Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
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 Ignite Medical Resort St Peters during CMS and state inspections, most recent first.
The facility failed to follow its neuro assessment policy and provide appropriate EMS handoff for multiple residents. One resident on anticoagulation fell from bed, sustained a head laceration, and reported lying on the floor for a long time without staff present; no neuro checks were documented, no first aid such as pressure to the wound was provided, and EMS found the resident alone using clothing to control bleeding while the RN remained at the nurses’ station and did not give a report. Another resident on apixaban with complex cardiopulmonary history developed lower extremity discoloration, had Doppler-confirmed DVT, and was later emergently transferred for dyspnea; EMS and family reported that no staff were present in the room on EMS arrival, the family provided the clinical history, and the nurse who eventually appeared was unaware of the situation and minimized the resident’s respiratory distress. A third resident with stroke, dementia, severe cognitive impairment, and prior falls rolled out of bed, reported hitting the head, and had only a single neuro assessment documented, with no ongoing neuro checks recorded per facility protocol for unwitnessed falls.
A resident with osteomyelitis, peripheral vascular disease, and HTN was assessed as high risk for falls but had no fall care plan in place. The resident rolled out of a low bed while reaching for a phone charger, struck the head between the bed and a recliner, and required hospital evaluation with sutures placed. On return, documentation noted safety checks and a low bed, but record review showed no fall risk or post-fall care plan and the MDS inaccurately reflected no fall history. Observation later found the call light on the floor and out of reach, and the resident reported being unable to summon help and lying on the floor for a long time. Staff interviews revealed the fall was not correctly entered into the EMR, so required post-fall assessments and documentation were not triggered, and no individualized fall interventions were developed despite facility policy.
A resident with CHF, ESRD, and other comorbidities was admitted with documented superficial skin loss on the buttocks and a care plan for skin risk that included barrier cream and turning/positioning, but no Braden Scale was completed at admission and no weekly skin assessments or skin sheets were documented. The resident spent most of the time and slept in a recliner without a pressure-relieving cushion, reported a sore bottom, and stated that staff applied some cream but that no nurse had inspected the area. The pressure injury was only discovered when a CNA assisted with toileting and observed an open, draining area on the buttock, which an LPN then described as appearing to be a Stage 3 pressure ulcer, with no prior nursing documentation or notification of the wound.
Surveyors found that the facility failed to administer ordered admission medications and to use available emergency medications for two residents with pneumonia, respiratory conditions, and chronic cardiac issues. One resident did not receive newly ordered antibiotics for pneumonia on the day they were prescribed, despite those drugs being listed in the emergency supply and no documentation of physician or pharmacy notification. Another newly admitted resident did not receive ordered anticoagulant, cardiac, antifungal, and nebulized bronchodilator doses on the evening of admission, even though some of these medications were present in the e-kit and the resident later reported not getting bedtime medications because they were unavailable. LPN interviews showed uncertainty about which drugs were in the e-kit, lack of access or use of the kit, and failure to obtain needed respiratory equipment from central supply, and the facility lacked a policy outlining how to obtain new medications or what to do when they were not available.
Surveyors found that medications were repeatedly left unsecured and unattended on a nurse’s station desk, on top of a treatment cart, and in unlocked medication and treatment carts, while residents and visitors passed nearby and no staff were in line of sight. Staff, including an LPN, RN, DON, and the Administrator, acknowledged that facility policy requires all medications and carts to be locked when unattended and that medications received from the pharmacy must be secured. In a separate finding, a resident recently admitted with influenza A pneumonia, bacterial pneumonia, COPD, and acute respiratory failure had four prescription inhalers from home lying on the bed without corresponding physician orders for all inhalers or an order to self-administer, and nursing leadership reported they were unaware of these bedside medications and stated that medications should be kept in a secure location.
A resident with multiple comorbidities, severe cognitive impairment, dependence for ADLs, and an unstageable pressure ulcer experienced a significant weight loss of nearly 14% over two months. Facility policy required investigation and intervention for significant weight changes, but weights were not consistently documented, and no specific weight-loss interventions were added to the care plan. The RD identified increased nutrient needs, recommended supplements (Pro Heal, Juven) and later recommended adding Magic Cup BID, but this recommendation was not communicated to the physician, not entered as a diet order, and not provided with meals, as confirmed by observations and interviews with the resident, family, LPN, RD, and Dietary Manager. Leadership staff stated they expected RD recommendations to be reviewed and communicated, but this did not occur, resulting in failure to implement and evaluate appropriate nutritional interventions for the resident’s weight loss.
