Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 St Louis Altenheim during CMS and state inspections, most recent first.
A resident’s room had a large dark water stain on the soffit and a stain around the bathroom light after an upstairs shower overflow, and the resident said the stain had been reported but remained visible from bed. The facility also left the 300-unit back hallway dark on multiple observations, with no ceiling lighting for several rooms, a missing light fixture, burn stains on the fixture, and a Hoyer lift left in the hall.
A resident with decreased mobility, lymphedema, and venous insufficiency developed MASD on the buttocks that was documented in progress notes, but the MAR/TAR showed no treatment orders for the area and shower sheets noted no new skin concerns. The resident reported buttock pain and family saw a wound, while the DON said she was unaware of any wound until it was observed as a purple/red open sacral area that bled. An LPN measured the wound and the NP later described it as acute/chronic with bilateral purple buttocks and an open sacral wound; a treatment order was not entered until later.
A resident with mildly impaired cognition, Parkinson’s disease, depression, anxiety, and a history of alcohol use had multiple bottles of wine and an open beer kept in the room despite the facility’s alcohol policy requiring alcoholic beverages to be treated like medication and stored in the med room. Staff were unclear about the resident’s alcohol status, the DON and Administrator gave conflicting statements about alcohol orders and care planning, and the resident’s sibling said they were unaware of any facility policy on alcohol storage.
Food storage and kitchen sanitation deficiencies were identified when two residents’ personal refrigerators lacked routine temperature logs, including one refrigerator with an outdated log and another with no log at all. The kitchen also had dust accumulation on ceiling fixtures above the food prep area and significant ice buildup in the walk-in freezer, with staff giving mixed responsibility for monitoring refrigerator temperatures and cleaning the affected kitchen areas.
A resident with dementia, hospice care, and dependence for ADLs was given personal care without first being told what was being done. When the resident repeatedly said to stop, grabbed the CNA’s hands, and said not to touch him/her, the CNA continued perineal care, applied cream, and fastened a brief while also repeating the resident’s words. The DON and Administrator stated staff should stop care when a resident asks them to stop and said they would not expect staff to mimic residents.
MDS Did Not Accurately Reflect Hospice Prognosis: A resident receiving hospice services had diagnoses including Alzheimer’s disease, diabetes, dementia, and major depressive disorder, and the care plan identified end-of-life care needs. The annual MDS marked hospice care as a special service, but incorrectly indicated the resident did not have a condition that may result in a life expectancy of less than 6 months. The MDS coordinator, Administrator, and DON all acknowledged the coding error during interview.
Failure to Provide ADL Assistance and Hygiene Support: A resident with severe cognitive impairment, dementia, and anxiety disorder was observed in the dining room with long, dirty nails and unclean hands while eating. The resident repeatedly used hands to eat, attempted to bite nonfood items such as a sock and meal ticket, and had a tray removed before finishing a meal. Staff stated residents should receive handwashing after meals and assistance when eating objects instead of food, and the DON and Administrator expected more dining room oversight and clean hands after meals.
Infection Control Failure During Perineal Care: A resident with diabetes, dementia, hemiplegia, and incontinence required dependent peri-hygiene assistance. During observed care, a CNA repeatedly changed gloves without hand hygiene and wiped the buttock area toward the genital area, including twice from back to front. An LPN, CNA, and the DON confirmed that hand hygiene should occur before, during, and after perineal care and that wiping should be front to back for infection control.
The facility failed to keep the kitchen free from pests. Pest control logs showed insects were observed in the kitchen and traps were changed out, but surveyors later saw multiple flies around the bulk bin area and near clean pots and pans, along with a beetle near the oven. A Dietary Aide said the kitchen has insects, and the Dietary Director and Administrator stated they expected the kitchen to be free from insects.
A CNA slapped a resident on the forearm while trying to put on a sock after the resident began flailing his/her arms. The resident had severe cognitive impairment, dementia, anxiety disorder, and documented behavioral symptoms and rejection of care. The resident appeared distressed and scared during the incident, and the facility’s investigation noted no injuries on assessment.
