Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barnes-jewish Extended Care during CMS and state inspections, most recent first.
A resident with multiple pressure injuries and moderate risk for skin breakdown did not consistently receive ordered wound care and offloading interventions. The care plan addressed pressure ulcers and skin risk but did not include a specific intervention to keep heels floated, despite a physician order to float heels at all times for a left heel pressure ulcer. Over several days, surveyors observed the resident repeatedly lying on the back with heels resting directly on the mattress and no heel elevation or protectors, and a sacral dressing with visible drainage that had not been changed since a prior date. CNAs were unaware of special wound instructions beyond keeping the resident clean and dry, while the wound nurse, unit manager, and DON acknowledged expectations that staff follow wound care orders and ensure heel offloading, which was not consistently done.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, nor did it always offer appealing meal options, as observed and documented by surveyors.
The facility failed to maintain an infection prevention and control program when staff did not wear appropriate PPE during high-contact activities with residents on enhanced barrier precautions. Multiple instances were observed where staff entered resident rooms without donning gowns or gloves, despite the presence of EBP signs indicating the need for such precautions.
The facility failed to ensure that each resident's care plan accurately reflected their needs and medical conditions upon admission. This deficiency was observed in five residents, including omissions of a g-tube, CPAP device, urinary catheter, PICC line, and wound care for surgical incisions. Staff confirmed that these elements should have been included in the care plans, indicating a lapse in adherence to the facility's Care Planning policy.
The facility failed to ensure that two residents received at least two showers or bed baths weekly. One resident, with cellulitis and wounds, reported not having a shower since arrival, while another resident with a below-the-knee amputation reported only one bed bath. Staff interviews revealed lapses in documentation and adherence to ADL care policies.
The facility failed to ensure a resident received care according to professional standards. The resident had a PICC line and a buttocks wound, but there were no orders for PICC line care, and wound treatments were not completed as ordered. Observations and interviews confirmed these deficiencies.
The facility failed to ensure that a resident admitted with an indwelling urinary catheter had a physician's order for its care. The resident's medical record lacked documentation and orders specifying the catheter's details, despite observations confirming its use. Interviews with staff indicated an expectation for such orders, highlighting a deficiency in following the facility's policy.
A resident experienced significant weight loss due to the facility's failure to provide recommended nutritional interventions and preferred foods. The RD's recommendations were not consistently followed, and nursing staff did not adequately document meal intake. The resident was served inappropriate foods, and there was a lack of communication between nursing and dietary staff.
The facility failed to obtain physician orders for a CPAP machine for a resident and did not ensure proper storage of CPAP masks for two residents. Observations showed improper storage of CPAP masks, and staff interviews revealed inconsistencies in the understanding and execution of proper CPAP mask storage protocols.
A resident with a history of significant health issues expressed suicidal ideation and feelings of depression, but the facility failed to provide necessary behavioral health services and follow-up care. The resident spent most of their time in bed, lacked a wheelchair, and felt isolated and unsupported. The facility did not adequately address the resident's psychosocial needs or document appropriate interventions in the care plan.
The facility failed to store and dispose of expired medications in accordance with professional principles, with expired medications found in one medication room and two treatment carts. Staff interviews revealed inconsistencies in the auditing and removal process, despite facility policies requiring the disposal of expired medications.