A resident admitted in the early evening with fracture pelvis, respiratory failure, and protein-calorie malnutrition, and ordered a regular mechanical soft diet, did not receive an evening meal from the facility. The family member reported that no staff offered food, a nurse stated the kitchen was closed, and the family had to purchase food from a local restaurant. The Dietary Manager stated that admission memos had prompted preparation of several trays, including one left in the kitchen window for this resident, but nursing never retrieved or delivered it. The tray remained in the window until the next morning, and the resident later reported being hungry and receiving little to eat for supper.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy for two residents with wounds and indwelling devices, including a urinary catheter, dialysis CVC, AV fistula, and multiple documented pressure and other wounds. Required EBP signage and PPE carts were absent from room entrances, and staff performed high-contact care activities such as transfers, toileting, linen changes, perineal care, catheter manipulation, and wound care wearing only gloves and no gowns, despite care plans and physician orders specifying EBP. Interviews with CNAs, an LPN, a nurse manager, the DON, the Administrator, and the Medical Director revealed uncertainty and lack of knowledge about which residents were on EBP and inconsistent implementation of the policy.
Failure to Perform Neuro Checks and Communicate with EMS After Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its own neurological assessment policy and professional standards of practice after resident falls and changes in condition, and failure to provide pertinent information to EMS. For one resident with osteomyelitis, PVD, hypertension, and an active order for Eliquis, nursing notes documented that the resident rolled out of bed while reaching for a phone charger, was found on the floor with a gash to the right temple, swelling, and a reported headache, and that 911 was contacted. Vital signs were abnormal, and the dressing to the resident’s left foot was no longer intact. There was no documentation of a neurological assessment despite the head injury and the facility’s policy requiring neuro checks for unwitnessed falls and head injuries. The resident later returned from the hospital with a negative CT scan and sutures to the forehead, but no neuro checks were documented in the record. The same resident reported lying on the floor for a long time after the fall, yelling for help and being unable to find the call light. The resident stated that when staff arrived, they said they could not get the resident off the floor because of the head injury and that they had to call 911, then left the room. The resident reported that no one applied anything to the head to stop the bleeding, and that the resident used a pair of pants to apply pressure. EMS personnel later confirmed finding the resident alone on the floor with pants on the forehead to control bleeding and no staff present in the room. EMS staff reported having to leave the room to locate a nurse, finding the RN at the nurses’ station, and that the RN came to the room only after EMS had the resident on the gurney, handed over paperwork, stated they were going to get an ice pack, and left without giving a report or providing care. The RN later acknowledged not starting neuro checks because the resident was going to the emergency room, not applying pressure to the laceration, not recalling if the resident was on blood thinners, and knowing that neuro checks should be done for unwitnessed falls. Another resident with a history including fractured pelvis, toxic encephalopathy, acute respiratory failure, interstitial pulmonary disease, atrial fibrillation, anemia, and an order for apixaban had a care plan addressing anticoagulant therapy and monitoring for adverse reactions. A nurse practitioner documented bluish discoloration on the dorsum of both feet and ordered stat arterial and venous Doppler studies. The Doppler results showed acute DVT involving multiple veins in the left lower extremity, and the physician was notified. The medical record contained no further documentation of the resident’s condition, no additional physician orders related to the Doppler findings, and no documentation of transfer to the hospital, despite ambulance records indicating an emergent transfer for dyspnea. EMS documentation and family interviews indicated that when EMS arrived, no staff were in the room, the family provided the history including Doppler results and physician conversation, and staff only appeared about 20 minutes later as EMS was exiting with the resident. The nurse who entered the room did not know what was going on with the resident and told EMS that the resident’s shortness of breath was normal, and the corporate DON later stated that the nurse on duty should have documented and given report to EMS. A third resident with stroke, dementia, severe cognitive impairment (BIMS of 4), dependence on staff for ADLs and mobility, and a history of multiple falls had a documented fall in which the resident rolled out of bed from the side opposite the fall mat and stated they hit their head. Nursing notes recorded that ROM and a neuro assessment were within normal limits for the resident and that vital signs were taken, with the resident transferred back to bed and the physician and responsible party notified. However, there was no documentation that neurological checks were completed per the facility’s neurological flow sheet protocol after this unwitnessed fall with reported head impact. The ADON confirmed that neurological flow sheets should be completed for every unwitnessed fall, that these are to be uploaded into the EMR, and that no such documentation existed for this resident. The ADON also confirmed that the fall for the first resident was not entered correctly into the EMR, so no post-fall assessment, neurological assessment, or care plan interventions were generated.
