Inspection Reports for
Cottages of Lake St. Louis
2885 Technology Dr, Lake St Louis, MO 63367, United States, MO, 63367
Back to Facility Profile7 Reports
Inspection Report — Mar 29, 2022
Complaint Investigation
Date: Mar 29, 2022
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Federal health survey (CMS-2567) and Missouri State Form included; complaint investigation (Missouri complaint numbers cited in the file).
Complaint Details
Complaint numbers cited in the file include MO185951, MO189591, and MO198352; the documents do not state whether the allegations were substantiated.
Findings
Six deficiencies were cited: four federal health deficiencies covering reporting of alleged violations, medication administration/professional standards (including controlled substances and PRN documentation), failure to initiate CPR, and fall supervision/accident hazards; two Missouri State Form deficiencies referencing nursing care and development/implementation of policies (state citations refer to the federal findings).
Deficiencies (2)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F658 and F689.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: Refer to F609.
Report Facts
residents sampled: 20
residents affected: 4
Inspection Report — Feb 11, 2020
Routine
Date: Feb 11, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health-care deficiency for failure to follow physician orders/medication administration (Coumadin) and one Missouri state licensure deficiency for nursing care per resident that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F658.
Report Facts
residents sampled: 3
Inspection Report — Dec 13, 2019
Routine
Date: Dec 13, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three deficiencies were cited: one federal health deficiency for unsanitary food storage/preparation and two Missouri state deficiencies related to food protection/temperature and food-contact surface sanitation.
Deficiencies (2)
19 CSR 30-87.030(13), Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(63) Food-Contact Surfaces Washed/Rinsed/Sanitized: Refer to F812.
Inspection Report — Dec 13, 2019
Life Safety
Date: Dec 13, 2019
Visit Reason
Federal CMS-2567 Life Safety Code forms (K-tag) and Missouri Department of Health and Senior Services State Form pages were included in this file; the survey is a Life Safety (fire safety) inspection. The survey type is not otherwise stated.
Findings
Twelve deficiencies were cited: six federal life-safety deficiencies involving corridor doors in multiple cottages that did not resist passage of smoke and/or were not self-latching or had gaps, and six Missouri state deficiencies under 19 CSR 30-85.032(2) (Class II*) referring to the life-safety findings.
Deficiencies (6)
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K363.
Report Facts
residents_potentially_affected: 8
Inspection Report — Jul 16, 2019
Complaint Investigation
Date: Jul 16, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation for MO157900.
Complaint Details
MO157900; substantiation not stated.
Findings
Two deficiencies were cited: one federal quality-of-care deficiency involving failure to provide timely catheter care for a resident, and one Missouri Class II nursing care deficiency referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F684.
Report Facts
residents sampled: 7
residents affected: 1
Inspection Report — Oct 30, 2018
Routine
Date: Oct 30, 2018
Visit Reason
This file contains a federal health survey (CMS-2567) and Missouri Department of Health and Senior Services state licensure survey (State Form); the survey type is not stated.
Findings
There are 7 federal health deficiencies addressing resident/family group response, employee screening/background checks, discharge summary documentation, activities programming, accident/elfopement supervision, sufficient nursing staff/call light response, and food safety/food storage/cleaning; and 11 Missouri state licensure deficiencies covering criminal history/employment screening, RN day-shift coverage, nursing staff sufficiency, protective oversight/voluntary leave, nursing care per resident condition, activity program, air duct maintenance, food protection/temperature and sanitation, ice dispensing/contamination, ventilation hood maintenance, and exercise rights/voice/grievances.
Deficiencies (11)
19 CSR 30-85.042(18)(A) Criminal History - Facility Policy/Procedure: Refer to F606.
19 CSR 30-85.042(35)(B) SNF RN-Day Shift, LPN/RN eve/nights: Based on interview and record review, the facility failed to provide the services of a registered nurse for eight consecutive hours on the day shift on multiple days as required.
19 CSR 30-85.042(37) Nursing Staff Sufficient/Qualified: Refer to F725.
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Based on observation, interview and record review the facility failed to provide appropriate protective oversight related to elopement/exit-seeking behavior (see findings and corrective actions referenced at F689).
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F689.
19 CSR 30-85.042(93) Activity Program: Refer to F679.
19 CSR 30-87.020(9) Air Ducts-Maintain: Refer to F812.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Refer to F812.
19 CSR 30-87.030(40) Ice Store/Dispense, No Contamination, Air Gap: Refer to F812.
19 CSR 30-87.030(55) Ventilation Hoods, Clean, Filters Removable: Refer to F812.
19 CSR 30-88.010(20) Exercise Rights/Voice Grievances: Refer to F565.
Report Facts
residents sampled: 16
new employees reviewed: 9
Inspection Report — Oct 30, 2018
Life Safety
Date: Oct 30, 2018
Visit Reason
CMS-2567 federal health and Life Safety Code forms and Missouri Department of Health and Senior Services State Form pages; Life Safety (K-tag) survey (state survey type not stated).
