualized to each resident's needs, but this was not consistently implemented.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 8 errors observed out of 31 opportunities, resulting in a 25.8% error rate. Multiple instances were documented where staff did not administer medications as ordered, did not follow manufacturer instructions, or inaccurately documented medication administration. For example, a resident with diabetes and COPD did not receive prescribed doses of Dapagliflozin and Senna, and was not instructed to rinse and spit after using Advair Diskus, contrary to manufacturer guidelines. The Certified Medication Technician (CMT) involved did not provide the omitted medications and later inaccurately documented their administration. Another resident with heart failure, kidney failure, and hyponatremia did not receive prescribed doses of Potassium Chloride, Thiamine, and Aspirin, as the CMT failed to obtain these medications from stock or packaging but still documented them as given. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) confirmed that staff are expected to administer all medications as ordered and not to document administration if medications were not provided. Additionally, insulin administration errors were observed for two residents with diabetes. In both cases, LPNs failed to prime insulin pens before administration, as required by manufacturer instructions for Tresiba and Novolog Flexpens. Interviews with nursing staff confirmed that insulin pens should be primed prior to dosing. These failures to follow proper medication administration protocols and documentation requirements contributed to the high medication error rate identified during the survey.
Failure to Provide Weekend and One-on-One Activities
Penalty
Summary
The facility failed to ensure ongoing resident-centered therapeutic activities were provided on weekends and failed to ensure activities were offered to residents who required one-on-one activities. The facility’s activity calendar for November 2025 showed scheduled activities on some weekend days, but interviews with alert and oriented residents on 12/4/25 indicated that activities were generally offered during the week in the afternoons and that there were no activities on weekends except occasional church services and bingo about once a month. The residents said they were bored on weekends and wanted more activities. The Activity Director stated he/she was the only activity staff member and worked Monday through Friday from 8:00 A.M. to 4:00 P.M., with no activity staff on weekends. He/She said weekend activities were self-directed and there were no structured activities during weekends. He/She also stated that one-on-one activities were provided for bed-bound residents, but he/she had not had time to do one-on-one activities, did not have a list of residents receiving them, and had no documentation showing one-on-one activities were provided. CNA D also stated he/she was not aware of any residents receiving one-on-one activities. Resident #2 was cognitively intact, had diagnoses including heart failure and diabetes, and had an activity assessment noting a preference for reading and word searches. While on COVID isolation in a private room under droplet precautions, the resident was observed lying in bed with a nonworking television and said he/she stared at the walls all day and night because staff were afraid to enter the isolated area. Staff knew the television was not working and had not offered any one-on-one activities during isolation. Resident #44 had cognitive impairment, diagnoses including cancer and dementia, and a care plan that included informing the resident of daily activities and assisting with participation if desired. The resident was observed in bed with no working television or radio, and staff and family members stated the television had not been working for several days; staff were aware of the problem, and the resident could benefit from having a working television.
NAs Worked Beyond Four-Month CNA Certification Requirement
Penalty
Summary
The facility failed to ensure Nursing Assistants (NAs) who were employed there were certified within four months of hire, affecting four of four sampled NAs. The facility’s policy stated that nurse aides must complete a state-approved training program and that the facility would not employ any individual as a nurse aide for more than four months unless the individual was competent and had completed an approved training and competency evaluation program or a competency evaluation program approved by the state. Review of the employee list showed NA L was hired on 7/7/25, NA M on 5/22/25, NA N on 5/21/25, and NA O on 7/28/25. Review of staffing schedules from 11/8/25 through 12/8/25 showed all four NAs continued to work beyond the four-month limit, with repeated scheduled shifts during that period. During interviews, the DON stated NAs have four months to take their CNA test and that two NAs had been taken off the schedule until they completed testing, but the DON did not know which NAs those were. CNA P stated that NAs must complete testing within four months, that NA O was no longer at the facility, NA L had received a separation letter, NA M had a test scheduled, and NA N had taken the knowledge test and had another test scheduled. The Administrative Assistant stated NAs cannot work if they have not completed their CNA test within four months and identified the staffing supervisor as responsible for tracking NA time.
Unlabeled and Improperly Stored Medications in Nurse Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted standards of practice. Surveyors identified one Certified Medication Technician cart, one nurse cart, one treatment cart, and one medication room, and reviewed two of the three carts and the medication room for medication storage. The facility’s Medication Labeling and Storage policy required medication labels to include the medication name, strength, and resident’s name, and required opened multi-dose vials to be dated and discarded within 28 days unless the manufacturer specified otherwise. During observation of the nurse cart, surveyors found one of two insulin pens open and undated. They also found a blue cup containing two green oval tablets with no resident name or label identifying the medication, and one bottle of Senna that was open with no lid on it. RN B stated the insulin pen did not have a name on it and did not know when it was opened, and could not explain why there were pills in a cup with no label or why the Senna bottle had no lid. The nurse removed the items from the medication cart and discarded them. The DON later stated there should not be medications in a cup with no label and medication bottles should have lids.