Failure to Care Plan and Implement Interventions for High Fall-Risk Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess and care plan for a resident identified as high risk for falls, and to implement post-fall interventions after an actual fall. The resident was admitted with osteomyelitis of the left ankle and foot, peripheral vascular disease, and hypertension, and was assessed on 02/16/26 as being at high risk for falls. On 03/01/26 at 4:30 p.m., nursing notes documented that the resident rolled out of bed while reaching for a phone charger, landing on the right side of the body between the bed and a recliner, and sustaining a gash to the right temple with swelling and headache, requiring transfer to the emergency room. Later that evening, notes indicated the resident returned from the hospital with sutures to the forehead, a negative CT scan, and that safety checks were in place with the bed in a low position and instructions given to report dizziness or lightheadedness. Despite the high fall risk assessment and the documented fall with head injury, review of the medical record from 03/01/26 through 03/10/26 showed no care plan addressing the resident’s fall risk or the actual fall. The comprehensive MDS dated 03/03/26 documented the resident as cognitively intact, able to make self-understood, and at risk for falls with no history of falls, even though a fall had occurred on 03/01/26. Observation on 03/10/26 found the resident in a low bed with the call light on the floor and not within reach, and the resident reported having been unable to find the call light at the time of the fall and lying on the floor for a long time before help arrived. Interviews with the ADON, MDS coordinator, interim DON, and Administrator confirmed that the fall was not correctly entered into the EMR, which prevented triggering of post-fall assessments and documentation, and that no fall care plan or interventions had been developed for this resident despite facility policy requiring assessment and care planning for residents at risk for falls and after every fall.
Failure to Prevent and Timely Identify Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services, including individualized interventions, to prevent the development and identification of a Stage 3 pressure ulcer on a resident’s buttock. The facility’s skin policy required a full-body skin assessment within 6 hours of admission, weekly skin assessments, quarterly Braden Scale risk assessments, and use of skin sheets by direct care staff to report abnormalities. For this resident, admitted with diagnoses including CHF, ESRD, heart failure, anemia, and depression, there was no Braden Scale completed upon admission and no documented weekly skin assessments after the initial admission assessment. The admission note documented normal skin color and temperature with no open areas but did note superficial skin loss on the buttocks, and the care plan identified risk for alteration in skin with interventions such as barrier cream and turning/positioning every two to three hours, yet there was no documentation that barrier cream was applied. In the days following admission, the resident was repeatedly observed sitting and sleeping in a recliner without a pressure-relieving cushion. The resident reported sitting in the recliner all the time, sleeping there because of fear of rolling out of bed, and primarily lying on his/her back. The resident stated that his/her bottom was sore and that staff had applied “some type of cream,” but also reported that no nurse had looked at the area. Observations on consecutive evenings and early mornings showed the resident in the recliner on his/her back, still without a pressure-relief cushion, despite the facility policy that staff should encourage bed use and provide a cushion for the recliner as needed. The pressure ulcer was identified only when a CNA responded to the resident’s call light for toileting and the resident complained of pain in the bottom while sitting on the toilet. The CNA observed an open area on the inner left buttock about the size of a quarter with bloody drainage and white tissue in the center surrounded by red to pink tissue, and reported not having seen it before. An LPN then assessed the area and described the larger open area as deep with white tissue and some drainage, with the appearance of a Stage 3 pressure ulcer, and also noted a superficial open area on the left buttock. The LPN stated he/she had not been notified of these open areas prior to that day. Review of the medical record showed no completed skin assessments after admission and no skin sheets per facility policy, and interviews with leadership confirmed expectations that Braden assessments, weekly skin checks, and prompt identification and reporting of skin issues should have occurred but did not in this case.