Findings
Thirteen deficiencies were cited: seven federal Life Safety (K/E) deficiencies covering emergency power, building construction/fire barriers, egress doors/delayed egress, fire alarm notification, sprinkler maintenance, smoke barriers, and fire drills; and six Missouri State Form deficiencies (19 CSR citations) that reference the related Life Safety findings.
Deficiencies (6)
19 CSR 30-85.022(3) Noncombustible Material Between Floors: Noncombustible Material Between Floors: Refer to K161.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Fire Alarm System-Test/Maintain: Refer to K343.
19 CSR 30-85.022(11)(D) Complete Sprinkler System: Complete Sprinkler System: Refer to K353.
19 CSR 30-85.022(16) Door Locks: Door Locks: Refer to K222.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Smoke Section Walls/Doors: Refer to K372.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: Fire Drill Requirements, Evacuation: Refer to K712.
14 CMS Surveys
Inspection Report — Jul 24, 2025
Complaint Investigation
Date: Jul 24, 2025
Visit Reason
The inspection was conducted due to complaints regarding the treatment of residents, specifically concerns about dignity and respect during care.
Complaint Details
The complaint investigation found substantiated issues regarding disrespectful treatment of residents. Resident #75 reported being abruptly awakened and treated discourteously by staff during night care. Resident #100 reported a caretaker throwing off his/her sheet without asking and touching a private area, though the resident did not feel scared or that the incident was sexual. Interviews with the Director of Nursing and Administrator confirmed expectations for respectful and dignified treatment of residents.
Findings
The facility failed to ensure that two residents were treated with dignity and respect. Residents reported feeling disrespected and discouraged by staff behavior during care, including abrupt awakenings, loud announcements, and inappropriate handling during bed checks.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Report Facts
Residents sampled: 18
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for staff behavior and resident care |
| Administrator | Administrator | Interviewed regarding expectations for staff behavior and resident care |
Inspection Report — Oct 16, 2023
Life Safety
Date: Oct 16, 2023
Visit Reason
CMS-2567 Life Safety Code survey (federal Life Safety form); Life Safety Code survey conducted (no complaint numbers cited).
Findings
4 life safety deficiencies were cited covering means of egress/exit signage, corridor doors that would not close or were stuck, essential electrical system/generator maintenance and lack of battery-powered lighting, and inadequate training/qualification for staff handling medical gases. All federal deficiencies were cited with scope/severity SS=F.
Deficiencies (4)
K211 Means of Egress - General: Observations found exit doors had large red stop signs posted on the inside of the door facing the direction of egress, which obstructed the means of egress and had the potential to affect residents in the building.
K363 Corridor - Doors: Corridor bedroom doors were observed stuck in the frame and failed to close properly, preventing required corridor doors from closing and potentially affecting residents in multiple cottages.
K918 Electrical Systems - Essential Electric System: The facility failed to ensure the essential electrical system and generator components were maintained and that battery-powered lighting was provided for the generator/transfer switch rooms; this condition potentially affected residents in multiple cottages.
K926 Gas Equipment - Qualifications and Training: Record review and interviews revealed personnel who handled medical gases had no documented training on the risks associated with handling medical gases.
Report Facts
residents potentially affected: 9
residents potentially affected: 10
residents potentially affected: 7
residents potentially affected: 7
Inspection Report — Oct 12, 2023
Complaint Investigation
Date: Oct 12, 2023
Visit Reason
Federal health survey (CMS-2567); a Recertification and Complaint survey was conducted.
Findings
Two federal health deficiencies were cited: one for failures in prevention, assessment, documentation, and treatment of pressure ulcers and one for unsafe food handling/temperature monitoring and dishwashing sanitation/labeling issues.
Deficiencies (2)
F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer: Based on observations, interviews, and record review, the facility failed to timely identify, assess, document measurements, and provide appropriate treatment and follow-up for residents' pressure wounds, resulting in progression and worsening of heel pressure ulcers for two residents.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observations, record review, staff interviews, and policy review, the facility failed to ensure thawed foods were properly labeled/dated, failed to monitor high-temperature dishwashers for effective sanitization, and failed to consistently monitor and document proper food temperatures during meal preparation and service.
Report Facts
residents_sampled: 21
Inspection Report — Jul 20, 2022
Routine
Date: Jul 20, 2022
Visit Reason
Federal CMS-2567 containing a COVID-19 Focused Emergency Preparedness and Infection Control survey; the survey is COVID-19 focused and no complaint number is stated.
Findings
No deficiencies were cited; the facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 and with the referenced emergency preparedness requirement.
