Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
78% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 1
Date: Jun 4, 2025
Visit Reason
The visit was conducted to review and address deficiencies related to the fire alarm system at St Elizabeth Hall.
Findings
The facility failed to ensure the complete fire alarm system was tested and maintained according to NFPA 72, 1999 edition. Multiple tamper signals failed to send alerts to the fire alarm control panel and emergency response center.
Deficiencies (1)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain: The facility failed to ensure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition. Several tamper signals on various zones failed to send signals to the fire alarm control panel and emergency response center.
Report Facts
Facility census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding scheduling correction of fire alarm defects |
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
The inspection was conducted to assess compliance with training requirements for staff providing care to residents with Alzheimer's disease or related dementias.
Findings
The facility failed to ensure that all direct care staff had completed the required three hours of Alzheimer's disease and dementia training. Multiple personnel files lacked documentation of this training despite the presence of residents with Alzheimer's disease.
Deficiencies (1)
19 CSR 30-86.047(63)(A) Alzheimer's/Dementia Training-Direct Care Staff, 3 hr. The facility failed to ensure all direct care staff had the required three hours of training on Alzheimer's disease and dementia care. Documentation was missing for multiple employees.
Report Facts
Census: 38
Census: 40
Number of sampled employees without training: 6
Training hours required: 3
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 5
Date: Jun 26, 2024
Visit Reason
The inspection was conducted to identify deficiencies in compliance with assisted living facility regulations and to review the facility's plan of correction for those deficiencies.
Findings
The facility failed to complete premove-in screenings for prospective residents, develop individualized service plans including fall history, maintain adequate staffing and proper fall assessment procedures, ensure staff training on safe transfers, and complete personal inventory sheets for residents. Multiple deficiencies were documented related to resident care, staffing, and documentation.
Deficiencies (5)
A4748 Premove-in screening requirements were not met as the facility failed to complete premove-in screenings for two of three sampled residents. The census was 38.
A4754 The facility failed to develop individualized service plans (ISP) including a resident's fall history for one of three sampled residents. The census was 38.
A4841 Staffing requirements were not met as the facility failed to notify a nurse for assessment after a resident fall and staff lifted the resident without qualified assessment. The census was 38.
A4860 The facility failed to develop a system to ensure all staff used proper transferring techniques when transferring residents off the floor for one of three sampled residents. The census was 38.
A8037 The facility failed to ensure personal inventory lists were completed for three of three sampled residents. The census was 38.
Report Facts
Census: 38
Sampled residents: 3
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 2
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to fire alarm system maintenance and room cleanliness at St Elizabeth Hall.
Findings
The facility failed to ensure the complete fire alarm system was tested and maintained according to NFPA 72, 1999 edition, and rooms were not kept neat, orderly, and cleaned daily. Both deficiencies potentially affected all 40 residents present during the inspection.
Deficiencies (2)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to ensure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition. The last annual fire alarm system inspection was completed on July 14, 2023, with no semi-annual inspection conducted as required.
19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily. The facility failed to ensure rooms were neat, orderly, and cleaned daily, as evidenced by a heavily loaded room with trash and combustible items.
Report Facts
Facility census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding fire alarm system inspection scheduling and room cleaning |
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 6
Date: May 18, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to fire hazards, medication regimen reviews, resident records, food service sanitation, and resident fund bond requirements at St Elizabeth Hall.
Findings
The facility was found deficient in fire hazard prevention, medication regimen reviews, resident record maintenance, food service sanitation, and maintaining a sufficient surety bond for resident funds. Multiple interviews and observations confirmed these deficiencies with a census of 45 residents.
Deficiencies (6)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard. The facility failed to ensure no section of the building presented a fire hazard when an oxygen transilling machine and oxygen tank were observed in a resident room.
19 CSR 30-86.047(54) Drug Regimen Review. The facility failed to ensure a pharmacist, physician, or registered nurse reviewed residents' medications every other month for four sampled residents, affecting all residents.
19 CSR 30-86.047(58)(A) Resident Record Admission Info. The facility failed to include the resident's preferred dentist in medical records for three of four sampled residents.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review. The facility failed to complete monthly medication regimen reviews and summaries for four sampled residents.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed. The facility failed to keep all non-food contact surfaces clean, with grease and food debris found on kitchen equipment over two days of observation.
19 CSR 30-88.020(14) Resident Fund Bond Requirements. The facility failed to maintain a surety bond sufficient to protect resident funds, with the bond amount insufficient by $7,500.
Report Facts
Census: 45
Surety bond amount: 51000
Surety bond shortfall: 7500
Average monthly balance: 38980.28
Average resident funds balance: 49443.97
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 1
Date: Mar 28, 2019
Visit Reason
The inspection was conducted to assess compliance with resident fund bond requirements as part of regulatory oversight of St Elizabeth Hall.
Findings
The facility failed to maintain a sufficient bond amounting to one and one-half times the average monthly balance of residents' funds for the preceding 12 months. The approved bond was $15,000, but an $18,000 bond was required based on reconciled bank balances, and the facility applied for an increase to $40,000 without departmental approval.
Deficiencies (1)
19 CSR 30-88.020(14) Resident Fund Bond Requirements were not met. The facility failed to maintain a sufficient bond equal to one and one-half times the average monthly balance of residents' funds for the preceding 12 months.
Report Facts
Residents affected: 39
Bond amount required: 18000
Approved bond amount: 15000
Requested bond increase: 40000
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 2
Date: Mar 1, 2018
Visit Reason
The inspection was conducted to assess compliance with regulations regarding individualized service plans and medication administration at St Elizabeth Hall.
Findings
The facility failed to ensure resident individualized service plans were updated to address resident needs and preferences. The facility also failed to maintain a safe and effective medication system, as evidenced by a medication error observed during the survey.
Deficiencies (2)
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to ensure resident individualized service plans were updated to address resident needs, services, goals, and preferences for two of four sampled residents.
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to ensure a safe and effective medication system when staff dropped a pill on the counter and administered it to a resident without proper procedure.
Report Facts
Census: 38
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