Failure to Administer Admission Medications and Use Emergency Supply for New Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered on admission and to follow procedures when medications were not available. For one resident with diagnoses including type 2 diabetes mellitus, pneumonia, and COVID, a stat chest x-ray on 1/13/26 showed pneumonia, and the physician ordered doxycycline 100 mg BID for five days and Augmentin 500/125 mg daily for five days. These orders were entered on the POS and MAR on 1/13/26 at 4:30 P.M., but there was no documentation that staff administered either antibiotic that day. The facility’s emergency medication supply list showed Augmentin 500/125 mg and doxycycline 100 mg were available, yet there was no documentation that staff notified the physician or pharmacy when the medications were not given or if they were not obtained from the emergency supply. For another resident admitted from the hospital with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, acute respiratory failure with hypoxia and hypercapnia, and chronic atrial fibrillation, hospital discharge orders included atorvastatin 80 mg at bedtime, Eliquis 5 mg BID, metoprolol 12.5 mg BID, nystatin suspension QID, and DuoNeb every six hours, with next doses due the evening and bedtime of the admission date. The POS reflected these orders, but the MAR showed staff did not administer the bedtime doses of atorvastatin, Eliquis, or metoprolol, nor the scheduled nystatin doses at 4:00 P.M. and 8:00 P.M., nor the DuoNeb dose at 8:00 P.M. The resident reported not receiving bedtime medications because the facility did not have them. The emergency medication supply list showed Eliquis 5 mg and metoprolol 25 mg were available, but they were not used. Staff interviews revealed confusion and inaction regarding medication availability and use of the emergency kit. One LPN stated the pharmacy delivered the resident’s medications the following morning, claimed no doses were due the prior night, and said he/she did not have access to the emergency kit, later acknowledging that Eliquis was in the kit and could have been administered. Another LPN stated there was an e-kit for after-hours or new admission medications but was unsure which medications it contained, confirmed the resident did not receive medications because the pharmacy had not yet delivered them, and reported the resident still had not received DuoNeb due to waiting on a nebulizer, despite central supply maintaining medical equipment such as nebulizers. The facility did not provide a policy related to obtaining newly ordered medications from the pharmacy or procedures to follow when medications were not available.
Unsecured Medications and Unauthorized Bedside Inhalers
Penalty
Summary
The deficiency involves the facility’s failure to secure medications in locked locations and to prevent medications from being left unattended, contrary to facility policy and professional standards. Surveyors observed multiple instances where medication cards and medication bottles delivered by the pharmacy were left on the nurse’s station desk and on top of a treatment cart for an extended period without any staff present or in line of sight, while residents and visitors walked past the area. The treatment cart was not in use and was positioned in front of the nurse’s station counter, making the unsecured medications easily accessible. Staff later confirmed that medications were not to be left unlocked or unattended and acknowledged that the medications had been left out since delivery because staff had not yet put them away. Additional observations showed that both the treatment cart and the medication cart, which contained medications, were left unlocked and unattended at the nurse’s station on another occasion, again with no staff in the area or in line of sight. Nursing staff, including an LPN and an RN, stated that medication and treatment carts should always be locked when unattended and that medications should never be left unattended at the nurse’s station or on carts. The DON and the Administrator both stated that staff were expected to lock medication and treatment carts when unattended and to secure medications with a lock upon receipt from the pharmacy, consistent with facility policies on medication labeling, storage, and administration. The facility also failed to secure medications for one resident by allowing prescription inhalers to remain at the bedside without appropriate orders or assessment for self-administration. A resident recently admitted with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, and acute respiratory failure reported having inhalers at the bedside that they self-administered and had brought from home. Observation revealed four prescription inhalers lying on top of the bed covers at the foot of the resident’s bed. Review of physician orders showed an order for a fluticasone furoate inhaler but no orders for tiotropium or albuterol inhalers and no order permitting bedside self-administration. Nursing leadership stated they were unaware of the inhalers at the bedside, confirmed that residents must be assessed and have an order to self-administer medications, and stated that even with such an order, medications should be kept in a secure location rather than on the bed. The Medical Director stated that all medications should be secured behind at least one locked door or drawer.