Unaddressed Water Stain and Poor Hallway Lighting
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment when a large dark brown water stain remained on the underside of the soffit in one resident’s room and a stain was also observed around the bathroom light. The resident, who had diagnoses including arthritis, anxiety, depression, and diabetes, was observed lying in bed and stated the stain had been present for some time after a shower overflowed upstairs. The resident said the issue had been reported to the facility and that the stain was a focus when lying in bed and was not liked because it remained visible from the bed. The facility also failed to maintain adequate lighting in the hallway on the 300 unit. Observations showed the back hall lights were off on multiple occasions, leaving the hallway for rooms 306 through 312, the nursing room, and the area near the nurses’ station and dining room very dark. A Hoyer lift was left against the wall in the hallway, and one light fixture had a missing light with dark burn stains. The Maintenance Manager stated the hallway lights were on the same switch and there were no smaller lights or night lights to keep the hall lit, and the Administrator stated she expected the 300 hallway to have light and items cleared from the hallway.
Untreated buttocks wound with delayed orders and incomplete documentation
Penalty
Summary
The facility failed to obtain treatment orders timely and thoroughly document a new skin issue for a resident who was found with an untreated wound on the buttocks/sacral area. The resident’s admission MDS showed mildly cognitively intact status, no unhealed wounds, and diagnoses including fracture of the sternum, lymphedema, and venous insufficiency. The care plan identified a potential for pressure ulcer development related to decreased mobility and directed staff to monitor and document changes in skin status, wound healing, signs and symptoms of infection, wound size, and stage. The resident’s ePOS included a weekly skin assessment order and therapy evaluations for a relieving seat cushion, but no treatment order for the buttocks. Shower sheets dated 9/13/2025, 9/24/2025, and 10/1/2025 documented no new skin concerns, and the October 2025 MAR/TAR contained no documentation of buttocks treatments. Progress notes documented moisture associated skin damage on 9/20/2025 with a small in-house wound on the buttocks, and again on 10/2/2025 with MASD. On 10/8/2025, a Braden score of 17 indicated mild risk, with friction and shearing noted as a potential problem and moisture occasionally present. During interview, the resident reported buttock pain and said staff had provided a small packet of cream, while the resident’s family member had seen a wound during a shower and purchased a larger tube of the same barrier cream. The DON stated she was unaware of any wound or documentation suggesting a wound until 10/8/2025. At observation that day, a purple/red area and an open area between the buttocks were seen and the area bled; the DON identified it as a sacral wound. An LPN measured the wound and stated there was no drainage except sanguineous bleeding, and the NP later described the wound as acute/chronic with bilateral purple buttocks and an open sacral wound, diagnosing primary dermatitis secondary to pressure. A treatment order was not entered until 10/10/2025.
Failure to Properly Supervise and Store Resident Alcohol
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents when staff did not follow its Alcoholic Beverages Policy regarding resident alcohol storage. The policy required alcoholic beverages to be treated as medication, labeled, and stored in the medicine room, but a resident had multiple alcoholic beverages kept in the room, including several small wine bottles and an open 16-ounce beer in the mini refrigerator, with another bottle on the nightstand. The resident’s record showed mildly impaired cognition and diagnoses including Parkinson’s disease, depressive disorder, anxiety, and protein-calorie malnutrition. The resident’s chart also showed a history of alcohol-related concerns in the care plan, including a focus noting the resident used to be an alcoholic and had suicidal ideation in the past. An order dated 8/12/25 allowed the resident to consume 1-2 alcoholic beverages daily as tolerated, but that order was later discontinued by the medical provider because the attending physician did not approve. Despite this, observations on multiple dates showed alcohol remaining in the resident’s room, including wine bottles and an open beer, and the resident stated the alcohol was purchased by a sibling and that the resident drank at the direction of the facility owner. Staff interviews reflected confusion about the resident’s alcohol use and storage. The DON and Administrator stated residents with alcohol orders also had care plans and medication holds, while the social worker was unaware of any residents allowed to drink in the facility. The resident’s sibling said they were unaware of any facility policy about alcohol use or storage. The medical provider stated he/she never ordered or authorized a script to consume alcohol and was aware only that the neurologist had written a letter indicating the resident may drink occasionally. The Administrator and DON later stated alcohol should not be in a resident’s room and questioned the care plan language noting the resident used to be an alcoholic.