Failure to Use EBP and Proper Infection Control During Resident Care
Penalty
Summary
The facility failed to follow infection control standards by not implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and by not consistently using proper hand hygiene and clean/dirty separation during personal care. The facility’s policy stated that EBP should be used for residents with indwelling devices such as urinary catheters and feeding tubes, and that staff should use hand hygiene, gowns, and gloves during high-contact activities. The Director of Nursing stated that residents with catheters or feeding tubes were on EBP and that staff should wear gown and gloves for direct care such as dressing, personal hygiene, and peri care. One resident had moderately impaired cognition, was totally dependent for toilet hygiene and transfers, had an indwelling urinary catheter, and had diagnoses including renal insufficiency and renal failure/ESRD. The resident’s room was observed multiple times with no EBP signage on the door and no PPE available inside or outside the room. During care, two nurse aides performed peri care, emptied the catheter drainage bag, and transferred the resident from bed to chair while wearing gloves but not gowns. Another resident had severe cognitive impairment, a feeding tube, and diagnoses including stroke, malnutrition, and adult failure to thrive. That resident’s room also had no EBP signage or PPE available, and staff provided tube-feeding care, toileting assistance, and dressing assistance while wearing gloves but not gowns. The facility also failed to follow infection control practices during peri care for another resident who was moderately cognitively impaired, always incontinent of bowel and bladder, and required substantial to maximal assistance for toilet hygiene. During observed care, a nurse aide placed the soiled brief and washcloth/towel directly on the floor, did not change gloves or perform hand hygiene between dirty and clean tasks, and cleaned the resident without using a new area of the washcloth after each wipe. The aide later picked up the soiled items from the floor and removed them from the room. Staff interviews confirmed expected peri care practices included using the four-corner method, keeping dirty items off the floor, and performing hand hygiene.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
Staff failed to treat residents with dignity and respect in two separate incidents. In one case, a staff member was observed using profanity while speaking on the phone and providing personal care to a resident with bipolar disorder, high blood pressure, and anxiety disorder. The staff member left the bedroom door open and did not draw the privacy curtain, exposing both the resident receiving care and their roommate to the inappropriate language and lack of privacy. The staff member continued to use profanity loudly enough to be heard outside the room and in the hallway. In another incident, a nurse aide provided perineal care to a resident with moderately impaired cognition, atrial fibrillation, high blood pressure, arthritis, and incontinence, without pulling the privacy curtain between beds. The resident's roommate was awake in the room during this time. The resident later stated a preference for the privacy curtain to be pulled and the door closed during care. Facility policies reviewed during the survey emphasized the importance of safeguarding resident privacy and treating all residents with dignity and respect.
Failure to Accurately Document Medication Administration and Resident Falls
Penalty
Summary
The facility failed to accurately document medication administration and resident incidents in accordance with accepted professional standards. For two residents, staff documented on the Medication Administration Record (MAR) that medications were given when, in fact, they were not administered. In one instance, a Certified Medication Technician (CMT) did not provide prescribed medications for diabetes and constipation because they were unavailable or not found, yet still recorded them as given. In another case, a CMT failed to administer potassium chloride, thiamine, and aspirin, but documented these medications as administered in the electronic medical record. Interviews confirmed that staff believed signing off on the MAR indicated the medications were given, regardless of actual administration. Additionally, the facility did not document a resident's fall and subsequent hospital transfer in the progress notes or care plan. The resident reported falling while being weighed, resulting in a hip fracture and hospital admission. Although the incident was verbally reported and the nurse assessed the resident, there was no written documentation of the fall or transfer in the resident's medical record. The facility's policy did not specify documentation procedures for falls, and the care plan lacked information on the resident's fall history or transfer status.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident complaints in a timely and non-retaliatory manner.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides (NAs) completed a nurse aide certification training program within four months of hire, as required. The NAs in question, identified as NA A, NA B, and NA C, had been employed for more than four months without obtaining certification. The Director of Nursing (DON) acknowledged the requirement for NAs to be enrolled in a state-approved training program leading to certification within the specified timeframe. The issue arose due to difficulties in accessing an approved clinical testing location for the final clinical exam, which could not be conducted at the facility. The closest testing site was 15-20 miles away, and some staff members lacked transportation, leading to delays in scheduling the final clinical exam, which had a waiting list of up to two months.
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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) |
|---|---|---|---|---|
| Heritage Care Center | 1.9 mi | ★★★★★ | 32 | 1 |
| Bentleys Extended Care | 2.1 mi | ★★★★★ | 8 | 0 |
| Normandy Nursing Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Amberwood Estates Nursing And Rehabilitation | 3 mi | ★★★★★ | 37 | 0 |
| U-city Forest Manor | 3.2 mi | ★★★★★ | 5 | 0 |
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