Failure to Implement and Communicate RD-Recommended Nutritional Interventions After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement, evaluate, and modify nutritional interventions to prevent significant weight loss for one resident. The facility’s own policy required a weight change investigation for significant weight changes of 5% or more in one month, 7.5% or more in three months, and/or 10% or more in six months, with subsequent contact of the dietician and physician, updating of interventions, and ongoing monthly investigation until weight stabilized. The resident’s care plan for nutrition and hydration, initiated in early December, identified potential for alterations in nutrition and hydration and directed staff to evaluate weight changes, determine percentage change, follow facility protocol for weight change, and monitor for signs and symptoms of malnutrition. The comprehensive MDS documented severe cognitive impairment, dependence for ADLs, an unstageable pressure ulcer, and increased nutritional needs, but no difficulty swallowing and no nutritional approaches at that time. The resident was admitted with multiple significant diagnoses including acute respiratory failure, pulmonary edema, CHF, diabetes, protein-calorie malnutrition, osteoporosis, and osteomyelitis of the left ankle and foot. Weights recorded in the EMR showed 192 lbs on 12/06, 185 lbs on 12/11, and 185.2 lbs on 12/13. On 12/16, the RD evaluated the resident, noted a weight of 185.2 lbs and increased nutrient needs related to a large chronic unstageable pressure ulcer to the left heel, and recommended discontinuing certain diet restrictions, changing to a regular no added salt diet with sugar-free beverages and diet condiments, and adding Pro Heal 30 ml BID and Juven BID. The January POS reflected the NAS diet, Juven BID, and ProHealth 30 ml BID, but there were no documented weights from 12/14 through 01/21, and a weight of 159.8 lbs was then recorded on 01/22, representing a 25.4 lb loss since 12/13. The RD’s 01/29 note identified this as a significant weight loss, noted the resident reported not being interested in food, and recommended adding Magic Cup BID at lunch and dinner, to be included as dietary fluids. Despite this recommendation, the January POS contained no order for Magic Cup, and no weights were documented from 01/22 through 02/22, with the next weight of 163.8 lbs recorded on 02/23. The February POS also showed no order for Magic Cup, and the resident’s nutrition/hydration care plan contained no interventions specifically addressing weight loss. Multiple meal observations on 02/23 and 02/24 showed the resident receiving meals without Magic Cup, and both the resident and a family member reported that Magic Cups had not been provided. The RD stated that recommendations were emailed to the Administrator, DON, DM, and Care Plan Coordinator, that she had noted significant weight loss and recommended Magic Cup BID, and that she did not know why these recommendations were not communicated to the physician. The DM acknowledged receiving RD emails and changing diet cards based on recommendations, but stated the resident did not have Magic Cup in the diet order and that he must have missed that RD recommendation. The Interim DON, Administrator, and Medical Director each stated they would expect RD recommendations to be reviewed and communicated to the physician for residents with weight loss, but this did not occur, and the facility failed to implement and integrate the RD’s recommended intervention for Magic Cup or to update the care plan with weight-loss interventions while the resident experienced a 13.98% weight loss in two months. Additionally, the facility did not consistently obtain and document weights per its policy and the resident’s care plan. There were gaps in weight documentation between mid-December and late January, and again from late January to late February, despite the resident’s known risk factors, existing pressure ulcer, and documented significant weight loss. The RD reported having noted weight discrepancies that had not been addressed. The MDS also showed that dental status was not assessed. Collectively, these inactions—failure to consistently monitor weights, failure to initiate and document weight change investigations as required by policy, failure to communicate and obtain physician orders for RD-recommended interventions, and failure to update the care plan with specific weight-loss interventions—led to the resident’s unaddressed significant weight loss. The facility’s own staff interviews confirmed that the process for handling RD recommendations was not effectively carried out. The LPN reported not seeing any Magic Cup recommendations in the resident’s record. The RD described a practice of emailing recommendations but not participating in IDT meetings, and acknowledged that her recommendation for Magic Cup BID was not communicated to the physician. The DM confirmed that he relies on RD emails to change diet cards and admitted that he must have missed the Magic Cup recommendation, resulting in no diet order for Magic Cup. Leadership staff, including the Interim DON, Administrator, and Medical Director, each stated expectations that RD recommendations be reviewed and communicated to the physician for residents with weight loss, but these expectations were not met in this case, contributing to the failure to implement appropriate nutritional interventions for the resident experiencing significant weight loss.