Failure to Follow Pressure Ulcer Treatment Orders and Offloading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatments and services to promote healing and prevent further breakdown for one cognitively intact resident with multiple pressure injuries. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, and benign prostatic hyperplasia, and was readmitted with intact skin. A Braden Scale score was initially documented as 16 (mild risk) and later recalculated to 13 (moderate risk). The care plan identified the resident as having pressure ulcers and being at risk for skin impairment due to immobility and incontinence, with interventions such as frequent repositioning, keeping the resident clean and dry, use of a low air loss mattress and gel cushion, daily skin checks, and treatments as ordered. However, the care plan did not include an intervention to keep the resident’s heels floated at all times, despite the presence of a left heel pressure injury and a physician order to float the heels. Wound documentation dated 2/24/26 showed three open pressure injuries: an unstageable sacral wound measuring 11 cm by 9.5 cm, a right gluteal pressure ulcer measuring 2.5 cm by 0.8 cm, and a left heel pressure ulcer measuring 3.3 cm by 5.5 cm. Physician orders dated 2/20/26 directed wound care to the buttocks with barrier cream every shift and as needed, and for the left heel to apply skin prep daily and float the heels at all times. Facility policy required use of the wound product selection guide, a physician order for all wound treatments, interventions to reduce pressure such as offloading heels and repositioning, and that all dressings be dated and initialed by the nurse applying the dressing. Multiple observations over several days showed the resident lying on his/her back in bed with heels resting directly on the mattress and no elevation or heel protectors, despite the order to float heels at all times. On one observation, the resident’s head of bed was elevated and the resident had slid down with the head wedged between the mattress and bedrail, and heels still on the mattress. On another observation, a sacral dressing extending down both buttocks was noted with brownish discoloration at the inner edges and dated two days prior; the CNA present was unaware of the drainage and unaware of any special wound instructions beyond keeping the resident clean and dry. The DON confirmed the sacral dressing date and stated she expected staff to follow physician orders and float heels even with an air loss mattress, and the Unit Manager also stated she expected staff to ensure heels were elevated off the surface. The wound nurse reported that both she and floor nurses were responsible for wound care and that wound care tasks could be passed between shifts, indicating shared responsibility for treatments that were not consistently carried out as ordered.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always provided with meals that met their specific dietary needs or preferences, as required.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program when staff did not wear appropriate personal protective equipment (PPE) during high-contact activities with residents on enhanced barrier precautions (EBP). Multiple instances were observed where staff entered resident rooms without donning gowns or gloves, despite the presence of EBP signs indicating the need for such precautions. This included activities such as administering IV medication, checking blood sugar, providing bed baths, and transferring residents, all of which are considered high-contact activities requiring PPE according to the facility's policy and CDC guidelines. For example, a Licensed Practical Nurse (LPN) was observed administering IV medication to a resident with a peripherally inserted central catheter (PICC) without wearing a gown or gloves. Similarly, a Registered Nurse (RN) and a Certified Nurses Assistant (CNA) were seen performing skin observations and bed baths without the required PPE. Another CNA was observed adjusting a resident's clothing and checking for wetness without gloves, and then handling soiled linens and entering another resident's room without sanitizing hands. Interviews with staff revealed a lack of consistent understanding and adherence to the EBP policy. Some staff members believed that gowns and gloves were only necessary for certain types of care, while others were unaware of the need to sanitize equipment and hands between resident interactions. The Director of Nursing (DON) confirmed that all staff had been educated on the use of gowns and gloves during high-contact activities, but observations indicated that this education was not effectively implemented. The facility's failure to enforce its EBP policy compromised the infection control program and increased the risk of transmission of multidrug-resistant organisms (MDROs).
Failure to Accurately Reflect Residents' Needs in Care Plans
Penalty
Summary
The facility failed to ensure that each resident's care plan accurately reflected their needs and medical conditions upon admission. This deficiency was observed in five out of seventeen sampled residents. Resident #199's care plan did not include the presence of a gastrostomy tube (g-tube) despite the resident receiving medications and nutrition through it. Similarly, Resident #299's care plan omitted the use of a continuous positive airway pressure (CPAP) device, which was necessary for treating sleep apnea. Resident #298's care plan failed to mention an indwelling urinary catheter, and Resident #301's care plan did not identify the use of a peripherally inserted central catheter (PICC) line. Lastly, Resident #248's care plan did not include wound care for surgical incisions on the right foot, despite the resident being admitted for rehabilitation and wound healing. Observations and interviews with staff confirmed these omissions. For instance, Resident #199 was observed with an enteral tube feeding infusing, and the resident confirmed the use of the g-tube for medications and nutrition. Staff members, including a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN), acknowledged that the g-tube should have been included in the care plan. Similarly, Resident #299's CPAP device was observed on the headboard, and staff confirmed that it should have been listed in the care plan. Resident #298 was observed with an indwelling urinary catheter, and staff confirmed that it should have been included in the care plan. Resident #301 was observed with a PICC line, and staff confirmed that it should have been included in the care plan. Resident #248's care plan did not include wound care for surgical incisions on the right foot, despite the resident being admitted for rehabilitation and wound healing. Interviews with the Director of Nursing (DON) and other staff members revealed that the responsibility for developing care plans lies with the Nurse Managers and the facility MDS Coordinator. The DON confirmed that baseline care plans should include all immediate needs, such as fall risks, skin conditions, and any medical devices or treatments required by the residents. The failure to include these critical elements in the care plans indicates a lapse in the facility's adherence to its Care Planning policy, which mandates the completion of initial care plans within 48 hours of admission.