Inspection Report — Mar 29, 2022
Complaint Investigation
Date: Mar 29, 2022
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form included; complaint investigation (Missouri complaint numbers cited in the file).
Complaint Details
Complaint numbers cited in the file include MO185951, MO189591, and MO198352; the documents do not state whether the allegations were substantiated.
Findings
Six deficiencies were cited: four federal health deficiencies covering reporting of alleged violations, medication administration/professional standards (including controlled substances and PRN documentation), failure to initiate CPR, and fall supervision/accident hazards; two Missouri State Form deficiencies referencing nursing care and development/implementation of policies (state citations refer to the federal findings).
Deficiencies (4)
F609 Reporting of Alleged Violations: Based on interview and record review, the facility failed to report an allegation of misappropriation of medication involving a Licensed Practical Nurse and Resident #8 to the state agency as required.
F658 Services Provided Meet Professional Standards: Based on interview and record review, the facility failed to ensure staff followed physician orders and to document administration of narcotic and PRN pain medications for multiple residents and failed to notify hospice/physician regarding a resident's condition as required.
F678 Cardio-Pulmonary Resuscitation (CPR): Based on interview and record review, the facility failed to initiate CPR or call 911 for one resident identified as full code who was found unresponsive on 2/27/22; past noncompliance was noted.
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, record review, and interview, the facility failed to monitor and modify fall interventions and failed to provide adequate supervision and prevention strategies for a resident at high risk of falls, resulting in falls with injury.
Report Facts
residents sampled: 20
residents affected: 4
Inspection Report — Jan 13, 2021
Routine
Date: Jan 13, 2021
Visit Reason
Federal CMS-2567 health survey (COVID-19 Focused Emergency Preparedness and Infection Control Survey as stated in Initial Comments).
Findings
No federal health or emergency preparedness deficiencies were cited; Initial Comments state the facility was found to be in compliance with CMS Emergency Preparedness (42 CFR 483.73) and CDC recommended practices for COVID-19.
Inspection Report — Sep 16, 2020
Routine
Date: Sep 16, 2020
Visit Reason
Federal CMS-2567 (health and emergency preparedness sections); a COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted.
Findings
No health or emergency preparedness deficiencies were cited on this CMS-2567; the facility was found in compliance with applicable COVID-19 infection control and emergency preparedness requirements.
Inspection Report — Jun 3, 2020
Routine
Date: Jun 3, 2020
Visit Reason
CMS-2567 federal infection control and emergency preparedness survey; the survey was a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey. No complaint numbers are stated in the file.
Findings
No deficiencies were cited. Initial comments state the facility was found to be in compliance with applicable COVID-19 emergency preparedness and infection control expectations.
Inspection Report — Feb 11, 2020
Routine
Date: Feb 11, 2020
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Two deficiencies were cited: one federal health-care deficiency for failure to follow physician orders/medication administration (Coumadin) and one Missouri state licensure deficiency for nursing care per resident that references the federal finding.
Deficiencies (1)
F658 Services Provided Meet Professional Standards: Based on interview and record review the facility failed to follow physician orders for administration of Coumadin for one resident, resulting in an incorrect start date for the alternating dosing and a missed dose.
Report Facts
residents sampled: 3
Inspection Report — Dec 13, 2019
Routine
Date: Dec 13, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); the survey type is not stated.
Findings
Three deficiencies were cited: one federal health deficiency for unsanitary food storage/preparation and two Missouri state deficiencies related to food protection/temperature and food-contact surface sanitation.
Deficiencies (1)
F 812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observation, interview, and record review the facility failed to ensure expired food items were discarded, food scoops were stored in containers with handles touching contents, and the bottoms of refrigerators/freezers were covered with dirt and food debris.
Inspection Report — Dec 13, 2019
Life Safety
Date: Dec 13, 2019
Visit Reason
Federal CMS-2567 Life Safety Code forms (K-tag) and Missouri Department of Health and Senior Services State Form pages were included in this file; the survey is a Life Safety (fire safety) inspection. The survey type is not otherwise stated.
Findings
Twelve deficiencies were cited: six federal life-safety deficiencies involving corridor doors in multiple cottages that did not resist passage of smoke and/or were not self-latching or had gaps, and six Missouri state deficiencies under 19 CSR 30-85.032(2) (Class II*) referring to the life-safety findings.
Deficiencies (1)
K363 Corridor - Doors: Based on observation and interview, the facility failed to maintain doors in Kris's Cottage to resist the passage of smoke; corridor doors did not latch or had gaps allowing visibility through.
Report Facts
residents_potentially_affected: 8
Inspection Report — Jul 16, 2019
Complaint Investigation
Date: Jul 16, 2019
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form); complaint investigation for MO157900.
Complaint Details
MO157900; substantiation not stated.
