Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 St Johns Place during CMS and state inspections, most recent first.
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.
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.
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 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 | — | 31 | 1 |
| Bentleys Extended Care | 2.1 mi | — | 7 | 0 |
| Normandy Nursing Center | 2.9 mi | — | 0 | 0 |
| Amberwood Estates Nursing And Rehabilitation | 3 mi | — | 8 | 0 |
| U-city Forest Manor | 3.2 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.