Failure to Provide Required ADL Care
Penalty
Summary
The facility failed to ensure that two residents' Activities of Daily Living (ADL) needs were met by not providing at least two showers or bed baths weekly. Resident #248, who was cognitively intact and had diagnoses including cellulitis and wounds on the coccyx and right heel, was observed with greasy hair and reported not having had a shower or bed bath since arrival. Although an LPN claimed the resident received a bed bath, it was not documented. Resident #249, also cognitively intact and with a below-the-knee amputation, reported receiving only one bed bath since admission and expressed feeling dirty. The facility's documentation confirmed only one shower for this resident, and the DON mentioned a history of ADL care refusal, although no refusals were documented for this period. Interviews with staff, including a CNA and the DON, revealed that showers and refusals should be documented in the resident's chart. The DON expected all residents to receive at least two showers or bed baths weekly and for nursing staff to document these activities. The failure to document and provide the required ADL care led to the deficiency noted in the report.
Failure to Follow Professional Standards of Practice for Resident Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, admitted from the hospital, had an open area on the buttock and a double lumen peripherally inserted central catheter (PICC) in the right side of the neck. There was no order for the PICC line dressing change, flushing, or care. Additionally, the facility staff did not complete treatment orders and apply dressing changes as ordered to the buttocks wound. Observations showed that the dressing over the PICC line was dated 5/14/24, and the wound on the buttocks was not treated as per the physician's orders on multiple occasions. The facility's policies required licensed nurses to perform infusion therapy and wound care according to state law and facility policy, with a prescriber's order needed for accessing, flushing, or locking a catheter. However, the resident's electronic medical record showed no order for the PICC line care. Interviews with the RN and the Director of Nursing confirmed that the resident should have had orders for the PICC line, including flushing, dressing change, and monitoring, and that wound treatments should be performed per physician's orders. Despite these requirements, the facility staff failed to follow the prescribed treatments for the resident's buttocks wound and PICC line care.
Failure to Obtain Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling urinary catheter had a physician's order to provide care for the catheter. The resident's electronic medical record and information card did not indicate the presence of the catheter, nor was there an order specifying the catheter's size, diagnosis, balloon size, routine for changing, and monitoring output. The resident's diagnoses included sleeplessness, seizure, bipolar disorder, and neurogenic bladder. Despite these conditions, the necessary documentation and orders for the catheter were missing. Observations confirmed the use of the indwelling urinary catheter, which was attached to the resident's bedrail. Interviews with a Registered Nurse and the Director of Nursing revealed that both expected to see a physician's order for the catheter, including specific details about its management. The absence of such an order indicates a failure to follow the facility's policy on obtaining and processing physician orders, leading to a deficiency in the care provided to the resident.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in significant weight loss. The resident experienced a weight loss of -10.35% from July 2023 to January 2024. Despite the Registered Dietician (RD) completing two nutritional assessments and noting a decline in the resident's meal intake, no additional nutritional interventions were recommended. The resident was not served fortified cheesy eggs as recommended by the RD, and the RD's recommendation for fortified pudding was not added to the resident's meal ticket. Additionally, nursing staff failed to consistently chart the resident's meal intake, which is reviewed during the RD's nutrition assessments, and the resident was not served preferred foods at meals. The resident's medical record showed multiple diagnoses, including Multiple Sclerosis, autoimmune hepatitis, hypothyroidism, high blood pressure, GERD, and depression. The resident had physician orders for fortified foods and nutritional shakes, but these were not consistently provided. The resident's weights showed a significant decline over several months, and the resident's meal intake documentation was often missing or incomplete. Observations revealed that the resident was served inappropriate foods, such as raw baby carrots and large steamed broccoli florets, which were not suitable for the resident's mechanical soft diet. The resident's food preferences, such as bananas and frosted flake cereal, were not consistently provided. Interviews with staff indicated a lack of communication and coordination between nursing and dietary staff. The RD and dietary staff were not aware of the resident's food preferences, and the facility did not have certain preferred foods in stock. The RD noted that the facility had stopped making fortified cheesy eggs and was in the process of identifying other options. The resident's care plan did not reflect the significant weight loss, average meal intake, or the RD's recommendations for additional nutritional interventions. The facility's policies and procedures for nutritional interventions were not followed, leading to the resident's continued weight loss and inadequate nutritional intake.