Failure to Provide Evening Meal to Newly Admitted Resident
Penalty
Summary
The facility failed to provide an evening meal to a newly admitted resident whose diagnoses included fracture of the pelvis, respiratory failure, and protein-calorie malnutrition. The resident was admitted to the facility in the early evening with a physician’s order for a regular diet with mechanical soft foods. According to the resident’s family member, they arrived at approximately 5:55 P.M., and no staff offered or brought any food to the resident. The family member reported seeing only one nurse, who stated the kitchen was closed for the day, leading the family member to go to a local restaurant to obtain food for the resident. The resident later stated that they were hungry, did not get much to eat for supper, and that their daughter had to bring food because the facility did not provide a meal tray. The Dietary Manager reported that they are notified of expected admissions via memo and that on the day in question they had prepared three or four meal trays for anticipated admissions, including a tray intended for this resident. The Dietary Manager explained that they must wait for nursing to enter the resident’s information into the EMR before entering diet information into the dietary system, and that if a resident is admitted before 7:00 P.M., nursing is expected to inform dietary of the admission and ask the resident what they would like for the meal. On this occasion, dietary staff were not informed that the resident had arrived, so they left a tray in the kitchen window for nursing to take when the resident came in. The next morning, the tray was still in the kitchen window and had not been passed to the resident. The Dietary Manager stated this was not the first time such an occurrence had happened. The DON, Administrator, and Medical Director each indicated in interviews that they would expect new or late-returning residents to receive some type of nourishment, such as a meal tray or sandwich.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds and Indwelling Devices
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy for residents with wounds and indwelling medical devices, resulting in staff not using required gowns and gloves during high-contact care activities. The facility’s March 2024 EBP policy required EBP for all residents with wounds or indwelling medical devices, regardless of MDRO status, and specified that gowns and gloves must be used for high-contact care such as dressing, bathing, transferring, toileting, changing linens and briefs, and device and wound care. The policy also required clear EBP signage on or near the resident’s door, availability of PPE near or outside the room, and staff education and competency regarding EBP. For one resident with an indwelling urinary catheter, the comprehensive MDS documented the catheter, and the care plan directed staff to provide EBP and use gowns and gloves during high-contact care. However, observations showed there was no EBP sign on the door and no gowns available inside or outside the room. A CNA entered the room without a gown or gloves, applied a gait belt, transferred the resident from a recliner to a wheelchair, handled the urinary catheter collection bag, and pushed the resident into the bathroom. In the bathroom, the CNA donned gloves but no gown, assisted the resident to stand, pulled down pants, removed an unsoiled incontinence brief, manipulated the catheter tubing, and attached it to the handrail. After the resident complained of a sore on the bottom, the CNA removed gloves and exited the room without handwashing. Subsequently, an LPN and the same CNA entered the bathroom wearing gloves but no gowns; the CNA assisted the resident to stand while the LPN wiped the resident’s bottom, noted blood on the tissue, and left after removing gloves. Another LPN then entered with gloves but no gown, cleansed and dressed an open wound on the buttock, and left after removing gloves and using hand sanitizer. The CNA then completed perineal care, catheter manipulation, clothing adjustment, transfers, and linen changes wearing only gloves and no gown. Interviews showed the LPN believed EBP should be used when applying creams, and the CNA was unsure what EBP was used for and stated he/she only wore gloves when caring for residents. For another resident with end stage renal disease, dependence on dialysis, multiple documented wounds (coccyx, left buttock, right arm, right heel), and a dialysis CVC and AV fistula, the care plan and physician orders specified EBP for wounds and dialysis CVC, with daily wound cleansing and dressing changes. Despite this, repeated observations showed no EBP sign on the door and no PPE cart or PPE door hanger outside the room. Staff, including an LPN and CNA, entered the room and performed high-contact care such as changing linens while the resident was in bed, and other care activities, wearing only gloves and no gowns. A guest and the resident’s spouse both reported that staff only wore gloves when providing care and wound care. In interviews, a CNA stated they relied on door signage to know when to wear a gown, an LPN stated uncertainty about whether the resident was on EBP and confirmed only glove use, and a nurse manager acknowledged that residents with dialysis access and/or wounds should be on EBP, that every such resident should have PPE outside the room, and that the EBP sign likely was never placed on the door. The DON stated that EBP was required for residents with MDRO history, draining wounds, or indwelling devices including catheters, IV lines, dialysis access, and central lines, and that nurse managers were responsible for setting up EBP, while the Administrator and Medical Director both stated they expected staff to know which residents should be on EBP and to use all required PPE.
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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 Peters
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Peters Post Acute | 0 mi | — | 7 | 0 |
| St Peters Rehab And Healthcare Center | 0.6 mi | — | 1 | 0 |
| Mcclay Senior Care | 3 mi | — | 1 | 0 |
| Garden View Care Center | 4.2 mi | — | 2 | 0 |
| Aspen Point Health And Rehabilitation | 4.6 mi | — | 3 | 0 |
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