Findings
Two deficiencies were cited: one federal quality-of-care deficiency involving failure to provide timely catheter care for a resident, and one Missouri Class II nursing care deficiency referencing the federal finding.
Deficiencies (1)
F 684 Quality of Care: Based on interview and record review, the facility failed to identify and provide needed care and services to one resident (Resident #2) with a urinary catheter; staff did not timely intervene when the catheter was obstructed, resulting in abdominal distention, discomfort and subsequent hospice/physician intervention.
Report Facts
residents sampled: 7
residents affected: 1
Inspection Report — Oct 30, 2018
Routine
Date: Oct 30, 2018
Visit Reason
This file contains a federal health survey (CMS-2567) and Missouri Department of Health and Senior Services state licensure survey (State Form); the survey type is not stated.
Findings
There are 7 federal health deficiencies addressing resident/family group response, employee screening/background checks, discharge summary documentation, activities programming, accident/elfopement supervision, sufficient nursing staff/call light response, and food safety/food storage/cleaning; and 11 Missouri state licensure deficiencies covering criminal history/employment screening, RN day-shift coverage, nursing staff sufficiency, protective oversight/voluntary leave, nursing care per resident condition, activity program, air duct maintenance, food protection/temperature and sanitation, ice dispensing/contamination, ventilation hood maintenance, and exercise rights/voice/grievances.
Deficiencies (7)
F565 Resident/Family Group and Response: The facility failed to provide resolutions to resident council grievances and lacked documentation of resident council response forms, with repeated resident complaints about activities, dining, staffing and no follow-up by staff.
F606 Not Employ/Engage Staff w/ Adverse Actions: The facility failed to complete Nurse Aide Registry/background checks for several newly hired employees (Environmental Service Staff F, Housekeeping Staff H, and RN G) upon hire.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary/recapitulation of stay for a discharged resident; no discharge summary was located in the electronic medical record.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide an ongoing program of meaningful activities based on resident assessment and preferences, with documentation gaps and residents reporting little or no routine activities.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate protective oversight for residents at risk of elopement; a resident exited the building activating an alarm with no timely staff response and alarms were not audible in resident rooms, though corrective actions were started during the survey.
F725 Sufficient Nursing Staff: The facility failed to ensure sufficient nursing staff and timely response to call lights, with residents reporting long waits and staffing records showing inadequate RN coverage and occasions with only one CNA on shift.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to ensure food items were labeled/dated and properly stored, and failed to maintain sanitary conditions and clean equipment (ice machines, range hood filters and storage), with multiple unlabeled/undated foods and accumulation of debris/grease noted.
Report Facts
residents sampled: 16
new employees reviewed: 9
Inspection Report — Oct 30, 2018
Life Safety
Date: Oct 30, 2018
Visit Reason
CMS-2567 federal health and Life Safety Code forms and Missouri Department of Health and Senior Services State Form pages; Life Safety (K-tag) survey (state survey type not stated).
Findings
Thirteen deficiencies were cited: seven federal Life Safety (K/E) deficiencies covering emergency power, building construction/fire barriers, egress doors/delayed egress, fire alarm notification, sprinkler maintenance, smoke barriers, and fire drills; and six Missouri State Form deficiencies (19 CSR citations) that reference the related Life Safety findings.
Deficiencies (7)
E041 Hospital CAH and LTC Emergency Power CFR(s): 483.73(e): The facility failed to develop and maintain an emergency generator fuel supply as part of its emergency preparedness plan; record review showed no evidence of an emergency fuel supply and the facility census was 39.
K161 Building Construction Type and Height CFR(s): NFPA 101: The facility failed to maintain required fire-resistance barriers between floors/attics in multiple cottages, with multiple ceiling penetrations and unsealed openings observed during the Life Safety Code tour.
K222 Egress Doors CFR(s): NFPA 101: The facility failed to ensure at least one exit door equipped with delayed egress locking released within 15 seconds when tested on exits in Betty's and Harper's Cottages.
K343 Fire Alarm System - Notification CFR(s): NFPA 101: The facility failed to ensure complete annunciator communication from the main fire alarm panel to annunciators in the cottages, with phone line/disconnect and trouble on the main panel noted.
K353 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101: The facility failed to maintain sprinkler heads free of paint, dust and debris in multiple cottages, with paint and fuzzy debris observed on several sprinkler deflectors.
K372 Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101: The facility failed to maintain smoke barrier integrity in multiple cottages, with multiple unsealed penetrations (pipes, vents, holes) through smoke barrier walls observed during the life safety tour.
K712 Fire Drills CFR(s): NFPA 101: The facility failed to ensure fire drills were conducted at varied times and on all three shifts and failed to ensure quarterly drills on each shift, with record review and interviews showing missing or clustered drills.
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