Failure to Obtain Physician Orders and Properly Store CPAP Masks
Penalty
Summary
The facility failed to ensure physician orders were obtained for the use of a CPAP machine for one resident and to ensure CPAP masks were properly stored while not in use for two residents. Resident #299 had a diagnosis of obstructive sleep apnea and used a CPAP machine, but there was no physician's order for the CPAP on admission, and the CPAP device was not listed on the resident's baseline care plan. Observations showed the resident's CPAP tubing and mask were improperly stored, and interviews with staff indicated that the resident was responsible for the CPAP machine's care, but there was no clear protocol for mask storage when not in use. A new order for the CPAP was obtained later during the survey period. The Director of Nursing confirmed that there should have been an order for the CPAP machine upon admission. Resident #146, who had diagnoses including COPD and obstructive sleep apnea, had physician orders for CPAP use and cleaning, but observations showed the CPAP mask was consistently stored improperly, uncovered, and without a barrier, either on the nightstand or in an open drawer. The resident was unsure about the cleaning and storage protocol for the CPAP mask, and staff interviews revealed inconsistencies in the understanding and execution of proper CPAP mask storage. The Director of Nursing and Administrator stated that either the resident or nursing staff should rinse off the mask and store it in a bag, and it was expected that CPAP use be indicated on a resident's care plan. However, this was not consistently followed, leading to the deficiencies noted in the report.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to maintain the highest practicable psychosocial well-being for a resident who expressed feelings of being better off dead and thoughts of unplugging their left ventricular assist device (LVAD). The resident, who had a history of stroke, heart disease, and other significant health issues, was admitted to the facility and had been receiving antidepressant medication. Despite expressing suicidal ideation and feelings of depression during a quarterly assessment, the facility did not follow up adequately with behavioral health services or counseling. The Social Services Coordinator (SSC) reported the resident's suicidal thoughts to a nurse, who then informed the Nurse Practitioner (NP) and sent the resident to the hospital for a psychiatric evaluation. However, the resident did not receive consistent follow-up care or counseling upon returning to the facility. The resident's medical record showed no therapy assessments after a certain date, and there was no documentation of social services follow-up between the initial report of suicidal ideation and the time of the survey. Observations revealed that the resident spent most of their time in bed, lacked a wheelchair to leave their room, and felt sad and isolated. Interviews with staff indicated that the resident's requests for a wheelchair and therapy were not addressed, and the resident did not receive regular counseling or social services support. The resident expressed a desire to be more active and engaged but felt restricted by the facility's limitations and lack of support. The Director of Nurses (DON) and Administrator acknowledged that the resident's feelings of sadness and suicidal ideation should have been followed up with appropriate interventions and documented in the care plan. However, there was no evidence of a coordinated effort by the facility's department heads to address the resident's psychosocial needs. The resident's care plan did not identify their reported feelings of depression, suicidal ideation, or activities of interest, indicating a significant deficiency in the facility's provision of necessary behavioral health services.
Failure to Properly Store and Dispose of Expired Medications
Penalty
Summary
The facility failed to store medication and medical equipment in accordance with professional principles, specifically regarding the expiration dates on stock medications in the medication rooms and medication carts. Observations revealed expired medications in one of two medication rooms and in two of six treatment carts. Specific expired medications included SunMark gentle laxative, HealthStart melatonin supplement, Rugby meclizine, SunMark mucus relief guafenesin, Amneal Folic Acid, GeriCare Oyster Shell Calcium, GeriCare Ferric X-150, GeriCare Magnesium Oxide, NorthStarX Omeprazole, and GeriCare Milk of Magnesium. These medications were found to be expired by several months, indicating a lapse in the facility's adherence to its Pharmacy Services and Procedures Manual, which mandates the removal and proper disposal of expired medications. Interviews with facility staff, including an LPN, a CMT, the DON, and the Administrator, revealed inconsistencies in the auditing and removal process of expired medications. While a facility pharmacy representative was reported to check the medication rooms and carts periodically, staff were unsure of the regularity and thoroughness of these audits. The facility's policy expects nursing staff to remove and dispose of expired medications, but the presence of expired medications in multiple locations suggests that this policy was not effectively implemented or monitored. The DON and Administrator confirmed their expectation that expired medications should be discarded and not administered to residents, highlighting a gap between policy and practice.
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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) |
|---|---|---|---|---|
| Mcknight Place Extended Care | 1.8 mi | — | 0 | 0 |
| Monarch Springs Wellness & Rehabilitation | 2.4 mi | — | 2 | 0 |
| U-city Forest Manor | 2.4 mi | — | 5 | 0 |
| Oak Park Care Center | 2.7 mi | — | 0 | 0 |
| Lutheran Convalescent Home | 3 mi | — | 0 | 0 |
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