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure two residents’ personal refrigerators had routine temperature tracking. One cognitively intact resident with COPD, muscle weakness, major depressive disorder, and anxiety disorder had a small refrigerator in the room that contained an undated container of soup, two opened containers of baking soda, candy, and a jar of salsa; the temperature log posted on the refrigerator was dated 2022. Another resident with CHF, dementia, diabetes, hemiplegia, and hemiparesis following cerebral infarction had a small refrigerator in the room containing nutritional shakes, orange juice, tea, and chocolate pudding, but there was no temperature log. Staff interviews showed conflicting responsibility for checking resident refrigerator temperatures, with housekeeping, maintenance, and the Administrator identifying housekeeping as responsible for routine monthly checks. The facility also failed to keep the kitchen ceiling above the food preparation station free from dust accumulation and failed to keep the walk-in freezer free from ice buildup. On repeated observations, two light fixtures and four surrounding ceiling tiles above the steam table area had dust accumulation, and the walk-in freezer had thick ice around the door frame and a large ice chunk in the center of the floor with food debris on top of it, measuring about 3 inches high. Dietary staff and the Dietary Director stated the ceiling should be clean and the freezer should be free of ice buildup, while maintenance was identified as responsible for cleaning the ceiling and dietary staff or maintenance for removing ice buildup.
Failure to Respect Resident Refusal During Personal Care
Penalty
Summary
The facility failed to honor a resident’s right to a dignified existence, self-determination, communication, and to exercise rights when staff did not inform a resident with dementia of the care being provided and did not stop care after the resident repeatedly said to stop. Resident #35 had dementia, hospice care, physical dependence for hygiene, eating, transfers, and daily care, and diagnoses that included Alzheimer’s disease, anxiety, and a mood disorder. The resident’s care plan directed staff to cue, reorient, supervise as needed, communicate with the resident, family, and caregivers regarding capabilities and needs, and anticipate and meet needs while monitoring communication problems. During an observation, CNA A and CNA C assisted the resident into bed, and CNA A removed the resident’s pants without first explaining the care. When the resident said, “Stop, please,” grabbed the CNA’s hands, and repeated that the care was too cold and that staff should get out, CNA A continued with perineal care, rolled the resident, applied cream to the buttocks, and put on a new brief. The resident continued to say, “Don’t touch me,” while CNA A kept providing care and said, “I am almost done.” CNA A also repeated the resident’s words during the interaction. The DON and Administrator stated staff should stop a task if a resident requests it and said they would not expect staff to mimic residents.
MDS Did Not Accurately Reflect Hospice Prognosis
Penalty
Summary
The facility failed to ensure that Resident #20’s MDS accurately reflected the resident’s status of having a life expectancy of less than 6 months while receiving hospice services. Resident #20’s record showed diagnoses including Alzheimer’s disease, diabetes, dementia, and major depressive disorder. The hospice record showed a hospice start of care date of 7/29/24, current benefit dates of 7/24/25 to 9/21/25, and a current certification of terminal illness dated 9/22/25 to 11/20/25. The resident’s care plan, revised on 8/21/24, identified that the resident was receiving hospice services for late onset Alzheimer’s disease and included end-of-life care interventions. Review of the annual MDS showed that hospice care was marked as a special service received while a resident, but the item asking whether the resident had a condition or chronic disease that may result in life expectancy less than six months was marked “No.” During interview, the MDS coordinator stated the MDS should be coded accurately and said the 6 months or less prognosis should not be marked unless there was physician documentation. The Administrator stated the resident’s MDS should have reflected a prognosis for a life expectancy of less than six months, and the DON stated she signs off on the MDS assessment and should have caught the error before submission. Later, the MDS coordinator stated that the six months or less to live should be marked on the MDS if the resident is on hospice.
Failure to Provide ADL Assistance and Hygiene Support
Penalty
Summary
The facility failed to ensure Activities of Daily Living care needs were met for a dependent resident with severe cognitive impairment, dementia, and anxiety disorder. The resident’s care plan directed staff to check nail length and trim and clean the nails as needed, provide finger foods when the resident had difficulty using utensils, and provide assistance and cueing with feeding. However, observations showed the resident’s nails were long, jagged, and had dark matter underneath, and the resident’s hands were dirty and sticky during meals. The resident was also observed with an oily, unkempt appearance and a sweat odor. During breakfast observations, the resident was seen eating scrambled eggs with his/her hands, sleeping with toast in hand, picking up and attempting to bite a sock and a meal ticket, and repeatedly using his/her hands to eat oatmeal and scrambled eggs after food fell into the lap. The resident’s breakfast tray was removed before the meal was finished on one occasion. Staff interviews indicated nursing staff were expected to wash residents’ hands after meals and assist residents who were eating objects instead of food, and the DON and Administrator stated they would expect more staff oversight in the dining room and for the resident’s hands to be clean after meals.
Infection Control Failure During Perineal Care
Penalty
Summary
The facility failed to follow acceptable infection control standards during perineal care for one resident. Resident #30 had diagnoses including diabetes, heart failure, dementia, right-sided hemiplegia and hemiparesis following stroke, and peripheral vascular disease. The resident’s care plan stated that he/she was dependent on staff for all ADL tasks, including peri-hygiene, and required dependent assistance with toilet hygiene due to bowel and bladder incontinence. During observation, CNA L and CNA J entered the resident’s room, washed their hands, and donned gloves. CNA J provided care but repeatedly removed gloves and put on new gloves without performing hand hygiene in between glove changes. CNA J washed the resident’s face and chest, cleansed the groin area, and then cleaned the genital area from front to back before rolling the resident to the left side. CNA J then washed the back and wiped the buttock area toward the genital area, including twice wiping from back to front. Interviews with an LPN, CNA L, and the Administrator/DON confirmed that hand hygiene should be performed before, during, and after perineal care, and that wiping should be front to back or from the genital area to the buttock area for infection control.
Kitchen Pest Control Failure
Penalty
Summary
The facility failed to ensure the kitchen was free from pests. Review of pest control logs showed that on 9/25/25 the pest control company treated the facility and observed insects in the kitchen, and on 10/6/25 the company changed out the facility pest traps. During observation of the kitchen on 10/7/25, multiple flies were seen around the bulk bin area. During another observation on 10/9/25, multiple flies were seen near the clean pots and pans, and a beetle was observed crawling on the ground next to the oven. During interview, a Dietary Aide stated the kitchen has insects and that a pest control company comes to spray. The Dietary Director stated he expected the kitchen to be free from insects and said pest control comes out to spray and treat the kitchen about once a month. The Administrator also stated she expected the kitchen to be free from insects.
Resident Slapped During Care
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a CNA slapped the resident on the left forearm during care. The resident had severe cognitive impairment, diagnoses of dementia and anxiety disorder, and was documented on the quarterly MDS as having physical behavioral symptoms directed toward others four to six days but less than daily, along with rejection of care one to three days. The care plan noted the resident was not always able to voice needs and that staff should anticipate needs, but it did not identify the resident’s behavioral symptoms or rejection of care. During observation, the CNA pushed the resident in a wheelchair into the lobby, bent over, grabbed the resident’s left pant leg, and raised the leg by the pant material to put on a sock. When the resident began flailing his/her arms, the CNA used his/her right hand to slap the resident’s left forearm. The resident showed a distressed and scared facial expression and began moving his/her feet in the wheelchair, which was locked. The surveyor reported the slap to an LPN, who immediately separated the CNA from the resident. The facility’s investigation recorded the CNA’s statement that the resident had been digging nails into his/her arm and that the CNA pulled back to release the nails, while the resident had no injuries on assessment and was not showing signs of fearfulness, tearfulness, or mental anguish.
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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) |
|---|---|---|---|---|
| Carrie Elligson Gietner Health Care Center | 0.3 mi | ★★★★★ | 8 | 0 |
| Magnolia Wellness Center | 1.3 mi | ★★★★★ | 10 | 1 |
| Pine Grove Manor | 2.2 mi | ★★★★★ | 20 | 1 |
| Lansdowne Village | 2.3 mi | ★★★★★ | 18 | 0 |
| Lemay Nursing | 2.8 mi | ★★★★★ | 0 | 0 |
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